**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to develop an individualized care plan to prevent falls for 4 residents (#74, #253, #149, and #89) of 6 residents reviewed for falls. The facility's failure resulted in Resident #74 sustaining a shattered Left Acetabulum (socket of hipbone) and Fracture of the Left Pubic Ramus (Pelvic break). Resident #253 sustaining a Left Femoral Fracture (break in the thigh bone). Resident #149 sustaining a Right Epidural Hematoma (blood accumulation between the skull and the brain) and Extra Axial Intracranial Hemorrhage (bleeding inside the skull but outside the brain) and went home on palliative care which placed these residents ( #74, # 253, #149, and #89) in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility failed to develop a discharge care plan for 2 residents (#249 and #250) of 5 residents reviewed for discharge. The facility's failure to provide a safe discharge for a previously homeless resident (Resident #249) resulted in homelessness on the day of discharge. The nursing home Administrator transported Resident #249 to an unidentified friend's home without prior approval from the resident friend. Resident #249 friend did not allow him to remain at her home. Friend #1 did not allow Resident #249 to stay. Resident #249 walked from the friend's home to a second friend's house who drove him to a motel where he stayed for approximately 2 months, was evicted, then hitchhiked to a third friend's home, and Resident #250 was discharged on 7/25/2023, the resident was discharged home in her wheelchair and was left saturated in urine and feces for 4 days. Resident #250 was hospitalized 6 days after discharge from the nursing home and diagnosed with Stage 1 Sacral and Bilateral Buttocks Decubitus Ulcers and multiple small 1-centimeter (cm) areas of Stage II Decubitus Ulcers which placed Resident #74, Resident #249, and Resident #149 in Immediate Jeopardy. The facility failed to develop a care plan to address the use of anticoagulant (blood thinner) medication use for 1 resident (#74) of 5 residents reviewed for unnecessary medications. The Administrator and the Director of Clinical Operations were notified of the Immediate Jeopardy for F656 on 9/18/2023 at 6:10 PM, in the conference room. The facility was cited Immediate Jeopardy at F656 (J). The Immediate Jeopardy began 5/17/2023 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated on-site by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction The findings include: Review of the facility policy Comprehensive Care Plan dated 5/1/2012, showed, .The interdisciplinary care plan is implemented to guide health center care staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident .Interdisciplinary team develops resident focused goals . Review of the facility policy Care Plans dated 8/2012, showed, .Care plans will be developed for all patients and residents based upon the RAI [Resident Assessment Instrument- instructions to complete the Minimum Data Set (MDS) assessments] manual guidelines . Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Fracture of the Left Acetabulum, Muscle Weakness, Abnormalities of Gait and Mobility, Aphasia, and Congestive Heart Failure. Review of Resident #74's Lift Transfer Evaluation, dated 6/27/2023, showed, Transfer/Walking Belt x 1 team member is required . Review of Resident #74's comprehensive care plan dated 7/21/2023, showed, .The resident is at risk for falls r/t [related to] weakness, hx [history] of falls, unsteady gait, need for assistance with ADLs .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs . Review of Resident #74 nurses progress note dated 7/21/2023, showed, .He has confusion episodes, alert & oriented x1. He is out of bed sitting comfortably in his wheelchair. Requires x2 max [maximum] assist with transfers. He uses wheelchair for mobility .Call light within reach . Review of Resident #74's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Score (BIMS) score of 14 indicating the resident was cognitively intact. He required extensive assistance of 1 person for bed mobility, transfers, walking, dressing, toileting, personal hygiene and bathing. He was occasionally incontinent of bladder and frequently incontinent of bowel. He had no falls prior to admission or since admission. Review of Resident #74's nurses change of condition progress note dated 7/27/2023, showed, .Situation: Resident laying in the floor at the bottom of the bed skin tear to middle of the back. Resident stated he fell out of his wheelchair trying to move to the other side of the bed .Resident laying in the floor at the bottom of the bed skin tear to middle of the back .educated resident to use the call light for assistance . Review of Resident #74's Post Fall Review dated 7/27/2023, showed, .07/27/2023 .[3:00 PM] .Therapy will complete wheelchair use and safety teaching with resident and will assess WC [wheelchair] for safety and possible addition of anti-roll backs [used on wheelchair to prevent it from rolling backwards] . Review of Resident #74's comprehensive care plan showed an update on 7/28/2023, .Fall 7/27/23. Therapy will complete wheelchair safety teaching . Review of Resident #74's Interdisciplinary Team (IDT) meeting note dated 7/28/2023, showed, .Fall 7/27/23 with 2 skin tears. Skin tears treated and orders written. therapy will complete wheelchair use and safety teaching with resident and will assess w/c [wheelchair] for safety and possible addition of an anti-roll backs . Review of an Occupational Therapy Treatment Encounter Note dated 7/28/2023, showed, .Precautions .impaired safety awareness/impulsive .COTA [Certified Occupational Therapy Assistant] instructed patient on how to properly maneuver w/c, lock/unlocked [unlock] brakes and navigating throughout environment with patient demonstrating fair carryover. Falls prevention education provided and importance of reaching out to nursing via call light when he is ready to go to bed . Review of Resident #74's change of condition nurses progress note dated 8/2/2023, showed, .Resident reported to day shift that he fell .Complaints of pain to left hip, discoloration to affected area .NP [Nurse Practitioner] notified and assessed pt .Order received to send to ER [emergency room] . Review of Resident #74's Post Fall Review dated 8/2/2023, showed, .05:30 .Location of fall .residents room .Prior to fall, patient was .in bed .Physical evaluation .Skin tear .Not witnessed .Immediate actions .[blank] . Review of Resident #74's facility investigation dated 8/2/2023, showed, .Resident reported fall in the bathroom. C/O [complaints of] pain to left hip. Knot noted to outer hip upon assessment . Resident reported to PT [physical therapy] that he fell in the bathroom [time of fall unknown] . Review of Resident #74's NP visit note dated 8/2/2023, showed, .Called to room. Pt. c/o hip [Left] pain. He reports he fell in the bathroom .he is found in bed .Nursing and PT staff are present .He has c/o severe pain to lt. [Left] hip with attempts to move him. He has knot to lt. [Left] outer hip .acute Left hip pain self-report of unwitnessed fall in bathroom . Review of Resident #74's Emergency Documentation dated 8/2/2023, showed, .c/o fall and hitting head but unsure when he fell. Per NH [Nursing Home] pt fell last pm but pat [patient] states it was in the daylight yesterday .Pt does c/o headache and is on blood thinners [medication used to aid with keeping blood clots from forming] .He reportedly is on blood thinners and hit his head. Unknown loss of consciousness as he is somewhat confused to the event . New area of suspected bruising along the left hip has more hyperdense appearance than other areas of edema .The left acetabulum [socket of the hip bone] is fractured, multiple fracture planes, some intersecting the acetabular margin .No evidence of left femoral fracture or dislocation .Impression .The left acetabulum has been shattered since prior examination .Simple fracture to the inferior left pubic ramus [a group of bones that make up part of the pelvis] .Small superfical hematoma along the left outer hip .Medical Decision Making .Acetabular fracture .Pelvic Fracture . Review of Resident #74's comprehensive care plan showed an update on 8/29/2023 (22 days after Physical Therapy identified Resident #74 had a second fall at the facility) for, .Place on contour mattress to assist in not rolling out of bed . During an observation and interview on 9/7/2023 at 9:25 AM, with Resident #74 he stated he had a .broke hip . from a fall. Observation showed the resident's bed was elevated and his call light was not within reach. An observation of Resident 74's room on 9/11/2023 at 1:14 PM, revealed the resident had a contour mattress on his bed. Continued observation showed the resident was in his wheelchair in the day room. During an interview on 9/12/2023 at 1:45 PM, Licensed Practical Nurse (LPN) #5 stated, .[Resident #74's Name] .yes he's a fall risk . She stated interventions in place to prevent falls included, .bed in low position .call light in reach .reminders .frequent checks . LPN #5 stated, .I do remember seeing him in the floor[unknown date for the first fall] but honestly don't remember who found him .he had a skin tear to his back . She stated no one had asked her any more details related to the [first] fall than what she put on the post fall evaluation and the fall investigation. She stated, .therapy will assess .possible for anti-rollbacks my immediate action was getting him out of the floor .we have a fall packet we do . During a telephone interview on 9/12/2023 at 6:11 PM, LPN #10 stated, . The fall interventions in place for Resident #74 were .just making sure his call light was in reach, make sure he's changed and didn't get up to go to the bathroom and stuff, making sure his urinal was in reach, and keeping a check on him .we don't know when he fell . She stated she had never assessed the resident after the fall [unknown date 8/1/2023 or 8/2/2023 Resident #74's second fall]. She stated, .when therapy went to get him .and he complained about hip pain, and they noticed bruises . During an interview on 9/13/2023 at 1:36 PM, LPN #12 stated Resident #74 had been assessed as a high risk for falls on admission to the facility and did not have individualized fall prevention interventions developed. During an interview on 9/13/2023 at 3:27 PM, the Administrator stated falls are addressed by the IDT [interdisciplinary] team. The Administrator stated, .So I have a morning stand up .clinical stand up .currently [LPN #12] .to ensure that the incident is completed appropriately, the investigation is completed thoroughly, and an appropriate plan of care is implemented . During an interview on 9/14/2023 at 11:38 AM, the Administrator confirmed, .fall interventions should be person centered . During an interview on 9/15/2023 at 2:35 PM, the DON [Director of Nurses] confirmed the new care plan intervention of a contour mattress was added to Resident #74's bed, to prevent a fall from the bed, after a second fall was reported on 8/2/2023. The DON confirmed this intervention was not an appropriate intervention since the resident reported he fell in the bathroom. Resident #253 was admitted to the facility on [DATE], with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, Myocardial Infarction, Difficulty Walking. Review of Resident #253's baseline care plan dated 3/30/2023, showed, .History of falls .Orient to room/call light .most used items within reach .Bed low position .Visual checks every 2 hours and as needed x 72 hours . Review of Resident #253's admission MDS assessment dated [DATE], showed the resident had a BIMS score of 15, indicating the resident was cognitively intact. The resident required extensive assistance of 2 staff for bed mobility and toilet use. Resident #253 was dependent on 2 staff for transfers. Resident #253 required extensive assistance of 1 staff for locomotion on unit, personal hygiene, and dressing. The resident had no falls. Review of Resident #253's comprehensive care plan dated 4/17/2023 showed, .Self-Care Deficit related to .assist X (2) team member/members for bed mobility and repositioning .The resident is at risk for falls r/t Gait/balance, Incontinence, Hemiplegia .Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response for assistance . Review of Resident #253's Post Fall Review dated 7/10/2023, showed, .Date and time of fall .7/10/2023 .2:40 .Resident rolled out of bed .Prior to fall .In bed .History of falls .Impaired safety awareness/judgement .Resident has confusion .Resident has laceration to left side of head/forehead. Complaints of left shoulder and back pain .Not witnessed . Review of the facility's fall investigation dated 7/10/2023, showed, .heard resident yell out for help .Went into resident's room where she was lying in the floor beside the bed on her left arm .Resident unable to give description .Left side of head was bleeding and she was complaining of shoulder and back pain . Vitals taken WNL [within normal limits] .Contacted [Ambulance] to take to ER .Injury Type .Laceration .face . Review of Resident #253's hospital Discharge summary dated [DATE], showed, .Fall from bed .Forehead laceration .Repaired in ER .Left femoral IT [Intertrochanteric] fracture. S/P [status post] . repair .Advanced Dementia .discharge home with home health . During a telephone interview on 8/29/2023 at 8:15 PM, Certified Nurse Assistant (CNA) #7 stated .she [Resident #253] was confused but she kinda knew too she would call me [NAME] [not the CNA's name] . CNA #7 stated the resident did sometimes try to get out of bed without assistance. CNA #7 stated the interventions used to prevent falls for Resident #253 were .we would lower the bed .and call light within reach . She confirmed Resident #253 was at risk for falls. During an interview on 8/31/2023 at 3:02 PM, LPN #12, also the facility's falls nurse stated the interventions used to prevent fall for Resident #253 were, .call light within reach .encourage resident to use for assistance .prompt response to all requests .educate resident family caregivers .encourage to participate in activity that promote .improve mobility .ensure she is wearing appropriate footwear when ambulating or mobilizing in wheelchair .LPN #12 confirmed the resident had no individualized interventions to address her frequent attempts to get up without assist. LPN #12 confirmed resident #253 sustained a fracture from her fall on 7/10/2023. During an interview with the Administrator 9/14/2023 11:38 AM, the Administrator confirmed Resident #253 did not have individualized interventions developed to prevent falls and had sustained harm when she fell on 7/10/2023 and sustained a left femur fracture. Resident #149 was admitted to the facility on [DATE] and discharged on 5/17/2023 with diagnoses including Unspecified Fracture of Right Femur, Unspecified Dementia, Adult Failure to Thrive, Alzheimer's Disease, Unspecified Hearing Loss, Insomnia, and Unsteadiness on Feet. Review of Resident #149's daily skilled Note dated 5/1/2023, .Alert .Disoriented .Decision Making Skills .Severely impaired .Bed mobility .Total Dependence .Transfer .Total Dependence . Review of Resident #149's baseline care plan dated 5/2/2023, showed .FALLS .History of falls .Interventions .bed in lowest position, personal items in reach, call light in hand . Review of Resident #149's comprehensive care plan dated 5/2/2023, showed .I have a physical deficit with transfers .Hoyer Total Lift Large (Green) Sling .Transfer/Slide Sheet for moving in bed .Self-Care Deficit related to: decreased functional abilities, impaired cognition/dementia, femur fracture, pain, weakness .Extensive assist x [times] 2 team member/members for bed mobility and repositioning . Further review showed no documentation a care plan had been developed to address Resident #149's risk for falls. Review of Resident #149's admission MDS dated [DATE], showed the resident had severely impaired cognitive status. The resident had no behaviors and required extensive assistance of 2 staff members for bed mobility, transfers, dressing, and toileting. Resident #149 had falls in the past month and the past 2-6 months prior to admission. Review showed the resident had a fall with fracture prior to admission to the facility. Resident #149 had no falls since admission to the facility. Review showed no documentation a comprehensive care plan had been developed to address Resident #149's risk for falls. Review of Resident #149's nurses progress note dated 5/9/2023, showed .Resident sitting on her wheelchair peddles [pedals] .Resident finished dinner and attempted to take herself to the bathroom .no injury noted no redness noted . Review of Resident #149's Post Fall Review dated 5/9/2023, showed .6:30 PM . Immediate actions .Assisted resident off of her wheelchair peddles [pedals] and back into her wheelchair. Educated Resident to use call light . Review showed no documentation a comprehensive care plan had been developed to address Resident #149's risk for falls after the fall on 5/9/2023. Review of Resident #149's nurses progress note dated 5/17/2023, showed .After assessing [Resident #149] it was found that she had a laceration to the back of her head, she was bleeding a lot, a cold cloth was held to the back of her head with pressure to help stop the bleeding .orders received to send [Resident #149] to .ER [Emergency Room] . Review of Resident #149's Post Fall Review dated 5/17/2023, showed, .20:10 [8:10 PM] .Activity at time of fall .Walking in room .Prior to fall, patient was .In bed .Patient's explanation of how they fell .Pt unable to reply .History of falls .Not witnessed .Immediate actions . Review showed there were no immediate actions documented. Review of Resident #149's emergency room Documentation dated 5/17/2023, showed .unwitnessed fall with bleeding from back of head . Impression .Acute extra-axial hemorrhage right temporal region .concerning for epidural hematoma . Review of Resident #149's emergency room Documentation dated 5/18/2023, showed .Discussed the situation here with the patient's [family members] .They report the patient has advanced age with dementia they do not want surgery .Assessment/Plan .Traumatic epidural hematoma . Review of Resident #149's hospital Palliative Care Consult Note, dated 5/18/2023, showed .96-yo [year old] female with Alzheimer's dementia and cerebrovascular disease, also right femur fracture in April 2023 treated conservatively without surgery .She was transferred 5/18/2023 after fall from standing with epidural hematoma .Per neurosurgical evaluation family declined operative intervention .Problem List .R [Right] Epidural hematoma .Extra-axial intracranial hemorrhage . Review of Resident #149's Hospital Discharge summary, dated [DATE], showed .Ultimately, patient elected to go comfort care with the help of her family. She was discharged home with hospice on 5/22 [5/22/2023] . During an interview on 8/23/2023 at 3:07 PM, LPN #12 stated .I oversee the falls .making sure that they complete their fall reports .making sure we update care plans and all that stuff . She stated .5/9/2023 .that was her [Resident #149's] first fall so she should have had just the basic general interventions making sure her positioning is good making sure she wasn't in pain or anything that would cause her to want to get up . The LPN stated .generally the care plan gets started on admission and things go over to the Kardex to let the CNAs know pretty much anything they need to know about this person . LPN #12 confirmed Resident #149's fall risk care plan was not developed until 5/17/2023, 8 days after the fall on 5/9/2023. The LPN confirmed the 5/9/2023 fall was from her wheelchair and the intervention listed on the post fall evaluation was .ensure the resident's call light is in reach and encourage the resident to use for assistance as needed the resident needs prompt response . The LPN confirmed the post fall evaluations were not added to the care plan. She stated when a resident falls .we review them in morning meeting, and we talk about them and that's when we put our heads together and come up with an intervention .now that we have an MDS they update the care plan . LPN #12 confirmed after Resident #149's fall on 5/9/2023, the intervention listed on the post fall evaluation to encourage the use of the call light was not appropriate. During an interview on 9/5/2023 at 3:13 PM, LPN #11 stated when a resident has a fall the new intervention would be added to the care plan by LPN #12. During a telephone interview on 9/14/2023 at 9:28 AM, the NP stated it was her expectation for the facility to develop a fall risk care plan for residents who are at high risk. NP stated encouraging Resident #149 to use her call light would not have been an effective intervention if resident had severe cognitive impairment. The NP confirmed when Resident #149 fell on 5/17/2023 and sustained an epidural hematoma she had sustained harm from the fall .yes that is harm . During an interview on 9/14/2023 11:38 AM, the Administrator stated .I attend the IDT meetings where we review falls and discuss interventions . He stated if a resident is at risk for falls it was his expectation for the facility to .develop a care plan intervention and implement it .so we should take account of any hospital records and family or acquaintance interviews as well as our own fall assessment .yeah I do [expect person centered interventions to be developed] . The Administrator confirmed the intervention to encourage use of the call light for Resident #149 was not appropriate. The Administrator confirmed if the facility had completed a thorough investigation of the fall on 5/9/2023 and implemented appropriate interventions the fall on 5/17/2023 could have been prevented. The Administrator confirmed the resident had sustained harm when she fell on 5/17/2023 and sustained an epidural hematoma. Resident #89 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart and Chronic Kidney Disease, Osteoarthritis, Acute Kidney Failure, Anxiety Disorder, Muscle Weakness, and Cognitive Communication Deficit. Medical record review of Resident #89's admission MDS dated [DATE], showed she had a BIMS score of 99, indicating the resident could not complete the interview. She required limited assistance of 1 staff member for bed mobility, transfers, walking in room, and personal hygiene. She required extensive assistance of 1 staff member for toilet use. Review of Resident #89's care plan dated 7/24/2023, showed . at risk for falls/injury r/t [related to] weakness, poor standing/transfer balance, cognitive deficits. Needs redirection at times for safety. Hx [history] of fall at home prior to admission .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Medical record review of Resident #89's nurse's progress note dated 8/2/2023, showed .Resident was sitting in shower chair while CNC [CNA] was opening door and she leaned forward, and her chair slid out from under her as she landed on her bottom . No injury noted. Medical record review of Resident #89's Post fall review dated 8/2/2023, showed .Date and time of fall .08/02/2023 10:45 [10:45 AM] .to/from shower .Patient's explanation .unable to communicate what happened .Witnessed .Immediate actions .She has been reminded again .her habit of leaning forward in her chair . Medical record review of Resident #89's care plan dated 8/2/2023, showed .[Resident #89] has had an actual fall .Fall 8/2/2023: encourage [Resident #89] to avoid leaning forward when in shower chair . Review of Resident #89's facility investigation dated 8/6/2023, showed .Resident found sitting on floor next to chair .said she was driving a car .Injury Type .Hematoma .Other info .more confusion with dementia. Unable to comprehend instructions with numerous reminders to sit back in chair and call for help . Medical record review of Resident #89's Post Fall review dated 8/6/2023, showed .07:45 [7:45 AM] .chair to floor .Patient's explanation .Sitting in chair and leaning forward as she does ths [this] frequently .Not witnessed .Immediate actions .Assist back to chair. Assessment completed with VSS, and neuro checks completed. Sent to ER for knot on forehead from apparent fall . Medical record review of Resident #89's ER documentation dated 8/6/2023, showed .This morning she was found on the floor and thought she was driving a car. Patient has severe dementia and cannot provide any history .CT scan [x-ray] showed a forehead contusion but no other traumatic finding .Currently do not see indication that she needs hospitalization Medical record review of Resident #89's care plan showed an update for 8/6/2023, .Fall 8/6/2023: Neuro-checks completed. Sent to ER for evaluation of hematoma. Returned from ER with no new orders. Staff to interview patient to further investigate reasoning for leaning forward and communicate with therapy Medical record review of Resident #89's IDT [interdisciplinary team] meeting note dated 8/7/2023, showed .fall 8/6 [8/6/2023] nursing to interview resident on forward leaning posture, perform pain assessment, will communicate findings with therapy . Medical record review of Resident #89's nurse's progress note dated 8/7/2023, showed .Spoke with resident about how she leans forward when she sits and ask her if she was experiencing any back pain. Resident reports that back pain was what got her in the habit of leaning forward while sitting but she does not have pain anymore. Encouraged her to practice sitting back in chair to prevent further falls. Resident agreed. No S&S of pain observed while talking with resident . Medical record review of Resident #89's care plan showed an update on 8/17/2023, for .[Resident #23] has had an actual fall .fall 8/17/2023: Therapy to evaluate for positioning while sitting . Review of Resident #89's facility fall investigation dated 8/17/2023, showed the resident stated .I got to pee . Resident assisted to the toilet and back to her chair safely. Reminded to use her call light for any help . Medical record review of Resident #89's Post Fall Review dated 8/17/2023, showed .Date and time of fall .08/17/2023 .chair to floor .bedroom .sitting in wheelchair in her bedroom .Resident prefers to bend over while sitting. She has muscle weakness and with confusions episodes requires frequent redirections .no apparent injury .not witnessed .Assessed for injury, no injury was noted and reported. Resident then assisted back to her wheelchair. Vitals signs and neuro checks obtained . Medical record review of Resident #89's OT [occupational therapy] progress note dated 8/17/2023, showed .Pt found in floor by OTR and CNA today .OTR educates pt to ensure she alerts staff prior to getting up. Pt with impaired safety awareness, increased confusion and has tendency to attempt to get up on her own. OTR and nursing discuss patient's need for increased supervision and checks with possible need for toileting schedule. No injuries sustained with fall . Medical record review of Resident #89's IDT meeting note dated 8/18/2023, showed .Actual fall 8/17/2023. Therapist to evaluate for seated positioning due to patient forward lean while in seated position . Review of Resident #89's facility fall investigation dated 8/19/2023, showed .Began Am med pass and resident was noted on floor in front of her chair. She was sitting up waiting on breakfast. She is noted for leaning forward while sitting as far as her head can go and at times between her knees. She is reminded consistently to sit up as staff passes her room. All staff aware of hx of falls and have been instructed to due [do] random room checks when passing by or just in the area .Immediate actions taken .VS taken and neuro checks performed, WNL. Incontinent of bowel and bladder. Assisted BTB [back to bed] .xferred [transferred] via ambulance to ER . Medical record review of Resident #89's ER [emergency room] documentation dated 8/19/2023, showed .Unwitnessed fall with L [left] hematoma from fall this am while eating breakfast .Allegedly, she had fallen from her wheelchair. The patient tells me that she has some mild-to-moderate pain in her mid and low back. She is normally non-ambulatory and wheelchair-bound .DISPOSITION .Discharge .no evidence of traumatic injury .Pt coming from [name of facility] for recent falls. [name of facility] stated patient has dementia, old hematoma on R side of face, new hematoma on L side of face. [unable to determine how many times the resident fell] . During an interview on 8/29/2023 at 1:07 PM, LPN #9 stated Resident #89 .she has a bad tendency to lean forward, you have to constantly remind her to sit up . LPN #9 confirmed the reminders are not effective due to the resident had a diagnosis of dementia. During an interview and observation with CNA #1 on 8/31/2023 at 10:22 AM, CNA #1 stated Resident #89 was not at risk for falls .no I don't think so .not that I know of, but I don't think so . Continued interview and review of the resident's Kardex [resident care information] showed the resident had a fall on 8/2/2023 and was to be encouraged to avoid leaning forward in shower chair. Further interview and observation of Resident #89 at 10:43 AM, showed the residents seated in w/c leaned all the way over on her knees asleep. Continued interview/observation showed CNA #1 confirmed Kardex/interventions only mentioned to encourage to not lean in shower chair and not for wheelchair. During an interview on 8/31/2023 at 3:02 PM, LPN #12 confirmed Resident #89 was at high risk for falls upon admission. She stated the interventions that were put in place were .call light [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to revise a comprehensive care plan timely for 3 residents (Resident #202, #61, and #16) of 28 care plans reviewed. The facility failed to revise interventions to the care plan timely for Resident #202 after the resident's family brought cigarettes and lit them, which led to 3 residents smoking unsupervised on 11/28/2023. Resident #61's care plan was not updated timely after the resident was discovered smoking unsupervised on 11/28/2022. Additionally Resident #16's care plan was not revised timely when he obtained cigarettes from a family, smoked cigarette unsupervised on 11/28/2022, attempted to bring cigarettes into the building on 4/19/2023, and tried to burn a staff member on 4/20/2023 with a lit cigarette. The facility's noncompliance placed Resident #202, #61, and #16 in Immediate Jeopardy. (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Clinical Operations were notified of the Immediate Jeopardy for F657 on 9/18/2023 at 6:10 PM, in the conference room. The facility was cited Immediate Jeopardy at F657 (J). The Immediate Jeopardy began 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated on-site by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled Comprehensive Care Plan dated 5/1/2012, showed .The interdisciplinary care plan is implemented to guide health center care staff in the provision of necessary care and services to obtain and maintain the highest practicable physical, mental, and psychosocial well-being of the resident .Interdisciplinary team develops resident focused goals . Review of the facility policy titled Care Plans dated 10/2021, showed .Care plans will be developed for all patients and residents based upon the RAI [Resident Assessment Instrument- instructions to complete the Minimum Data Set (MDS) assessments] manual guidelines .Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change . Review revealed Resident #202 was admitted to the facility on [DATE] and discharged on 3/8/2023, with diagnoses including Chronic Obstructive Pulmonary Disease, Patient's Noncompliance with other Medical Treatment and Regimen, Acute and Chronic Respiratory Failure with Hypoxia, and Schizoaffective Disorder Bipolar Type. Review of Resident #202's care plan dated 4/21/2022, revealed the resident was at risk for smoking related injury related to smoking independently. Review of the care plan revealed, .Complete smoking safety assessment per Center guideline .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Review smoking guideline with patient and or family .Storage of smoking material per Center guideline . Continued review revealed the resident's care plan was not revised timely after the smoking incident on 11/28/2022. Resident #202 was discharged from the facility on 3/8/2023 and the resident's care plan was not revised timely. (Revised 3/22/2023, 14 days after the resident was discharged from the facility). Review of Resident #202's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status Score of 15 which revealed the resident was cognitively intact. Review of Resident #202's Activities note dated 11/28/2022 revealed, .This AD [Activity Director] saw this resident out in the courtyard with two other residents[Resident #61 and Resident #16] smoking .I explained to them that it was not the designated smoking time and they couldn't be smoking unsupervised .This resident said she understood .I then went inside and reported it to the nurse on [the name of the hall] and the ADON [Assistant Director of Nursing] . Resident #61 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder Bipolar Type, Anxiety, and Acute Chronic Diastolic Heart Failure. Review of Resident #61's Care plan dated 7/8/2021, revealed the resident was care planned for smoking related injury related to smoking independently. Review of interventions revealed, .Provide smoking apron while smoking if needed, she is safe to smoke without one but can request one if needed .Assist to and from Designated Smoking Area .Assure smoking material is extinguished prior to patient leaving smoking area .Complete smoking assessment per Center policy Assessment .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Place patient in position to assure visualization of ashtray .Review smoking policy with patient and or family .Storage of smoking materials per Center policy . Continued review revealed Resident #61's care plan was not revised timely after the smoking incident on 11/28/2022. The resident's care plan was not revised timely (Revised 9/4/2023, 280 days after the smoking incident on 11/28/2022). Review of Resident #61's quarterly MDS dated [DATE], revealed the resident had a BIMS of 9 which indicated the resident was moderately cognitively impaired. Review of Resident #61's Activities note dated 11/28/2022 revealed, .This AD saw this resident out in the courtyard with two other residents smoking .I explained to them [Resident #61, #202 and #16] that it was not the designated smoking time and they couldn't be smoking unsupervised .I asked her [Resident #61] to put the cigarette out and she did so .This resident said she understood .I then went inside and reported it to the nurse on [name of hall] and the ADON . Review revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Acute on Chronic Diastolic Heart Failure, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Peripheral Vascular Disease, Major Depression Disorder, and Chronic Kidney Disease. Review of Resident #16's Care plan with a date initiated 2/20/2020, revealed the resident was care planned for at risk for smoking related injury related to being a smoker. Review of interventions in place revealed, .Assure smoking material is extinguished prior to patient leaving smoking .Complete smoking assessment per Center policy .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources .Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Review smoking policy with patient and or family .Storage of smoking materials per Center policy . Review revealed Resident #16's care plan was not revised timely following the smoking incidents on 11/28/2022, 4/19/2023, and 4/20/2023 (18 days after the smoking incident on 11/28/2022, 82-83 days after the incident on 4/19/2023 and 83 days after the incident on 4/20/2023). Review of Resident #16's Activities note dated 11/28/2022 revealed, .This AD saw this resident out in the courtyard with two other residents [Residents #202 and Resident #61] smoking a cigarette unsupervised and not at designated smoking times .I went outside explained to this resident that is was not time to smoke [that it was not the time to smoke] and told him to put thecigarette [the cigarette] out .He then told me to leave him the [explicit] alone and go back inside .I told him I would when the [he] put the cigarette out he then threw it in the flower pot still lit .I put the cigarette out while he was telling me to leave it alone .I then went inside and reported it to the nurse on [name of the hall] and the ADON . Review of Resident #16's quarterly MDS dated [DATE], revealed the resident had a BIMS of 15 which indicated the resident was cognitively intact. Review of Resident #16's quarterly MDS dated [DATE] revealed the resident had a BIMS of 15 which indicated the resident was cognitively intact. Review of Resident #16's Activities note dated 4/19/2023 revealed, .[Name of Resident #16] .was seen by multiple other residents put a cigarette in his shirt pocket .He then went into the facility .[Name of medical records personnel] was smoking the residents at this time and informed me of him having the cigarette .I stoppedhim [stopped him] in the front hall I could visibly see the cigarette .I said to him that he could not have the cigarette .that he needed to give it to me .He said it was broken and he was going tofix [to fix] it .He said I don't have a lighter I have a broken cigarette .He continued to argue about not giving to me but did eventually hand me the cigarette .The cigarette was not broken I took the cigarette out to the box realizing that it wasn't one of [Resident #16's] own cigarettes .The other smokers said that another female smoker gave him the cigarette . Review of Resident #16's Activities note with an effective date of 4/20/2023 revealed, .I was doing the 10am [10:00 AM] smoke time on 4/20/23 [2023] . [Name of Resident #16] came out he is currently out of cigarettes he went to another resident and tried to get her to give him her cigarette I stopped her [name of resident unknown] and explained to them that they cannot share cigarettes he told me I needed to go mind my own business .He then rolled over [in his wheelchair] near the bench .I then went to let some other residents back into the facility .When another Male resident rolled by him and handed off a half smoked cigarette [another resident gave Resident #16 his lit cigarette he had smoked] .I immediately went over and held my hand out and told him to give me the cigarette he then attempted to burn me with the cigarette .I told him not to burn me .I explained again why they aren't suppose to share cigarettes and told him again to give me the cigarette he hit it again [smoked the cigarette again] and then handed it to me . During an interview on 9/13/2023 at 12:43 PM, the AD stated she was walking by the courtyard window in the hall near the dining room area on 11/28/2022 and entered the courtyard and observed Resident #61 in the courtyard with 2 other residents smoking a cigarette. The AD stated she asked all 3 residents how they had lit their cigarette. The AD stated, .They [Resident #202, #61, and #16] gave me a non answer they said they just did [in answering how they were able to light their cigarettes] .They put cigarettes out in ashtray .I reported it to Nurse [the AD could not recall the nurse's name] on [name of hall] .She told me to make a note in each chart .I made a note in all residents' chart .That was the first time I caught residents [Residents #202, #61, and #16 smoking unsupervised] . During an interview on 9/13/2023 at 3:19 PM, LPN #1 revealed she was Resident #61's nurse. The LPN stated, .Care plan used to guide the resident's care .We update the care plan so we can give the correct care to residents .Care plans should updated with a change in the resident . During an interview on 9/13/2023 at 4:33 PM, Housekeeper #2 stated, . Residents still finding ways to sneak in cigarettes out to the courtyard .Since been here .an ongoing issue [residents obtaining cigarettes] .I randomly see them resident smoking .Issues smoking half cigarettes .unsupervised like [Resident #16] he has been caught multiple times [smoking unsupervised] .I told nurse can't remember nurse .I caught [Resident #16] smoking unsupervised early June 2023 .He had a half cigarette in his hand in the morning . During an interview on 9/14/2023 at 8:22 AM, the Administrator stated, .We treat the incidents of smoking unsupervised or violation of smoking, resident holding on to cigarettes not disposed in trashcan .We write in the progress notes .He [Resident #16] was discussed in 9/2023 he had cigarette in his possession .Problems related to smoking typically discussed with the interdisciplinary team [IDT] team. The Administrator stated [Resident #16] was discussed in morning meeting [morning stand up meeting] and [with] IDT .Discussed with care plan updates . During an interview on 9/14/2023 at 9:02 AM, and review of Resident #16, #61, and #202s care plan, LPN #12 stated, .There are occasions when residents caught smoking unsupervised on both shifts . The LPN confirmed Resident #16's care plan related to smoking was not revised timely following the incident on 11/28/2022 (Resident #16's care plan was not revised until 12/16/2022 18 days following the unsupervised smoking incident on 11/28/2022). The LPN confirmed Resident #16's care plan was not revised timely following the incidents on 4/19/2023 and 4/20/2023 (82-83 days following the incident on 4/19/2023 and 4/20/2023). The LPN confirmed Resident #61's care plan related to smoking dated 7/8/2021was not revised timely following the incident of Resident #61 smoking unsupervised on 11/28/2022 to include interventions of observing the patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources, patient to not have cigarettes or smoking material on person, and assure smoking material is extinguished prior to the patient leaving the smoking area. The LPN stated Resident #202's care plan was not revised timely on 3/22/2023 (Resident #202 was discharged on 3/8/2023 the resident's care plan was revised 14 days after the resident was discharged ). The LPN stated .All 3 residents [Residents #16, #61, and #202] involved in 11/28/2022 smoking incident care plans were updated related to smoking but revised late . During an interview on 9/15/2023 at 3:16 PM, the DON confirmed Resident #202, #61 and 16's care plan was not revised timely following the incident on 11/28/2022, when Residents #202, #61 and #16 were out smoking unsupervised. The DON stated, . [Resident #61's] care plan should have been updated to prevent reoccurrence of any concerns related to smoking and to inform staff what occurred .They [Resident #202's family] her family gave the cigarettes to [Resident #202] and she passed them out to the other to residents [Residents #16 and #61] . The DON stated she did not know how the resident's cigarettes were lit on 11/28/2022 and their safety was at risk due to not being supervised by the facility. The DON stated, . They could have caught on fire or got burn .It should been updated [care plan] sooner following the incident on 11/28/2022 .[Resident #16] care plan should have update with review of smoking policy and education, and interventions added related to incident on 11/28/2022 sooner not timely done .The care plan should have been updated from incident 4/19/2023 .[ Resident #16] got a cigarette already lit from another resident who was smoking and attempted to burn the AD . The DON confirmed Resident #202, Resident #61 and Resident #16 care plans should have been revised with interventions after each incident to prevent reoccurrence. The DON confirmed not updating or revising Residents #16, #61, and #202 care plan related to smoking placed the residents at risk for harm or injury. During an interview on 9/18/2023 at 8:54 AM, the Medical Director (MD) stated, .Care plan should cover all ADLs [activities of daily living] if smoking we should recognize and think forward on what needs to be done .think ahead how to prevent burn and fire and should be put in care plan . The MD confirmed residents smoking unsupervised care plans should be revised timely by the facility. The MD stated, . [Resident #16's] care plan should be updated [revised timely] .If someone [Resident #16] being aggressive like that [attempting to burn staff] .The care plan should have been updated [revised] to reflect [the] incident of him [Resident #16] trying to bring in[a] cigarette from outside in courtyard[Resident #16 brought a cigarette from the designated smoking area into the facility on 4/19/2023]. The MD stated care plans guide the residents care and informs staff how to provide care to the resident. The MD confirmed the facility failed to revise Resident #16, #61, and #202 care plan timely placed the residents at risk for harm following the incident of residents smoking unsupervised. Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 9/22/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. Review of the facility's in-services and sign in sheets, documentation and interviews showed the Discharge Care Coordinator, MDS Nurse, and Unit Managers were in-service on 9/19/2023 on development of individualized care plans and discharge care plans and updating the care plans timely. 2. Review of the facility's in-services and sign in sheets and documentation showed all nursing staff working on 9/19/2023 and 9/20/2023 had been provided the education on individualized and update resident care plans to include change in resident smoking status and noncompliance with the smoking policy as well as education on resident centered interventions implementation. 3. Interviews with the Certified Nursing Assistants (CNA)'s assigned to monitor smoking residents revealed they were aware they were to observe for the resident's ability to smoke safely and review of the current care plan. They were educated and aware if a resident exhibited unsafe smoking practices, they were to stop the resident from smoking and ensure the residents safety. The CNA's were to notify a Licensed Nurse to ensure the resident was reevaluated. 4. Interviews with Nursing staff revealed they were educated to evaluate a resident who exhibited non safe smoking practices and was educated to update the residents care plan with interventions to ensure the safety of the resident and other residents in the facility. 5. Medical record review of resident #16, and 61's care plan revealed their care plans were revised. Review revealed residents had an admission and quarterly smoking assessments were completed and documented. Smoking residents had documented changes related to their safety. 6. Review of all 22 resident's smoking assessments and documentation revealed their care plans had been revised to reflect their noncompliance with the smoking policy and concerns related to smoking. Medical record review revealed Residents #61 and # 16's care plans had been revised related to their noncompliance to the smoking policy and need for supervision. 7. Interviews with various disciplines revealed they were educated if they observed any resident smoking unsupervised, at non designated smoking times, residents refusing to turn in any smoking paraphernalia they were to immediately to notify the Administrator and Director of Nursing. 8. Review of smoking care plan audit tools were utilized by the facility and care plans were updated regarding smoking policy violations by the residents. Noncompliance at F-657 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure a safe discharge for 2 residents (Resident #249 and Resident #250) of 5 residents reviewed for discharge. The facility's failure resulted in Resident #249, who was homeless, being discharged to an unknown friend's house who did not allow the resident to stay, Resident #249 then walked to another friend's house who drove him to a motel where Resident #249 resided for approximately 2 months at which time he was evicted from the motel and hitchhiked to another friend's house. Additionally, the facility's failure resulted in Resident #250 being home alone where she sat in a wheelchair for 4 days in urine and feces before she was provided incontinence care by a home health staff. Resident #250 was hospitalized 6 days from discharge with multiple Stage I and Stage II pressure ulcers on her buttocks and sacrum from prolonged exposure to urine and feces. This failure placed Resident #249 and Resident #250 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Clinical Operations was notified of the Immediate Jeopardy (IJ) on 9/18/2023 at 6:10 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F660. The facility was cited at F660 at a scope and severity of J. The Immediate Jeopardy began on 6/16/2023 and was removed on 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated onsite by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy Discharge Planning dated 5/1/2012, showed, .The Social worker or designee will be responsible for discussing discharge plans with each resident .admitted to this facility .Updates and changes in discharge plans can occur at any time, due to change of condition or resident changing plans. These changes will be documented in the general notes of the Electronic Medical record .Social Services responsibilities for assisting resident for discharge to home may include .setting up follow-up appointments, setting up home health, and assist in acquiring health related equipment, etc . Review of the facility policy Discharge Against Medical Advice dated 5/1/2012, showed, .To assure that the resident .understands their actions. Encourage the resident .to discuss their motivation for wanting to leave the facility. Every attempt to resolve their concerns should be made and this should be used only as a last resort. Inform the resident .of the possible complications of their discharge action .Document the discharge including any reasons given .Anytime someone discharges Against Medical Advice [AMA] and the facility believes this is an unsafe discharge, Adult Protective Services [APS] must be notified . Resident #249 was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder, Unspecified Dementia, Weakness, and Repeated Falls. The resident was discharged AMA on 6/16/2023. Review of Resident #249's nurse's progress note dated 12/29/2022, showed, .Patient arrived to facility via [by] ambulance at 4 pm [4:00 PM]. He is alert and oriented to self and place but not time . Review of Resident #249's comprehensive care plan dated 12/30/2022, showed, .I have a physical functioning deficit r/t [related to] cognitive decline . Review of Resident #249's comprehensive care plan showed an update on 1/6/2023, for, .I have a physical functioning deficit r/t cognitive decline, repeated falls with need for assistance with personal care and abnormalities of gait and mobility . Review of Resident #249's Nurse Practitioner (NP) note dated 3/31/2023, showed, .Nurse update. Stable. Pt seen in bed- sits up easily. Pt reports desire to go the hell home as soon as therapy is completed . Review of Resident #249's Psychiatric (Psych) NP noted dated 4/4/2023, showed, .Pt [Patient] on MD [Medical Doctor] Board r/t [increased] forgetfulness .highly attention seeking [with] no c/o [complaints of] sleep appetite .concerned [with] d/c [discharge] .Practitioner Orders .Vitamin E 400u [units] po [by mouth] qd [every day] r/t cognition, continue reality grounding . Review of Resident #249's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 9, indicating he had moderate cognitive impairment. Further review showed no active discharge planning had occurred for the resident. Review of Resident #249's comprehensive care plan showed an update on 4/10/2023, for, .The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia .cue reorient and supervise as needed . Further review showed no documentation of discharge planning. Review of Resident #249's NP note dated 5/29/2023, showed, .Nurse reports stable. [up] [with] walker, goes out on passes [with] family .Dementia .Forgetfulness . Review of Resident #249's Psych NP note dated 6/6/2023, showed, .forgetfulness concerned [with] d/c .Insight fair Judgement fair Impulse Control fair Orientation .memory Attn/conc [attention/concentration] poor .cognitive decline [with] multiple comorbidities . Review of Resident #249's involuntary discharge notice dated 6/6/2023, showed, .Place where resident is going .[homeless shelter] .Date Nursing Home Provided Notice and the Proposed Move .Nursing home gave the resident these pages on: 6/6/2023 .Nursing home wants to move resident on: 7/6/2023 .The resident can choose to move before the 30 days is up. This is up to the resident .Reason for discharge or transfer .You did not pay your bill from the nursing home. The nursing home already told you this and the nursing home gave you time to pay .You got better. And you do not need care in a nursing home now .You have an outstanding balance that you have not paid. You did not pass a [NAME] [Preadmission Evaluation], meaning you are not medically eligible for Medicaid to pay for long-term care in a skilled nursing facility for you. You do not require a nursing home level of care . Further review showed the Administrator, the Physician, and the resident all signed on 6/6/2023. Review of an email sent from the Ombudsman to the Administrator dated 6/6/2023, showed, .[the Administrator] I have reviewed the involuntary Discharge Notice tendered to [Resident #249]. In no uncertain terms may you consider discharging [Resident #249] to [homeless shelter]! It is not now nor will it ever be a safe discharge location . Review of an email sent from the Administrator to the Ombudsman dated 6/6/2023, showed, .We'll void the notice and continue to work with [Resident #249] as we have been for months until a different discharge location can be obtained . Review of Resident #249's Medication Administration Record dated 6/1/2023-6/16/2023, showed the resident had received medications including B-12 tablet for protein calorie malnutrition, Claritin tablet for allergic rhinitis, Folic Acid tablet for protein calorie malnutrition, Vitamin E tablet for cognition, and Amlodipine Besylate tablet for hypertension. Record review revealed Resident #249 signed a Release From Responsibility For Discharge Against Medical Advice on 6/16/2023 at 5:17 PM. Review revealed the form was also signed by the Administrator and the Director of Nursing (DON). Review of Resident #249's nurse's progress note dated 6/17/2023 (recorded 1 day after the AMA was signed by Resident #249) showed, .6/16/23 Resident returned from LOA [Leave of Absence] and stated he was leaving and would not be coming back to facility. Advised this was an AMA discharge and he would not have prescriptions or HH [Home Health] set up. Continued to say he was leaving and began to pack up belongings. All belongings were packed up by resident and he informed the Administrator he was going to stay with a friend. Resident denied any unmet needs and was advised to follow up with PCP [Primary Care Physician]. Requested transport and the facility provided transport [by the Administrator] to address given by resident . During an attempted telephone interview on 8/21/2023 at 10:55 AM, Resident #249 did not answer telephone and the sureyor was unable to leave message. During an interview on 8/21/2023 at 10:56 AM, Resident #249's Friend #2 stated, .I live in the apartments where he lives . She stated she did not know where he was. She stated Friends #3 and #4 would know more about him than she would. During an interview on 8/21/2023 at 12:16 PM, the DON stated, .he had what he called a wife but was not his wife at another facility .they lived together and got evicted because they would not stop smoking in the apartment . She confirmed it was Friend #1 and stated .I don't know what happened to her .we tried to find him placement but once your evicted from government housing it's very hard to get again . The DON stated Friend #3 was not the one he went home with .Friend #3 did not want to help .I think [the Administrator] was the last person to talk to [Resident #249] .it was late afternoon . During an interview on 8/21/2023 at 12:36 PM, the Administrator stated, .[Resident #249] had gone out on leave with [Friend #3] and he came back and told us that he was discharging and we explained that would be AMA and he didn't care and he started packing his stuff .he thought [Friend #3] would transport him . The Administrator stated the resident said he had a friend that was willing to take him in but Resident #249 did not know the friend's name. The Administrator stated, .[Resident #249] called them on the phone .I heard him talking to them, he was in the front office in the lobby .he went to his room to pack up his things and [Friend #3] left him .he was very frustrated and [Resident #249] called [Friend #5] .he said 'hey I'm gonna need somewhere to stay again' and then [Resident #249] said 'Ok' .he was gonna walk so I asked him not to do that .we could help him with transportation .he did not want an uber .so I took him he told me where to go he did not know the address but he knew the streets .I watched him [Resident #249] go to the door [of the residence where the Administrator and Resident #249 arrived] and his friend took him inside .it was a female . The Administrator stated the resident did not have a home to discharge to and stated, .the only address he gave me was the address to the friend [#249] when I dropped him off . During an interview on 8/21/2023 at 1:30 PM, the Social Service Director (SSD) stated, .we kinda provided him a motel I think .people would pick him up and take him home on the weekends .and he ended up leaving with some other female .we had spoken a couple of times about getting him a place and he was very adamant that he would only live in a house that he didn't want an apartment .it's very hard to find a rental house .those are basically the comments that he made to me . [Resident #249] mentioned if he could get a house that would be nice but he didn't want to live in an apartment . She stated she had worked at the facility since 5/1/2023 and stated she had still been in training at that time [a reference to when discharge for Resident #249 was being pursued] .I was learning a lot during that time .I was stepping in just kinda talking to people .I didn't actively search [for Resident #249 housing] and told him how to apply for section 8 if he wanted it .he had [Friend #1] and [Friend #3] .they would show up and pick him up and take him home for weekends and bring him back and drop him back off .just from my observation of him he probably practiced some unsafe choices .but he appeared capable of caring for himself .he did leave without medical advice but in my mind I wouldn't be concerned that he couldn't fend for himself or care for himself . During an interview on 8/21/2023 at 3:03 PM, Registered Nurse (RN) #1 stated Resident #249 was .forgetful very .his cognition varied from day to day .one day he'd be fine the next day he would not .he got around physically pretty good .he did go on outings with family sometimes . During an interview on 8/21/2023 at 3:08 PM, Licensed Practical Nurse (LPN) #1, stated Resident #249 was .he was very forgetful .he would ask several times a day which way to the courtyard .he would go .they would come get him and he would stay gone .I think he left AMA .he had family that would come in so they might have come in and basically took him. He had [Friend #1] and [Friend #3] that he was close with . During an interview on 8/21/2023 at 3:11 PM, LPN #2 stated Resident #249 was, .alert, confused, more forgetful than confused .physically he ambulated and went out and smoked .called [Friend #1] frequently .she was at a facility also . She stated he could care for himself .he went out some .and from what I understand he was looking for an apartment or whatever .[the Administrator] is the one that come and told me he was here to get stuff and was leaving AMA . During an interview on 8/22/2023 at 8:38 AM, the Administrator stated he had let the Ombudsman know in an email that the facility had voided the notice of discharge and would continue to help the resident find a discharge location. During a telephone interview on 8/22/2023 at 8:44 AM, the Ombudsman Assistant, stated Resident #249, .has a history of alcohol, and drug abuse . He stated his assistant had gone to the facility after their office had received the involuntary discharge notices and talked to the Administrator and the plans were for him to remain in the facility. He stated, .We were going to close the case because there were no discharge plans at the time. The facility told her [the Ombudsman's Assistant] he [Resident #249] had advanced dementia and there were no plans to discharge due to cognitive impairments. He probably wouldn't have been able to make heads or tails out of this involuntary discharge notice .we did not do any additional work on it . The Ombudsman stated he had not been informed by the facility that the resident had been taken to a friend's house and no contact information had been obtained from the friend. Further interview with the Ombudsman's assistant she stated, .There was no way he could care for himself .I had a 30 minute conversation with him and later that day he couldn't remember having a conversation with me .he was admitted to the nursing home because he could not care for himself .he stated the resident had been living with a friend [Friend #1] .the APS Coordinator was very familiar with this case and had worked on it intensively he and [Friend #1] were in the process of being evicted [from his previous home] when he was placed in the nursing home . During a telephone interview on 8/22/2023 at 10:09 AM, Resident #249's Friend #1 stated she had lived with Resident #249 prior to him entering the facility and she still talks to him, .yeah when his phones on, it ain't on right now .he's in motel .no I don't know the name of it . She stated she had not talked to the resident in a few days .I ain't been able to get ahold of him .it's been a few days ago [since she spoke to him] . She stated he had been residing in a motel, .since [name of facility] released him . She stated she did not know who took the resident to the motel, .I think a friend took him . She stated he was able to get his medicine and food. During a telephone interview on 8/22/2023 at 10:26 AM, Resident #249's Friend #4 stated, .I tried to call him yesterday and I didn't get no answer .the last time I heard from him he was in [another town] .I don't know if he's on the street or in jail or what .it rung [the phone] and nobody didn't answer . Friend #4 stated he and Friend #3 had been taking the resident out of the facility on passes .[Friend #3] took him back to [name of town where the facility is located] and went by the social security office to get the paperwork he needed to get in a low rental apartment .when she took him back [to the facility] and he threw a fit and didn't want to get out of the car and once he got out he said he was getting his stuff and leaving and that's when [Friend #3] left him .it was my understanding that the Administrator was gonna help him get an apartment .he called me a couple days later and he was in [another town] and that was the last I heard .he had just got out of the hospital [prior to being admitted to the facility] because he was in DTs [detox] from drinking vodka .I don't know if he's back on it or not .he was getting real forgetful .it's been probably a month since I heard from him A telephone interview was attempted on 8/22/2023 at 10:37 AM, Resident #249 did not answer. During an interview on 8/22/2023 at 1:06 PM, LPN #3 stated Resident #249 did have some confusion, .before he left .he would call and tell people to come get him and he was in the process of looking for a house or something .he was able to dial numbers .used the phone every day .called his [Friend #1] . She stated he had a paper with phone numbers written on it that he used to make phone calls. She stated, .I've never seen him cook but he's got sense to call an order something . During an interview on 8/22/2023 at 1:14 PM, LPN #4 stated Resident #249 .he could remember my name .he would say [LPN #4] bought me [Fast food] .he was ambulatory independent .he was pretty social .he had talked about not wanting to be here for a long time .he might have had some memory problems but he knew to feed himself and bathe himself .he also had friends who would come check up on him .[Friend #1] called 4 to 5 [NAME] a day .and had [Friend #3] that would check up on him . She stated, .he just needed a few reminders .he as able to voice whenever he wanted or needed something .he'd said stuff about he wanted to get out and get an apartment or get out and stay with a friend he was with it so it was hard for him to stay here . She stated she did not feel he could live alone, .no maybe assisted living at most . A telephone interview on 8/23/2023 at 12:01 PM, was attempted, Resident #249 did not answer. During a telephone interview on 8/23/2023 at 1:44 PM, Discharge Care Coordinator (DCC ) #1 stated she had worked at the facility .from march 13th 2023 to June 8th 2023 .I did know the patients name [Resident #249] .he was already on the long term side when I came in and I did the short term [resident discharges] .we didn't have a social worker the majority of the time I was there .there was the only person that did the discharge planning was [the DON] .she had multiple roles .we all were playing dual roles because we were constantly short staffed .she [DON] basically did discharges for us she was more versed .she had a little bit more experience .she kept that [discharge planning] going until we got the social worker in .and she [the Social Services Director] was new too .the best of my knowledge was I trained her a little bit but everybody was kinda new . She stated she had not been involved with Resident #249's discharge planning or discharge and had already quit working at the facility before the resident had discharged . During a telephone interview on 8/23/2023 at 1:52 PM, Psychiatric NP stated she had seen Resident #249, .April 4th 2023 .interviewed in w/c [wheelchair] attention seeking .on 6/6/2023 .forgetfulness .on vitamin for E for cognition .and I didn't titrate up to that .my report from the nurses was forgetfulness concerned with discharge but that was actually from the previous time I saw him on April 4th .was when I started the Vitamin E .continue reality grounding .I don't remember him .my purpose is to make sure they can maintain homeostasis [stability] in the facility . During a telephone interview on 8/29/2023 at 10:53 AM, Resident #249's Friend #4 stated, .he showed up at my door yesterday he hitchhiked from up past [name of a town] .he had made a sign and some girl picked him up and brought him down here .said he'd been sleeping in the woods .he had been staying in the motel [Friend #4 not sure how long Resident #249 was at the motel] .they was some lady that worked up there that was supposed to be getting him an apartment .all he had yesterday when he got here was his blue jeans and a shirt .he said he hadn't ate in 4 days .I gave him a shower and fixed him something to eat and now I don't know what to do .he's definitely got dementia and I don't think he can take care of himself . He stated he and Friend #3 could not let the resident stay at their home and needed references of someone who could help find Resident #249 a place to stay. During a telephone interview on 8/29/2023 at 1:58 PM, Resident #249 stated the facility had told him he could not stay there, .no they told me .my social security wouldn't give them none of my check because they said I wasn't sick enough .after that they told me I could leave at any time . He said he did not know if the facility had tried to help him find a place to live, .they didn't tell me about it but my friend here said that they did .my memory is not good . He stated he had stayed in the motel, .I don't know a few months I got a ride with a truck driver and he brought me here and a girl brought me the rest of the way .well I was gonna walk [from the facility] and the Administrator didn't want me to but one of his people drove me to a friend's house .[Friend #5] [Resident #249] stated he had only stayed at Friend #5's house for about an hour, .not even a day .I went to get a pack of cigarettes and all my stuff was sitting out on the porch . He stated he had not called and asked her if he could stay with her prior to the facility taking him to her house, .no she'd always been a friend I didn't figure she'd mind . He stated after he left Friend #5's house he had walked to another friend and stated, .my memory is not what it was .he had a machine shop about a mile [from Friend #5's house] .it was a friend of mine [who took him to the motel] . He was not sure of that friend's name, .they would feed us, well a friend did, they [the motel] didn't feed us . [Resident #249] stated he had stayed at the motel, .10 weeks or so and he had left the motel, .it's been 3 or 4 days ago .they wanted me to vacate immediately and this county sheriff stuck a 12 gauge in my chest and I'm a little old man with a walking stick and can't see good . [Resident #249] stated from the motel, .I got a ride to [another town] from this truck driver and this girl came and stopped and picked me up and brought me here .they're trying to find me an apartment [Friend #4] is . He stated his social security check, .its direct deposited to [bank] .I've got a card and all I have to do is take my bank card and buy anything with it .it's as good as money .since I've been through this where I can't remember anything they [the bank] give me this card . [Resident #249] stated when he left the facility, .well they told me they just brought me from the hospital and I wasn't a resident .I was just like a ghost in the wood box .when they [the facility] found that they couldn't get my social security and the social security office told them I wasn't sick enough and they didn't like that . he stated he had left the facility, .yes against physicians order APA [AMA] .I don't read and write very well .that girl read it to me . He stated he knew what the AMA meant, .yes that I was on my own they wanted me to leave but I have to sign that paper . He stated he had improved physically while at the facility .I got out of the wheelchair and I use a walking stick now . He stated he did willingly sign the AMA .they [the facility] wanted me to leave and I wanted to leave and I told them I'd sign anything .I've got a flip phone and I got it for $35 a month so I got the phone and unlimited everything for 100 dollars and it comes directly out of my check .it never runs out [of minutes] . He stated he had not been answering his phone in the past few days .it quit working and they [Friend #3 and #4] took the battery out and put it back in and its working . During a telephone interview on 8/30/2023 at 11:59 AM, the Motel Clerk stated the resident [Resident #249] had stayed at the motel .probably 2 months .he can come back anytime .there was a nonpayment of rent from Monday to Friday . She stated he had left the motel on Friday 8/25/2023. She stated she had called an officer to ask him to leave due to non-payment. During a telephone interview on 9/14/2023 at 9:28 AM, the NP stated, .in my note on 3/31 I didn't write anything about him being disoriented or anything he wanted to go the hell home .[homeless shelter] does good work, [homeless shelter] deals with homeless .I wish they [the facility] had talked to the friend but I assume he [the resident] had talked to the friend .that's too bad they [the facility] couldn't have taken him to the hotel . She confirmed the resident living in a motel and hitchhiking to a friend's house .wasn't a good environment . During an interview on 9/14/2023 at 11:38 AM, the Administrator stated, .[Resident #249] had a lot of friends and acquaintances he had a network of people .that he chose to go out on pass with . The Administrator confirmed the resident did not have a home and stated .to my knowledge he didn't have a home .I did not want him to walk .I wanted him to be safe and make sure there was someone there that could assist him .I did not speak with the person [where the Administered dropped him off] . The Administrator confirmed he had not spoken to the person and had not confirmed she was willing to let the resident live with her. He confirmed he did not hear the other persons side of the conversation when the resident made the phone call prior to the Administrator driving the resident to the house. He confirmed he did not know the name or address of the individual he left the resident with and stated .from the conversation I overheard it sounded like he had an agreement .he discharged AMA and I helped provide him transportation to a home . He confirmed he had not documented discussions he had with the resident. He confirmed he had not contacted APS to follow up with the resident to ensure he was in a safe environment .I did not . The Administrator confirmed the resident had not been discharged to a safe environment. During an interview on 9/14/2023 at 2:18 PM, the DON, .in the beginning when he [Resident #249] came I tried to figure out living situations .I tried to talk her[previous apartment manager] into taking him back and they wouldn't do it .looks like the only note I put on him was a discharge . DON stated .he told us he was going to stay with a friend . She confirmed she had not spoken to the friend prior to the facility taking the resident to her house and stated, .I did not speak with her .I did not call APS . Interview confirmed the facility did not follow up to check the status of the resident after discharge, .the follow up we could have done better . Resident #250 was admitted to the facility on [DATE], with diagnoses including Anxiety, Depression, Cerebral Infarction, Chronic Kidney Disease, Morbid Obesity, Difficulty in Walking, Weakness, and Unsteadiness on Feet. The resident was discharged home on 7/5/2023. Review of Resident #250's Baseline Care Plan dated 5/8/2023, showed, .Anticipated discharge date .[blank] .Anticipated Discharge Destination .Home . Review of Resident #250's comprehensive care plan dated 5/10/2023, showed, .I have a physical functioning deficit with transfer and require assistance of extensive .Transfer/Slide sheet for moving up in bed . Review of Resident #250's admission MDS assessment dated [DATE] , showed the cognitive status section had not been completed. She required extensive assistance or 2 staff members for bed mobility, she was totally dependent for transfers with 1 staff member assistance, she was dependent with 1 staff member assistance for locomotion on and off unit, she needed extensive assistance of 1 staff member for dressing, extensive assistance of 2 staff members for toilet use, and supervision of 1 staff member for personal hygiene. The resident required a wheelchair for mobility. Review of Resident #250's comprehensive care plan dated 5/16/2023, showed, .Self Care Deficit related to CVA [Cerebral Vascular Accident], decreased functional abilities .weakness, Cerebral infarct .Bilateral Halo [flexible bed assistant bar for limited mobility residents]rails to bed for increased bed mobility . Further review showed no discharge plan of care had been developed for the resident. Review of an insurance fax dated 7/3/2023, showed, .Date 7/3/2023 .Reviewer notes .100th day is 7/7 [7/7/2023]. I am assuming she will be transitioning to LTC [Long Term Care-remaining at the facility] .Next review Date .7/7/2023 . Review of Resident #250's Physical Therapy (PT) Discharge summary dated [DATE], showed, .DC [Discharge] Location .Patient discharged to reside in this LTC [Long Term Care] facility. (pt filed for an extended stay to continue with therapy since pt is still needing extensive assistance to get out of bed and transfer) .Prior living Description .She lives alone and has a few neighbors that help her with apartment cleaning and community errands .Prior equipment .Lift chair/recliner, hospital bed, Rollator, FWW [Front Wheeled Walker], manual chair, electric w/c bedside commode .D/C [discharge] Reason: discharged per Physician or Case Manager .Discharge Recommendations: recommend skilled therapy to continue when insurance coverage approves pt's request for an extension . Review of Resident #250's Occupational Therapy (OT) Discharge summary dated [DATE], showed, .Patient discharged to reside in this LTC facility. (Pt will remain here, awaiting additional insurance approval) .Patient will be discharging to facility (seeking additional approval to stay here) as she is not ready to discharge home (needing max [maximum] assist with LB [lower body] ADLs and significant assist with transfers (mod [moderate assistance] x [times] 1-2 [staff members]). Patient is making significant gains and would benefit from more skilled therapy services prior to when she eventually returns home. Pt is not safe to discharge home at this time even with appropriate DME [Durable Medical Equipment] available . Review of Resident #250's discharge MDS assessment dated [DATE], showed the resident had a BIMS score of 15, indicating she was cognitively intact. She had a planned discharge to the community. She required extensive assistance for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, personal hygiene, and was totally dependent for bathing. She was receiving scheduled pain medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, review of facility documentation, observation and interview, the facility's Administration failed to follow facility policy and procedures to ensure safe discharges for Residents #249 and #250; failed to provide adequate supervision for falls prevention, investigating, and implementing resident-centered interventions for 3 Residents (#149, #253, and #74); failed to provide effective leadership to address the elopement of 1 resident (#252); placing the Residents [#249, #250, #149, #253 and #74] in Immediate Jeopardy (IJ) , (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Also, the facility's Administration failed to follow facility policy and procedures to ensure a safe smoking environment for Residents #202, #61, #16, and #48) which placed the residents in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Clinical Operations was notified of the Immediate Jeopardy (IJ) on 9/18/2023 at 6:10 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F835. The facility was cited at F835 at a scope and severity of J. The Immediate Jeopardy was effective 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated onsite by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy Discharge Planning dated 5/1/2012, showed, .The Social worker or designee will be responsible for discussing discharge plans with each resident .Updates and changes in discharge plans can occur at any time .Social Services responsibilities for assisting resident for discharge to home may include .setting up follow-up appointments, setting up home health, and assist in acquiring health related equipment . Review of the facility policy Discharge Against Medical Advice dated 5/1/2012, showed, .To assure that the resident .understands their actions .Every attempt to resolve their concerns should be made and this should be used only as a last resort. Inform the resident .of the possible complications of their discharge action .Anytime someone discharges Against Medical Advice [AMA] and the facility believes this is an unsafe discharge, Adult Protective Services [APS] must be notified . Review of the facility policy Falls dated 2/2017, showed, .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls .when a risk factor for falls is identified a corresponding intervention addressing that risk factor is developed .the intervention is documented on the care plan and on the caregiver guide .The identified intervention is initiated .Post fall .The patient is physically assessed for injuries .A fall huddle is called to help in investigating circumstances around the fall .The post fall evaluation is completed to assist in developing interventions to prevent future falls .The fall event and intervention is recorded on .patient's care plan and caregiver guide .Implement intervention identified .IDT [Interdisciplinary Team] reviews post fall investigation and summaries the recommendations for interventions . Review of the facility policy Elopement dated 4/2017, showed, .When an elopement occurs .Document condition notifications and times of actions deployed . Review of the facility's policy, Safe Smoking, dated 11/1/2016, revealed .To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents .To assess the ability to smoke safely and determine any measures needed to protect residents from possible self-inflicted injury due to smoking .Any resident who identifies themselves as desiring to smoke .will be assessed for safety related to smoking .This assessment will be reviewed and updated with any change of condition .The results of the safety evaluation will drive the care plan interventions related to safe smoking .A resident may be re-evaluated for safety needs if there is an observed change in their ability to smoke safely .Tobacco materials (cigarettes/cigars .) themselves, in addition to fire igniting materials, may have increased control or be removed if smoking policy violations have occurred or as general safety policy for all residents .For the benefit of our non-smoking residents, smoking residents may only smoke in the designated Smoking Area at the center .Supervised smokers can only smoke with a staff member present in the smoking area .Various types of protective equipment are to be available in each center .Protective equipment may include fire blankets at each designated smoking area and smoking aprons for individuals assessed as requiring this safety equipment .Each designated smoking area is provided with ashtrays made of noncombustible material and safe design . Resident #249 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Dementia, Weakness, and Repeated Falls. The resident was discharged AMA on 6/16/2023. Review of Resident #249's Psych NP note dated 6/6/2023, showed .forgetfulness concerned [with] d/c .Insight fair Judgement fair Impulse Control fair Orientation .memory Attn/conc [attention/concentration] poor .cognitive decline [with] multiple complicities . During an interview on 8/21/2023 at 12:36 PM, the Administrator stated .[Resident #249] had gone out on leave with [Friend #3] and he came back and told us that he was discharging, and we explained that would be AMA and he didn't care, and he started packing his stuff . The Administrator stated the resident said he had a friend that was willing to take him in but he [Resident #249] did not know the friends name and stated it wasn't anyone listed in the resident's chart .he was gonna walk so I asked him not to do that .I was unable to get a taxi over here so I took [transported] him he told me where to go he did not know the address but he knew the streets .I watched him go to the door and his friend took him inside .it was a female . Interview continued, The Administrator referenced the discharge notice and resention by stating .we gave him the notice [involuntary discharge notice] but it had not run out [of days] yet .our Ombudsman informed me that was not an appropriate discharge destination so I rescinded that notice . The Administrator stated the resident did not have home to discharge to and had contacted the Ombudsman about the resident discharging to a homeless shelter. The Ombudsman voiced strong objection of the resident discharging to a homeless shelter. The resident ultimately resided in a hotel for 2 months and was evicted for non-payment. I don't know if he had a plan [discharge plan] .I had to give him a discharge notice and up until that point he had not given me any other address .typically we want to get things in order and notify the physician and he said I'm leaving and went to pack his stuff up . During an additional interview on 9/14/2023 at 11:38 AM, the Administrator confirmed the resident did not have a home .to my knowledge he [Resident #249] didn't have a home .he [Resident #250] discharged AMA and I helped provide him [Resident #249] transportation to a home . He [Resident #250] confirmed he had not documented discussions he had with the resident. He confirmed he had not contacted APS to follow up with the resident to ensure he was in a safe environment .I did not . The Administrator confirmed Resident #3 had not been discharged to a safe environment. During interview on 9/13/2023 at 3:10 PM, with the Administrator concerning the unsafe discharge of Resident #250, the Administrator stated the discharge didn't sound optimal. He offered the Social Services Director (SSD) failed to fax to the home health provider, didn't follow up with the home health services or Resident #250. The Administrator agreed the SSD lacked serious competency to provide a safe and orderly discharge. The Administrator confirmed the SSD needed additional training. Interview revealed the Administrator didn't want to speculate in reference to Resident #250's unsafe discharge that led to her remaining in the wheelchair she was placed in for 4 days, in her own urine and feces and readmitted to the hospital 6 days after discharge with several Decubitus ulcers. Review of the medical records for 3 residents (#249, #253, and #74) revealed Resident #2 did not have a falls care plan developed after her first fall and sustained a second fall with major injury in 2023. Resident #253 had increasing confusion and restlessness not addressed in her care planning and had a fall with major injury in 2023. Resident #74 sustained a fall in his bathroom at a timeframe still undetermined. Resident #74 stated his return to bed was done by 2 unidentified staff members and a mechanical lift. Resident #74 was not assessed by the staff for an undetermined amount of time, perhaps greater than 12-16 hours, due to the night nurse stating the fall did not happen on her shift. It [the fall/injury] was discovered by the therapy staff at 10:00 AM the following day. Resident #74 was sent to the hospital with major injuries diagnosed. Review of facility documents revealed the 3 resident falls, for Residents #149, #253, and #74 were not completely investigated so root cause analysis and contributing factors were not identified. During an interview on 9/13/2023 at 3:35 PM, with the Administrator, the fall for Resident #74 was reviewed. The Administrator revealed he had not interviewed Resident #74 after his fall in the facility on 8/1/2023 or 8/2/2023. Interview revealed he had not made any inquiries about what had actually occurred causing Resident #74 to sustain major injuries with a shattered Acetabulum (hipbone) and fracture pelvic bone. Continued interview revealed the Administrator was not aware Resident #74 was put back to bed from the floor by 2 unidentified staff members, with the help of a mechanical lift. Interview revealed the Administrator was unaware the resident was not assessed from the time of the fall until the rehab staff discovered his injury due to pain on movement and a large amount of bruising at 10:00 AM on 8/2/2023. The Administrator confirmed Resident #74 was left in an extremely unstable condition from the time of the fall until he was admitted to the hospital after 11:30 AM the 8/2/2023. During an interview on 9/14/2023 at 3:50 PM, the Administrator stated, falls are our most recurrent accident problem .presently no PIP [performance improvement plan] has been developed by the QAPI committee . Continued interview revealed the QAPI committee, led by the Administrator, did not revisit the effectiveness of the facility's plan of correction for falls and elopement submitted to the State Survey Agency in September of 2022. Record review showed Resident #252 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Alcohol Abuse, Acute Kidney Failure, and Cognitive Communication Deficit. He was discharged on 5/16/2023 to an Assisted Living Facility. Review of Resident #252's Elopement Risk Evaluation dated 2/23/2023, showed .Is the resident physically able to leave the building on their own .Yes .Is the resident cognitively impaired .Yes .Is there a history of wandering or elopement .Yes .Wanderguard in place . Review of Resident #252's nurse's progress note dated 3/4/2023 at 6:53 PM, showed .Patient exit seeking and redirected by therapy .Wander guard in place and functional and patient placed on 15 min safety checks at this time. Currently patient is positioned at the west nurse's station for extra precaution . Review of Resident #252's medical record showed no documentation the resident had eloped from the building, was found in the parking lot, and had been out of the building for an undetermined amount of time. Review of a picture of a text message provided by RN #4, undated, showed the Administrator had sent the RN a text message which showed .[Name of Administrator] .It needs to be something to the effect that he exhibited exit-seeking behavior and was redirected by staff. Wander guard in place. We don't need to say he was found outside .18:44 [6:44 PM] . During an interview on 9/14/2023 at 11:38 AM, the Administrator stated he was unable to remember how he had been made aware of Resident #252's elopement on 3/4/2023 .I do not recall . He confirmed the incident had not been documented in the resident medical record. He confirmed the incident should have been documented and stated he was not aware of why the incident had not been .in hindsight there opportunities for me to improve . He confirmed a thorough investigation had not been completed. He stated he had not reported the incident to the State Survey Agency because .when you look at the state reporting website it tells me that it is not a reportable incident so I took it as we do not report incidents of elopement without serious injury .I didn't feel like it met that criteria so if I was wrong .if I had looked at it in a different fashion I would have reported it . The Administrator confirmed Resident #252 had been in the parking lot unattended for an undetermined amount of time and the resident was at risk for injury or harm .his potential for risk was increased yes . During the course of the investigation portion of the survey concerns were identified of Residents' #202, #61, and #16 had smoked in the designated smoking area at undesignated smoking times and were unsupervised during the smoking session. After the facility became aware of the unsafe smoking practices of the residents' no preventive measures were implemented. The facility failed to protect all residents from potential harm related to unsafe smoking practices. During an interview on 9/14/2023 at 2:54 PM, the DON stated .Our hands are tied .We know they .tend to not follow the rules .and we have to follow [Resident #16] .closer .If [any resident violate [the facility's smoking policy]rules, make unsafe for all [residents in the facility] . During an interview on 9/18/2023 at 9:07AM, the Administrator confirmed after the incident on 11/28/2022 when Residents #202, #61, and #16 were observed smoking unsupervised no changes were put in place to address concerns related to residents not smoking safely at the facility. Resident #48 was admitted to the facility on [DATE], with diagnoses including Nicotine Dependence, Chronic Respiratory Failure with Hypoxia, Unspecified Mood [affective] Disorder, Morbid Obesity, Obstructive Sleep Apnea, and Type 2 Diabetes Mellitus. Review of the comprehensive care plan dated 8/15/2023, revealed .The resident [Resident #48] has a behavior problem r/t [related to] .attempts to smoke without supervision .Focus .At risk for smoking related injury related to being a smoker .Goal .Will have no smoking related injuries through next review .Interventions .Assist to and from Designated Smoking area .Assure smoking material is extinguished prior to patient leaving smoking area .Observe patient for unsafe smoking behaviors or attempts to obtain smoking material from outside sources. Immediately inform facility management .Patient not to have cigarettes or smoking material on person .Place patient in position to assure visualization of ashtray .Provide smoking apron while smoking .Review smoking policy with patient and or family as needed .Storage of smoking materials per Center policy .has the potential for impaired breathing due to dx [diagnosis] of acute on chronic respiratory failure, COPD [chronic obstructive pulmonary disease], CHF [congestive heart failure], Obstructive Sleep Apnea. Non-compliant with O2 [oxygen] and CPAP [continuous positive airway pressure - a device to aid in breathing when sleeping] use . Review of Resident #48's Smoking assessment dated [DATE], showed Resident #48 was currently a smoker and intended to smoke while residing at the facility. Resident had no history of smoking related incidents documented. Resident #48 was documented to be cognitively intact, able to make himself understood, able to remain alert during the course of smoking, and able to communicate the need for help if lit materials fall on him. Resident required wheelchair access to smoking area. The summary concluded resident would not require supervision with smoking. Staff reviewed the policy related to smoking times and storage of smoking materials with the resident. Interventions were implemented and care plan was updated. Review of the Resident #48's admission MDS dated [DATE], revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Further review revealed the resident required extensive assist of 2 staff members for bed mobility, toileting, dressing and transfers. During an observation on 9/7/2023 at 10:18 AM, revealed Resident #48 seated upright in a wheelchair, in the smoking area with a lit cigarette. Gauze dressings intact to both lower extremities. Resident observed without a smoking apron in place while smoking. Resident #48 without an oxygen container in place on the wheelchair. Staff were present during the smoke break. Review of a nurses note dated 9/10/2023 at 10:17 AM, by Licensed Practical Nurse (LPN) #11 showed .Resident noted with a cigarette butt and ashes on the floor by his bed. Also noted with a pack of cigarette on his bedside table. Resident stated that cigarette just fell out of his pocket. Educated resident on not smoking in his room or inside the facility due to safety hazard. Resident is on continuous O2 [oxygen] therapy. Incident reported to supervisor for f/u [follow up] . Review of Resident #48's Smoking assessment dated [DATE], showed Resident #48 currently smoked at the facility, resident was able to verbalize/demonstrate an understanding of the facility's smoking policy, times to smoke and place to smoke. The summary concluded resident would require supervision with smoking, and resident would require the use of smoking apron while smoking. Staff reviewed the policy related to smoking times and storage of smoking materials with the resident; care plan initiated/updated. During an observation on 9/12/2023 at 10:17 AM, Resident #48 seated upright in a wheelchair, in the smoking area with a lit cigarette. Gauze dressings intact to both lower extremities. Resident observed without a smoking apron in place while smoking. Resident #48 without an oxygen container in place on the wheelchair. Staff were present during the smoke break. Review of a nurses note dated 9/12/2023 at 12:24 PM, Registered Nurse (RN) #2 wrote .Late entry .On Sunday 9/10/23 at approximately 10:30 AM .nurse informed me that [Resident #48's name] had cigarettes in his room. As this is a safety issue, I went into [Resident #48's name] room and removed all of the cigarettes that were on his bedside table and on the floor beside his bed. Patient denied that he was smoking in his room. I educated the resident on the facility smoking policy. I informed him that because he is utilizing oxygen in the room, he is at risk of hurting himself and others if he smokes in his room. I also asked him to turn over any cigarettes that visitors and family bring in for him into the nurses station. I let him know that these cigarettes would be available to him during designated smoke times. Patient voiced understanding . During an observation on 9/13/2023 at 1:23 PM, Resident #48 in the smoking area, sitting upright in a wheelchair with a lit cigarette in hand. Gauze dressings intact to both lower extremities. Resident without oxygen container on wheelchair. Resident #48 had no smoking apron in place while smoking. Staff were present during the smoke break. During an observation on 9/13/2023 at 4:10 PM, Resident #48 in the smoking area, sitting upright in a wheelchair with a lit cigarette in hand. The resident had gauze dressings intact to both lower extremities. The resident was without oxygen container on wheelchair. Resident #48 had no smoking apron in place while smoking. Staff were present during the smoke break and observed the resident not wearing a protective smoking apron. During an interview on 9/13/2023 at 4:11 PM, [NAME] #3 stated .I don't know his name .he's new and he is heavy and has bandages on his legs .I've had to wake him up with a cigarette in his hand . she confirmed the cigarette was lit when the resident was observed dozing off. During an interview on 9/13/2023 at 4:15 PM, the Director of Nursing (DON) stated .On Sunday [9/10/2023] a cigarette butt was found on [Resident #48's name] floor, under his bed . The DON confirmed when staff found the cigarette butt in the floor, under the bed, no incident report was completed or formal investigation documented, only a nurse's progress note was written in Resident #48's electronic medical record. The DON stated Resident #48 wears Oxygen while in his room. The DON confirmed Resident #48's smoking assessment was reevaluated on 9/11/2023. The DON confirmed Resident #48's diagnosis of Sleep Apnea was not taken into consideration when completing the new smoking assessment. During an interview on 9/13/2023 at 4:25 PM, Resident #48 denied going outside to smoke unattended. Continued interview revealed Resident #48 confirmed he had to be woken up at times during smoking sessions due to having Sleep Apnea. During an interview on 9/13/2023 at 4:44 PM, Dietary Aide #3 stated .I don't know them by names .I don't know their rules .I know I see a nurse out there with that box [smoking material box] .but sometimes they are by their selves . During an interview on 9/14/2023 at 9:50 AM, LPN #11 confirmed while observing the cigarette butt on the floor, she also had observed loose cigarettes and a pack of cigarettes. She suspected the resident's friends/family brought cigarettes in for Resident #48. LPN #11 confirmed resident needs to wear a smoking apron while on smoke breaks. During an interview on 9/14/2023 at 10:00 AM, CNA #8 stated Resident #48 goes out regularly for smoke breaks. CNA #8 stated the resident took extinguished cigarette butts and placed them in his shirt pocket and returned inside the building. CNA #8 stated the incident was not reported to nursing of Resident #48 bringing extinguished cigarette butts back in the building. During an interview on 9/14/2023 at 10:08 AM, RN #2 confirmed she was made aware on 9/10/2023, a cigarette butt was found on the floor under Resident # 48's bed. RN #2 stated loose cigarettes and a pack was in the room on the bedside table. RN #2 confirmed she gathered the cigarettes and placed them in the smoking box RN #2 confirmed no lighter was present in the room, she stated she asked the resident, and he denied having a lighter. RN #2 stated she spoke with Resident #48's emergency contact and reviewed the smoking policy as to how cigarettes may enter the facility. RN #2 confirmed the CNA's from either side (East and West) alternate the times for when they monitor the smoke breaks. RN #2 confirmed the admission nurse completes the initial smoking assessment and residents are assessed as needed thereafter. During an observation of the designated smoking area on 9/14/2023 at 10:17 AM, revealed 12 residents were supervised for smoking with a CNA. The residents were seated in chairs and others were seated in their mobility devices. During an interview on 9/14/2023 at 10:20 AM, CNA #1 confirmed she had observed Resident #48 smoking unattended within the past 2 weeks, CNA stated she reported the observation to the nurse (LPN #11). During an observation on 9/14/2023 at 10:36 AM, the fire blanket pink/red box mounted on the wall in the designated smoking area and there was no fire blanket readily available for staff/residents in case of a fire while residents smoked in the designated smoking area. The fire blankets were replaced after the noncompliance was identified by surveyor. Refer to F660 and F689 Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 9/22/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. Review of the facility's documentation and interviews showed the Administrator, Discharge Care Coordinator, MDS Nurse, Social Services Director, and Unit Managers (IDT Team) on 9/19/2023 held a Care Coordination meeting to discuss safe discharges and the potential need for community services which would ensure a safe and orderly discharge and resident had accommodations to meet their needs. 2. Review of the facility's inservices and sign in sheets and documentation showed the Director of Care Coordination completed education regarding After Care Calls to be made on 2-3, 7-9, and 27-28 days post discharge. 3. Review of facility documentation and interview the Director of Clinical Education was provided education for falls prevention, investigation, and implementing resident centered interventions after each fall. Medical record review of 1 resident fall showed person centered interventions were implemented and verified in place. 4. Interview with the Administrator, Senior Director of Operations and Director of Operations revealed care coordination meetings were held to discuss residents who are scheduled to discharge, unplanned discharges will be discussed to ensure a safe, orderly discharge. 5. Review of facility documentation and facility's inservices and sign in sheets, and interview revealed Licensed Nursing staff received education regarding falls prevention, investigation, and implementing resident centered interventions. Staff voiced positive statements and understanding regarding the falls education provided. Noncompliance at F-835 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility documents, observation and interviews, the governing body failed to establish and implement policies regarding effective management and training of the facility's new hires in key staff positions and operation of the facility. The Governing Body's failure placed 2 resident (#250 and #249) of 6 discharged residents reviewed for the potential of unsafe and non-orderly discharge; placed 3 residents (#149, #253, and #74) of 5 residents reviewed for falls at high risk for repeat falls; and the Administrator's failure to provide adequate leadership to address the elopement of 1 resident (#252) placed the resident in an unsafe environment. The governing body's failure to ensure staff were adequately trained resulted in unsafe discharges, falls with major injury, elopement and unsafe smoking practices for Resident's (#202, #61, #16, and #48) which placed all 99 residents in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator and the Director of Clinical Operations was notified of the Immediate Jeopardy (IJ) on 9/18/2023 at 6:10 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F-837. The facility was cited at F-837 at a scope and severity of J. The Immediate Jeopardy began on 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated onsite by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the Social Services Director's job description included, .One year of supervised social work experience, in a healthcare setting, working directly with individuals .help solve health and welfare problems .makes appointments and acts as a liaison .develops discharge plans .Arranges for post discharge services and follow-up care . Resident #250 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Chronic Kidney Disease, Morbid Obesity, Weakness, and Unsteadiness on Feet. She was discharged to her home on 7/5/2023. Review of Resident #250's Occupational Therapy (OT) Discharge summary dated [DATE], showed .Patient will be discharging to facility (seeking additional approval to stay here) as she is not ready to discharge home (needing max [maximum] assist with LB [lower body] ADLs [activities of daily living) and significant assist with transfers .1-2 [staff members]). Patient is making significant gains and would benefit from more skilled therapy services prior to when she eventually returns home .is not safe to discharge home at this time even with appropriate DME [durable medical equipment] available . Review of Resident #250's Home Health Visit Note Report dated 7/9/2023, showed .Integumentary .Abnormal integumentary assessment findings .Erythema .location .Groin, Buttocks .indicate Patient pain scale rating .8 .Patient with recent SNF stay .Her BLE [Bilateral Lower Extremities] is pitting 3 plus edema and has severe pain with movement. She is MAX assist .stand with 2 people .Patient was sitting in wheelchair alert and oriented x4 .She states she had been sitting in her own urine and feces since after being discharged from [name of nursing facility] .She was upset because she wasn't able to get up and clean herself up. Patient does not have assistance from anyone. Patient is needing more than home care services can provide. Nursing and Physical therapy could barely get patient to stand up to get stool off the patient. Patient's skin was excoriated from sitting in urine and feces for several days .She has severe pain when moving legs. Has wounds on both legs that are weeping. Patient agreed to go back to emergency room . Record review of Resident #250's hospital records, dated 7/12/2023, showed .patient . return home for approximately 3-4 days with failure to thrive .Patient home approximately 3-4 days with inability to care for self Assessment/Plan .Stage I decubitus ulcer and pressure area .Bilateral lower extremity edema .brought to ED [Emergency Department] .after being at home alone and not able to get up defecating on self .Patient lives alone .Patient unable to stand and ambulate and states home health cleaned her up .Over the past 3 days she has been unable to get up and defecating and urinating on herself .Patient states her bottom was hurting because of sores on at that she was defecating and urinating on herself .Skin .rash bilateral [both] anterior [front] shins .stage I [redness] sacral decubitus [bedsore above the tailbone area] ulcer bilateral as well as scattered multiple small 1 cm [centimeter] areas of stage II ulcer [shallow open bedsore] bilateral buttocks .ED course .brought to the emergency department disheveled, covered in feces and urine. Lives alone. Has not been able to get up or move and has been defecating on self for the past several days. Was discharged home after meeting her maximum rehab stay. Appears to have UTI [Urinary tract Infection]. Treated with IV [Intravenous] Rocephin [antibiotic] .Received IV fluids. Patient unable to stand or walk. She is severely and physically deconditioned. Patient is unsafe discharge home to continue solitary living even with intermittent home health . Review of Resident #250's After Care call [follow up from nursing facility] dated 7/13/2023, showed it was not completed. During an interview on 9/14/2023 at 11:38 AM, the Administrator confirmed the facility's governing body included himself, the Director of Nursing, and the Regional [NAME] President of Nursing. The Administrator confirmed the processes in place for discharge were approved by the governing body. Interview continued and he confirmed he had not been aware PT and OT (physical and occupational therapy) had documented Resident #250 was not safe to be discharged home and stated he had not been aware the resident required the assistance of 2 persons for transfers. He confirmed the discharge had been unsafe for Resident #250 and stated the facility should have .ensured appropriate resources were in place prior to discharge . Resident #249 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Dementia, Weakness, and Repeated Falls. The resident was discharged AMA on 6/16/2023. Review of Resident #249's Psych NP note dated 6/6/2023, showed .forgetfulness concerned [with] d/c .Insight fair Judgement fair Impulse Control fair Orientation .memory Attn/conc [attention/concentration] poor .cognitive decline [with] multiple complicities . During an interview on 8/21/2023 at 12:36 PM, the Administrator stated .[Resident #249] had gone out on leave with [Friend #3] and he came back and told us that he was discharging, and we explained that would be AMA [against medical advice] and he didn't care, and he started packing his stuff . The Administrator stated the resident said he had a friend that was willing to take him in but he [Resident #249] did not know the friends name and stated it wasn't anyone listed in the resident's chart .he was gonna walk so I asked him not to do that .I was unable to get a taxi over here so I took him he told me where to go he did not know the address but he knew the streets .I watched him go to the door and his friend took him inside .it was a female . Interview continued, .we gave him the notice [involuntary discharge notice] but it had not run out [of days] yet .our Ombudsman informed me that was not an appropriate discharge destination so I rescinded that notice . The Administrator stated the resident had not had home to discharge to. I don't know if he had a plan [discharge plan] .I had to give him a discharge notice and up until that point he had not given me any other address .typically we want to get things in order and notify the physician and he said I'm leaving and went to pack his stuff up . During an additional interview on 9/14/2023 at 11:38 AM, the Administrator confirmed the resident did not have a home .to my knowledge he [Resident #249] didn't have a home .he [Resident #250] discharged AMA and I helped provide him [Resident #249] transportation to a home . He [Resident #250] confirmed he had not documented discussions he had with the resident. He confirmed he had not contacted APS to follow up with the resident to ensure he was in a safe environment .I did not . The Administrator confirmed Resident #249 had not been discharged to a safe environment. The facility's failure to provide a safe discharge for a previously homeless resident (#249) resulted in homelessness on the day of discharge. The nursing home administrator took Resident #249 to an unidentified friend's home. The friend did not allow Resident #249 to stay. Resident #249 walked from the friend's home to a second friend's house who drove him to a motel where he stayed for 2 months, was evicted, then hitchhiked to a third friend's home. The facility's non-compliance in providing a safe and orderly discharge for each resident discharged requires immediate action to prevent re-occurrence. Resident #149 was admitted to the facility on [DATE], with diagnoses including Unspecified fracture of Right Femur, Unspecified Dementia, Adult Failure to Thrive, Alzheimer's Disease, Unspecified Hearing Loss, Insomnia, Unsteadiness on Feet, and Depression. She was discharged on 5/17/2023. Review of Resident #149's nurses progress note dated 5/17/2023, showed .CNA told this nurse that [Resident #149] .had a fall. After assessing [Resident #149] it was found that she had a laceration to the back of her head, she was bleeding a lot, a cold cloth was held to the back of her head with pressure to help stop the bleeding .orders received to send [Resident #149] to .ER [Emergency Room] . Review of Resident #149's Post Fall Review dated 5/17/2023, showed there were no immediate actions documented. Review of Resident #149's emergency room Documentation dated 5/17/2023, showed .unwitnessed fall with bleeding from back of head .Impression .Acute extra-axial hemorrhage right temporal region .concerning for epidural hematoma . Review of Resident #149's Palliative Care Consult Note from the hospital dated 5/18/2023, showed .96-yo female with Alzheimer's dementia and cerebrovascular disease, also right femur fracture in April 2023 [related to a fall at home] treated conservatively without surgery. She was transferred 5/18/23 [5/18/2023] after fall from standing with epidural hematoma. Per neurosurgical evaluation family declined operative intervention . During a telephone interview on 9/14/2023 at 9:28 AM, the NP stated it was her expectation for the facility to develop a fall risk care plan for residents who are at high risk. She stated encouraging Resident #149 to use her call light would not have been an effective intervention if she had severe cognitive impairment. The NP confirmed when Resident #149 fell on 5/17/2023 and sustained an epidural hematoma that she had sustained harm from the fall .that is harm . Review of the medical record for Resident #149 revealed the resident did not have a falls care plan developed after her first fall and sustained a second fall with major injury. Resident #149 sustained a Right Epidural Hematoma (when blood accumulates between the skull and the covering of the brain) and Extra Axial Intracranial Hemorrhage (bleeding inside the skull but outside the brain) during a fall on 5/17/2023. Resident #253 was admitted to the facility on [DATE] and discharged on 7/10/2023, with diagnoses including Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, Non-Stemi Myocardial Infarction, Dysphagia, Anxiety Disorder, and Difficulty Walking. Review of the medical records Resident #253 had increasing confusion and restlessness not addressed in her care planning and had a fall with major injury. Resident #253 sustained a Left Femoral Fracture (break in the thigh bone) after a fall on 7/10/2023. Review of Resident #253's facility's fall investigation dated 7/10/2023, showed .This nurse heard resident yell out for help. Went into residents room where she was lying in the floor beside the bed on her left arm .Resident unable to give description .Left side of head was bleeding and she was complaining of shoulder and back pain. Vitals taken WNL [within normal limits]. Contacted [Ambulance] to take to ER .Injury Type .Laceration .face . Review of Resident #253's comprehensive care plan update on 7/10/2023, revealed .Fall 7/10/2023. Sent to ER for evaluation .will update with new interventions on return from hospital . During an interview on 9/14/2023 at 3:50 PM, the Administrator stated .falls are our most recurrent accident problem .presently no PIP [performance improvement plan] has been developed by the QAPI committee . The facility failed to provide adequate supervision to prevent further falls for Residents #149, and #253. Thorough investigations were not completed to include a root cause analysis to facilitate individualized fall prevention interventions for Residents #149. The facility failed to implement appropriate interventions to prevent falls for Residents #149, and #253. Resident #74 was admitted to the facility on [DATE] and readmitted on [DATE] and 8/15/2023 with diagnoses including Fracture of the Left Acetabulum, Chronic Obstructive Pulmonary Disease, Diabetes and Congestive Heart Failure. Review of Resident #74's Nurse Practitioner's note, dated 8/2/2023, showed .Called to room. Pt. c/o [complaint of] hip pain. He reports he fell in the bathroom- he is found in bed .Nursing and PT staff are present. He has c/o [complaint] severe pain to lt. [Left] hip with attempts to move him. He has knot to lt. [Left] outer hip .acute Left hip pain self-report of unwitnessed fall in bathroom . Review of Resident #74's EMS [emergency medical service] records, dated 8/2/2023, showed .pt was found lying semi-Fowler s [head of bed raised to 30-degree angle] in bed, alone. The crew asked the pt [patient] what happened .he said he fell sometime yesterday when it was day light and started having left hip pain this morning .The nurse stated he fell sometime in the night and is complaining of left hip pain . Review of Resident #74's hospital record, dated 8/2/2023, showed .c/o fall and hitting head but unsure when he fell. Per NH [Nursing Home] pt fell last pm but pt states it was in the daylight yesterday .Pt does c/o headache and is on blood thinners .He reportedly is on blood thinners and hit his head. Unknown loss of consciousness as he is somewhat confused to the event .New area of suspected bruising along the left hip has more hyperdense appearance than other areas of edema .The left acetabulum is fractured , multiple fracture planes, some intersecting the acetabular margin .No evidence of left femoral fracture or dislocation .Impression: The left acetabulum has been shattered .Simple fracture to the inferior left pubic ramus .Small superficial hematoma along the left outer hip . The Governing Body failed to develop evidence based best practice policies to address falls and fall prevention. The ongoing problem of falls, identified as the primary unsafe adverse outcome by the Administrator, not being addressed by the QAA committee in 2023. The governing body had not provided oversight and accountability of the QAA committee to develop effective corrective actions to address elopement and unsafe smoking. Record review showed Resident #252 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Alcohol Abuse, Acute Kidney Failure, and Cognitive Communication Deficit. Review of Resident #252's nurse's progress note dated 2/23/2023, showed .Resident states that he needs help. I asked what he needed, and he stated (I have to get out of this place) .He insists that he needs to go. Wander guard [bracelet to prevent exiting doors equipped with a wander guard sensor] placed on ankle . Review of Resident #252's nurse's progress note dated 3/4/2023 at 6:53 PM, showed .Patient exit seeking and redirected by therapy .Wanderguard in place and functional and patient placed on 15 min safety checks .Currently patient is positioned at the west nurse's station for extra precaution . Review of Resident #252's medical record showed no documentation the resident had eloped from the building, was found in the parking lot, and had been out of the building for an undetermined amount of time. Review of a text message provided by RN #4, undated, showed the Administrator had sent the RN a text message which showed .[Name of Administrator] .It needs to be something to the effect that he exhibited exit-seeking behavior and was redirected by staff. Wander guard in place. We don't need to say he was found outside .18:44 [6:44 PM] . During a telephone interview on 8/28/2023 at 2:25 PM, RN #4 (worked dayshift on 3/4/2023 on a different hall) stated .I knew a little after the fact .I heard he was out by the [facility sign by the road] sign .he was in his wheelchair . She stated she had not been assigned to care for the resident that day but had received a text message from the Administrator directing her on what she was to chart in the resident's medical record .so I was the only administration at the time [working that day] .I was directed on how to chart the incident [by the Administrator] .I have text messages by my Administrator .I do have the text message as to what to chart exactly .I know he did have a wanderguard on and he did get out the front door .RN #4 stated none of the staff realized the resident was missing .or how long he had been outside .he was a wanderer . She confirmed the Administrator directed her to chart [in the electronic medical record] vaguely. The RN confirmed the resident had been out of the facility for an undetermined amount of time on 3/4/2023. The RN confirmed the resident had a wanderguard bracelet in place, no alarm sounded on the front door to alert staff he had exited. The RN stated if the Physical Therapy Assistant (#1) had not seen the resident, .it would have been a while [before staff noticed he was missing] . The RN stated she did not feel the resident could have moved out of the way of a moving car in the parking lot .I don't think he would have realized it was dangerous and I don't think he could have gotten out of the way .oh yeah [could have been hit by a car] he wasn't communicating at that time from the stroke .no [could not have controlled the wheelchair on the slant of the parking lot toward the road] .he could have tipped the wheelchair over .I don't think he could have stopped it [the wheelchair], he could use his left hand a little .if he had tipped over [the wheelchair] he could not have gotten himself up on his own . During an interview on 9/14/2023 at 11:38 AM, the Administrator stated he was unable to remember how he had been made aware of Resident #252's elopement on 3/4/2023 .I do not recall . He confirmed the incident had not been documented in the resident medical record. He confirmed the incident should have been documented and stated he was not aware of why the incident had not been .in hindsight there [are] opportunities for me to improve . During an interview on 9/13/2023 at 3:10 PM, with the Administrator he confirmed the Social Services Director (SSD) inability to provide a safe discharge for Resident #250. He responded .opportunity to improve .plan to reach out to 1 of our other centers to come here to train her [SSD] . Continued interview confirmed the Discharge Car Coordinator (DCC) had 1 day of training with a traveling DCC. During an interview on 9/14/2023 at 3:50 PM, the Administrator stated falls are our most recurrent accident problem .presently no PIP [performance improvement plan] has been developed . Resident #202 was admitted to the facility on [DATE] and discharged on 3/8/2023, with diagnoses including Chronic Obstructive Pulmonary Disease, Patient's Noncompliance with other Medical Treatment and Regimen, Acute and Chronic Respiratory Failure with Hypoxia, and Schizoaffective Disorder Bipolar Type. The facility failed to provide adequate supervision and a safety measure of ensuring a fire blanket was readily available while Resident #202 smoked in the designated smoking area. The facility failed to investigate the unsafe smoking incident for Resident #202. Resident #61 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder Bipolar Type, Anxiety, and Acute Chronic Diastolic Heart Failure. The facility failed to provide adequate supervision and a safety measure of ensuring a fire blanket was readily available while Resident #61 smoked in the designated smoking area. The facility failed to investigate Resident #61's unsafe smoking practices. Resident #16 was admitted to the facility on [DATE], with diagnoses including Acute on Chronic Diastolic Heart Failure, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Peripheral Vascular Disease, Major Depression Disorder, and Chronic Kidney Disease. Review of Resident #16's Activities note dated 11/28/2022, revealed .This AD saw this resident out in the courtyard with two other residents [Resident #61 and Resident #16] smoking a cigarette unsupervised and not at designated smoking times .I went outside explained to this resident that is was not time to smoke [that it was not the time to smoke] and told him to put thecigarette [the cigarette] out .He then told me to leave him the [expletive] alone and go back inside .I told him I would when the [Resident #16] put the cigarette out he then threw it in the flower pot still lit .I put the cigarette out while he was telling me to leave it alone .I then went inside and reported it to the nurse on [name of the hall] and the ADON . Review of Resident #16's Activities note dated 4/19/2023, revealed .[Name of Resident #16] .was seen by multiple other residents put a cigarette in his shirt pocket .He then went into the facility . [Name of medical records personnel] was smoking the [monitoring residents smoking in the designated smoking area]residents at this time and informed me of him having the cigarette .I stoppedhim [stopped him] in the front hall I could visibly see the cigarette .I said to him that he could not have the cigarette .that he needed to give it to me .He said it was broken and he was going tofix [to fix] it .He said I don't have a lighter I have a broken cigarette .He continued to argue about not giving to me but did eventually hand me the cigarette .The cigarette was not broken I took the cigarette out to the box realizing that it wasn't one of [Resident #16's] own cigarettes .The other smokers said that another female smoker gave him the cigarette . The facility failed to provide adequate supervision and a safety measure of ensuring a fire blanket was readily available while Resident #16 smoked in the designated smoking area. The facility failed to investigate Resident #16's unsafe smoking incidents. During an interview on 9/14/2023 at 8:22 AM, the Administrator stated, .We treat the incidents of smoking unsupervised or violation of smoking [as a resident smoking incident] .resident holding on to cigarette not disposed in trashcan [when residents attempt to keep their cigarettes on themselves or in their rooms] .We write in the progress notes instead . Problems related to smoking typically discussed with the interdisciplinary team [IDT] team .He [Resident #16] was discussed in 9/2023 he[Resident #16] had cigarette in his possession . During an interview on 9/14/2023 at 9:02 AM, LPN #12 stated, .There are occasions when residents [are] caught smoking unsupervised on both shifts .Some families give residents the cigarettes or visitors will come in and residents ask them for cigarettes and visitors give [residents cigarettes] .If family brings cigarettes [in to residents] they bring them lighters .If visitor come [in to visit residents] they light cigarettes for residents .[For Residents# 202, #61, and #16] it was [Resident #202's Family member brought the cigarettes in at that time [11/28/2022] .She [Resident #202's Family member brought packs [cigarette packs] in and gave the resident [Resident #202] the cigarettes. [Resident #202] told me her Family member brought her in the cigarettes over weekend of 11/28/2022. When I saw her [Resident 202's Family Member] that day[unknown date] .[LPN #12] told her [Resident #202's Family Member] .she definitely could not give her [Resident #202] a lighter for any reason .She {Family Member] told me she was sorry and didn't realize it was a big deal to give cigarettes .to residents or light cigarettes for them .I told the resident [Resident #202] she had to turn those [cigarettes] in .I don't know how many cigarettes she gave me .not sure how many she had .I would guess central supply took them in [central supply staff] .[Resident #202 Family Member] admitted that she had been giving the resident [Resident #202]cigarettes' and maybe lighter [LPN #12 was unsure if Resident #202's Family Member provided Resident #202 with a lighter] if another visitor or someone else family lit the cigarettes .I was made aware by resident [Resident #202] because they [Resident #202, #61 and #16] had got caught [smoking in the designated smoking area unsupervised] on 11/28/2022 . Resident #48 was admitted to the facility on [DATE], with diagnoses including Nicotine Dependence, Chronic Respiratory Failure with Hypoxia, Unspecified Mood [affective] Disorder, Morbid Obesity, Obstructive Sleep Apnea, and Type 2 Diabetes Mellitus. Review of a nurses note dated 9/10/2023 at 10:17 AM, by Licensed Practical Nurse (LPN) #11 showed .Resident noted with a cigarette butt and ashes on the floor by his bed. Also noted with a pack of cigarette on his bedside table. Resident stated that cigarette just fell out of his pocket. Educated resident on not smoking in his room or inside the facility due to safety hazard. Resident is on continuous O2 [oxygen] therapy. Incident reported to supervisor for f/u [follow up] . During an interview on 9/14/2023 at 10:20 AM, CNA #1 confirmed she had observed Resident #48 smoking unattended within the past 2 weeks, CNA stated she reported the observation to the nurse (LPN #11). During an interview on 9/14/2023 at 2:54 PM, the DON stated .Our hands are tied .We know they .tend to not follow the rules .and we have to follow [Resident #16] .closer .If [any resident violate [the facility's smoking policy]rules, make unsafe for all [residents in the facility] . The facility failed to provide adequate supervision, safety measures such as fire blanket and smoking apron. The facility failed to investigate the incident of Resident #48 when he was smoking unsupervised. During an interview on 9/18/2023 at 9:07AM, the Administrator confirmed after the incident on 11/28/2022 when Residents #202, #61, and #16 were observed smoking unsupervised no changes were put in place to address concerns related to residents smoking unsupervised in the building. During an interview on 9/18/2023 at 9:07 AM, with the Administrator, he would not engage in conversation related to the unsafe practices observed with smoking. The Administrator did confirm, after the incident on 11/28/2022, when 3 residents were found smoking unsupervised, no changes were put in place by the facility to address safe smoking, and it continued to be a concern. The Governing Body was not made aware by the Administrator of the unsafe smoking practices at the facility, the topic was not discussed in QAPI or identified as a concern until the SA [State Agency] made the concern known during the survey. During an interview on 9/18/2023 at 9:07 AM, with the Administrator, he would not engage in conversation related to the unsafe practices observed with smoking. The Administrator did confirm, after the incident on 11/28/2022, when 3 residents were found smoking unsupervised, no changes were put in place by the facility to address safe smoking, and it continued to be a concern. The Governing Body was not made aware by the Administrator of the unsafe smoking practices at the facility, the topic was not discussed in QAPI or identified as a concern until the SA [State Agency] made the concern known during the survey. During an interview on 9/21/2023 at 4:15 PM, with the Senior Director of Operations, she stated the facility had not been following the policies and procedures, put into place with accompanying guides, to implement and/or revise care plans, facilitate safe discharges, develop individualized interventions in an effort to prevent falls, and decrease the risk of elopement. She stated if the policy and procedures were followed, communication within the IDT would be mandatory. The governing body should acknowledge responsibility for governance through effective leadership, focusing on indicators of outcomes of care that had placed all 99 residents in unsafe care environments. During an interview on 9/21/2023 at 4:15 PM, with the Senior Director of Operations, she stated the facility had not been following the policies and procedures, put into place with accompanying guides, to implement and/or revise care plans, facilitate safe discharges, develop individualized interventions in an effort to prevent falls, and decrease the risk of elopement. She stated if the policy and procedures were followed, communication within the IDT would be mandatory. The governing body should acknowledge responsibility for governance through effective leadership, focusing on indicators of outcomes of care that had placed all 99 residents in unsafe care environments. Refer to F656, F657, F660, and F689 Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 9/22/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. Review of the facility's documentation and interviews showed the HRC [human resource coordinator] upon completion of general orientation will complete education of 72-hour meeting and care coordination. 2. Review of facility documentation and interview revealed education was provided to the IDT Team regarding safe discharges, falls prevention, smoking safety, and elopement prevention. Interview of 4 Staff revealed education was completed. 3. Review of facility documentation and interview the Governing Body conducted education with key personnel on 9/21/2023 to evaluate the need for re-orientation and to identify areas of concern and develop a training plan. Interview with the Director of Clinical Education revealed the facility is developed and implemented a training program on 9/19/2023. 4. The Director of Social Services received education regarding on safe and orderly discharges. Interview with the Social Services Director revealed she had completed education provided by the facility and had encouraged the facility to give more education. 5. The QAPI Committee conducted root cause analysis and developed the allegation of compliance, the finding of the RCA was a gap of understanding of key personnel in education on 72 hour and Care Coordination Meetings, Safe

Based on facility policy review, facility document review, medical record review, observation and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to reassess and monitor ongoing concerns with falls (Residents #149, #253, and #74) and elopement (Resident #252). The facility failed develop an effective QAPI program that recognized concerns related to safe smoking by Resident's (#202, #61, #16, and #48) and failed to ensure systems and processes were in place and consistently followed by staff to prevent an elopement, falls and an unsafe smoking environment. The failure of the QAPI Committee to ensure a safe environment for smoking and to develop corrective actions for elopement and falls, placed all residents in Immediate Jeopardy (IJ). The Administrator was notified of the Immediate Jeopardy (IJ) on 9/18/2023 at 6:10 PM, in the Administrator's Office. The facility was cited Immediate Jeopardy at F865. The facility was cited at F865 at a scope and severity of J. The Immediate Jeopardy began on 11/28/2022 and was removed 9/22/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 9/21/2023 at 10:15 PM, and the corrective actions were validated onsite by the surveyors on 9/22/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy QAPI [Quality Assurance & Performance Improvement] Center Plan dated 7/7/2023, revealed, .Identify opportunities for improvement .Address gaps in systems or processes .Develop and implement an improvement or corrective plan .And continuously monitor the effectiveness of our interventions .Adverse event monitoring .causes are analyzed, and performance improvement activities are implemented . Review of the medical records for 3 residents (Resident #149, Resident #253, and Resident #74) revealed Resident #149 did not have a falls care plan developed after her first fall and sustained a second fall with major injury in 2023. Resident #253 had increasing confusion and restlessness, that was not addressed in her care planning, and had a fall with major injury in 2023. Resident #74 sustained a fall in his bathroom at a timeframe still undetermined, he stated his return to bed was done by 2 unidentified staff members and a mechanical lift, he was not assessed by the staff for an undetermined amount of time, perhaps greater than 12-16 hours, due to the night nurse stating the fall did not happen on her shift and it was discovered by the therapy staff at 10:00 AM the following day. Resident #74 was sent to the hospital with major injuries diagnosed. Review of facility documents revealed the 3 falls for Residents #149, #253, and #74 were not completely investigated so root cause analysis and contributing factors were not identified. Interview on 9/14/2023 at 3:50 PM, with the Administrator confirmed, falls are our most recurrent accident problem .presently no PIP [performance improvement plan] has been developed by the QAPI committee . Continued interview confirmed the QAPI committee did not revisit the effectiveness of the facility's plan of correction for falls and elopement submitted to the State Survey Agency in September of 2022. Review of Resident #252's medical record revealed he was exit seeking and wore a wander guard bracelet. Review of facility documents revealed Resident #252 eloped 3/4/2023, out of the front door of the facility, was on the grounds in his wheelchair for an undetermined amount of time before a staff member, leaving for the day, saw him in the parking lot, headed toward the street. Interview on 9/14/2023 at 3:50 PM, with the Administrator confirmed he had expended a large sum of money to arm the front door to respond to the wander guard system. Interview confirmed an investigation was not completed to identify a root cause analysis and also examine the contributing factor of staff not recognizing the resident was out of the building for an undetermined amount of time. Continued interview confirmed the QAPI committee did not revisit the effectiveness of the facility's plan of correction for elopement that was submitted to the State Survey Agency in September of 2022 after an elopement. Review of the facility's yearly Center Assessment Tool, dated 7/20/2023, revealed the facility being a smoking facility was not addressed within the Physical Environment portion of the assessment, or within any part of the tool. Review of the medical records of 4 residents (Resident #202, Resident #16, Resident #61 and Resident #48) revealed unsafe practices with smoking. Review of Resident #16's care plan revealed a lack of threatening behaviors being addressed by the facility to ensure the safety of all the residents in the facility. Resident #202, #61 and #16 smoked in the designated smoking area and at designated smoking times. After the facility became aware of unsafe smoking practices the facility failed to protect the residents from potential harm related to smoking. During an interview on 9/14/2023 at 2:54 PM, the DON stated .Our hands are tied .We know they .tend to not follow the rules .and we have to follow [Resident #16] .closer .If [any resident violate [the facility's smoking policy]rules, make unsafe for all [residents in the facility] . During an interview on 9/18/2023 at 9:07AM, the Administrator confirmed after the incident on 11/28/2022 when Residents #202, #61, #16, and #48 were observed smoking unsupervised no changes were put in place to address concerns related to residents smoking unsupervised in the building. During observations of the 5 smoking breaks during various times of the survey revealed supervising staff failed to follow safety procedures, such as each smoker being assessed for smoking prior to participating, residents not wearing a smoking apron if required, a fire blanket was not present, ash trays were not emptied after the last smoke break, and appropriate ash trays/cans were not in use to prevent potential fires. During an interview on 9/14/2023 at 3:50 PM, with the Administrator confirmed the QAPI committee had not addressed the ongoing problem with smokers occasionally smoking unsupervised (Resident #202, Resident #61, Resident #16, and Resident #48) facility policy for safe practices for supervised smoking not followed, and the threatening behaviors of Resident #16. Refer to F689 Validation of the Allegation of Compliance (AOC) to remove the immediate Jeopardy (IJ) was conducted on 9/22/2023 through review of facility documentation, medical record reviews, and interviews. Surveyors verified the AOC by: 1. Interview and review of the facility documentation revealed all members of the Quality Assurance Performance Improvement Committee were educated on the facility's Quality Assurance Policy and procedure and the important of conducting an ADHoc meeting when new concerns are identified to discuss and determine immediate actions needed to address the identified area of concern to prevent safety issues related to unsafe smoking, practices, falls, and elopement. The Committee was educated to continue meeting monthly and review the effectiveness of the plans and adjust the plans as needed to ensure and maintain compliance. Review and interview with the Administrator revealed he was educated by the Regional [NAME] President on 9/19/2023. Interviews with the Senior Director of Clinical Services, Director of Clinical Services, Discharge Care Coordinator (DCC), and Social Service Director confirmed they were educated. 2. Review of the facility documentation dated and interviews with all disciplines revealed the staff were educated to immediately report any identified deficient practice to the Administrator or DON to ensure the new concern can be addressed through the facility's Quality Assurance Performance Committee (QAPI). The QAPI Committee will initiate a plan of correction (POC) to include education any systemic changes, and auditing to ensure compliance was sustained. 3. Interviews with all disciplines revealed they were in-service to report any identified deficient practice to the Administrator or the DON to ensure the new concerns could be address by the QAPI Committee. Noncompliance at F-865 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.