**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure that an Agency Certified Nurse Aide (Agency CNA) possessed the information and skill set necessary to recognize an important change in condition for one of four sample residents (Resident (R) 1) when R1 experienced chest pain during the night and the Agency CNA did not report it to the nurse on duty. Failure to report a residents change in condition has the potential to cause harm to residents. Findings include: Review of the facility's policy titled, Acute Condition Changes-Clinical Protocol, revised in March 2018, indicated .Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. The policy indicated .The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). Review of the Resident Face Sheet located in R1's electronic medical record (EMR) under the Demographics tab indicated R1 was admitted to the facility on [DATE], with diagnoses which included traumatic arthropathy, left knee-patellar instability, atherosclerotic heart disease of native coronary artery without angina pectoris, and atherosclerosis of coronary artery bypass graft(s) without angina pectoris-history of coronary artery bypass graft (CABG) four times. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/15/24 and located in R1's EMR under the MDS 3.0 tab indicated R1 had a Brief Interview for Mental Status (BIMS) score of five out of 15 which revealed R1 was severely cognitively impaired. Review of a statement provided by the facility and written by Skilled Nursing Facility (SNF) Certified Nurse Aide (CNA) 10 indicated that on the morning of 11/27/24 she was scheduled as the day aide on R1's nursing care unit. The statement indicated CNA10 received a report from the Agency CNA that had worked the night shift on that unit. The statement indicated that the Agency CNA told her that R1 had been up all night with chest pain and CNA10 asked if the Agency CNA had reported this to the nurse on duty that night, Licensed Practical Nurse (LPN) 3, and the Agency CNA replied that she had not reported it. The statement indicated that CNA10 reported it right away to the nurse coming on duty. During an interview on 03/20/25 at 10:53 AM, CNA10 stated she was the CNA on that unit for the day on 11/27/24, and when getting report from the Agency CNA, she mentioned that R1 had been up all night with chest pain. CNA10 stated she asked the Agency CNA if she had reported it to the nurse that had been on duty, and she said no. CNA10 stated she reported it to LPN3 right away. Review of the statement provided by the facility, from LPN3 indicated that between 7:15 and 7:20 AM on 11/27/24, she was told that R1 had experienced chest pain all night. The statement indicated that LPN3 questioned R1 about chest pain and R1 was able to tell LPN3 that she was short of breath and had pain in the middle of the chest (by pointing to the location). The statement indicated the physician, and the family member were notified and R1 was sent to the hospital. Review of a Progress Note, dated 11/27/24 at 7:48 AM, located in R1's EMR under the Resident Progress Notes indicated that R1 told LPN3 that she was having shortness of breath and chest pain overnight, the chest pain was located in the middle of the chest, radiating to the shoulders and the arms felt more weak than usual. The Progress Note indicated R1 denied having nausea, headache, dizziness, jaw pain or back pain. The Progress Note indicated R1's temperature was 97.3 degrees Fahrenheit with an oxygen concentration of 92% on room air, a blood pressure of 94/56, with a pulse of 91 beats per minute. The Progress Note indicated that the Physician was notified and R1 was sent to the hospital via ambulance. During an interview on 03/19/25 at 1:30 PM, the Family Member (FM) said R1 told a CNA that she was having chest pain and asked for help. The Family Member said this was not documented and said, they do not get it. The Family Member said that she was not saying the outcome would have been different, because R1 had been through a lot medically. During an interview on 03/20/25 at 11:45, the Medical Director said he was R1's physician. The Medical Director said the Agency Aide did not inform the Nurse on duty on the night shift but as soon as the day nurse was made aware of the information and assessed R1, he was notified. He said R1 had multiple co-morbidities and was terribly ill and frail, in general, for a long time. The Medical Director said the incident did not cause harm to R1 and said he did not feel that the outcome would have been different if he had been notified earlier. The Medical Director said that as soon as they discovered it, they acted, called us, and sent her out. Review of the Orientation Packet provided by the facility, that was received by the Agency CNA indicated the packet did not include the [Facility Name] Physician Notification Practice Guidelines from AMDA [American Medical Directors Association] which included guidelines relative to when staff should report things to a Nurse on duty and what to look for. Review of the [Facility Name] Physician Notification Practice Guidelines from AMDA indicated .Chest pain that is new onset, or recurrent, which is not relieved in 20 minutes by previously ordered Nitroglycerin pills x three doses, accompanied by a change in vital signs, diaphoresis, nausea, vomiting or shortness of breath should be reported immediately . During an interview on 03/20/25 at 9:00 AM, the Administrator said the facility used an Orientation Packet for facility staff as well as all Agency personnel that worked in the facility. The Administrator said that the Agency CNA that provided care on R1's nursing care unit on 11/27/24 received the packet and her signature, dated 09/17/24, was found on the document when it was reviewed. The Administrator said that the Agency CNA involved in this incident was no longer allowed to work at the facility. The Administrator also said that LPN3 was no longer employed at the facility. The Administrator said the packet had been revised to include information related to what needed to be reported and when. She said the revised packet has been provided to all Nursing Agencies that had their staff working at the facility.

Based on review of the facility policy and interview, the facility failed to ensure that seven of the 34 Skilled Nursing Facility (SNF) Certified Nurse Aides (CNA) 6, CNA9, CNA11, CNA13, CNA25, CNA29, and CNA33 reviewed for Continuing Education Requirements of 12 hours every 12-month period. Failure to ensure all CNAs receive the required ongoing education has the potential to decrease the quality of care for residents residing at the facility. Findings include: Review of the facility's policy titled, Continuing Educating Certified Nurse Aides, dated August 2022, indicated All nurse aide personnel participate in 12 hours continuing education per employee employment year. It further indicated Annual continuing education credits are no less than 12 hours per employee employment year. Review of the Continuing Education Records provided by the Administrator indicated seven CNAs were overdue for completing the 12-hour requirement as of 03/19/25. 1. Review of CNA6's Continuing Education Record indicated CNA6 had a date of hire (DOH) of 03/01/23. Based on the facility policy and date of hire, CNA6 should have completed her 12 hours by 03/01/25. 2. Review of CNA9's Continuing Education Record indicated CNA9 had a DOH of 03/13/24. Based on the facility policy and date of hire, CNA9 should have completed her 12 hours by 03/13/25. 3. Review of CNA11's Continuing Education Record indicated CNA11 had a DOH of 02/17/21. Based on the facility policy and date of hire, CNA11 should have completed his 12 hours by 02/17/25. 4. Review of CNA13's Continuing Education Record indicated CNA13 had a DOH of 03/07/22. Based on the facility policy and date of hire, CNA13 should have completed her 12 hours by 03/07/25. 5. Review of CNA25's Continuing Education Record indicated CNA25 had a DOH of 03/01/23. Based on the facility policy and date of hire CNA25 should have completed her 12 hours by 03/01/25. 6. Review of CNA29's Continuing Education Record indicated CNA29 had a DOH of 03/04/21. Based on the facility policy and date of hire, CNA29 should have completed her 12 hours by 03/04/25. 7. Review of CNA33's Continuing Education Record indicated CNA33 had a DOH of 03/27/24. Based on the facility policy and date of hire, CNA33 should have completed her 12 hours by 03/27/25. During an interview on 03/19/25 at 3:40 PM, the Administrator stated she was aware that some of the CNAs had not met the 12 hours every 12-month period, determined by their employee year, date of hire, for continuing education according to the facility policy and regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility did not provide 2 (R3 & R2) of 2 Residents who smoked and 2 (R1 & R4) of 3 Residents reviewed for falls the supervision and assistance to prevent accidents. * Staff smelled cigarette smoke in R3's room on multiple occasions. The Facility did not complete a smoke assessment or revise R3's smoking care plan to prevent further occurrences of smoking in R3's room. * The Facility identified R2 as being the only current Resident residing in the Facility who smokes. The Facility did not complete a smoking risk assessment and did not develop a smoking care plan. * R1 was observed being left alone in the bathroom. Interview with DON-B reveals R1 should not have been left alone in the bathroom. The Facility did not determine the root cause of R1's fall on 1/4/24. * R4 was observed alone in her room. An intervention on R4's fall care plan is R4 is to be in supervised areas when up. R4 was observed with a chair alarm and then without the chair alarm during survey. The facility did not thoroughly investigate and determine the root cause of R4's falls on 9/7/23, 9/20/23, 11/7/23, 11/9/23, & 12/15/23. Findings include: The Smoking Policy not dated under procedure documents the following: * Resident and/or Resident Representative will be informed at time of admission that [Facility's Name] is a smoke free facility, which includes surrounding campus. A copy of the facility smoking policy will be provided. * Upon resident request for use of an electronic cigarette or tobacco cigarette, nursing will conduct an Elopement assessment & a Smoking Risk assessment. These assessments will determine resident's ability to safety smoke supervised or unsupervised off facility premises. Assessments will then be performed quarterly and with significant change. * If resident is deemed unsafe per nursing assessments for independently smoking off premises, direct supervision will be provided by facility staff or resident representatives. A smoking apron will be provided by facility if indicated per nursing assessment. * Nursing will educate resident on risk associated with smoking and offer resident information on smoking cessation. * If resident or resident representative should choose to smoke/allow smoking despite nursing education and offers of cessation, resident and/or resident representative will sign a facility smoking agreement. * Under no circumstance may smoking materials be stored in resident's room. All smoking materials (i.e. cigarettes, lighters, e-cigarettes, and cartridges) will be locked in medication room of unit resident is living in. * Resident and/or Resident representative will be responsible for providing smoking materials. * Facility will ensure that there is a clear path to the designated smoking area (side walk next to facility grounds). 1. R3 was admitted to the facility on [DATE] and discharged on 1/28/24. R3's diagnoses includes alcohol dependence, insomnia, anxiety disorder, nicotine dependence, severe protein-calorie malnutrition, and hypotension. R3's face sheet for smoking status documents Current every day smoker. The smoking care plan with a start date & edit date of 1/19/24 documents the following approaches: * Assess resident for safety while smoking. Start date & edit date of 1/19/24. * Resident will not smoke with oxygen on. Start date & edit date of 1/19/24. * [R3's first name] educated facility is a non smoking campus and smoking in room is strictly prohibited. Educated on the risks vs benefits. Cigarette and lighter were taken to be stored in the nursing office. Resident can smoke outside off the property. She is aware of the rules, and asking for cigs (cigarettes) and lighter when needed. Start date & edit date of 1/19/24. * Safe smoking observation quarterly. Start date & edit date 1/19/24. The nurses note dated 1/19/24 at 2:33 p.m. includes documentation of Resident was admitted from [Hospital Name]. She is admitting with Bronchitis, cough, weakness, some leg swelling and some therapy. She is A&Ox3 (alert and orientated times three) and is able to make her needs and wants known This nurses note was written by RN (Registered Nurse)-Q. The nurses note dated 1/21/24 at 7:03 p.m. documents Resident was smoking in her room so this writer took her cigarettes and placed them in the med (medication) room. This nurses note was written by RN-E. The nurses note dated 1/22/24 at 11:58 a.m. documents Writer spoke with resident regarding smoking in her room, she said she only took four puffs. Writer stated we are a smoke free facility. Resident stated she is trying to quit and is chewing the gum. Resident stated she feels like a prisoner because she cannot go outside. Writer told resident she is allowed to go outside in the courtyard area due to safety concerns with weather and ice she cannot go out the front door by herself. Maintenance cleared a path for resident to go outside and meditate per resident request. This note was written by DON (Director of Nursing)-B. The nurses note dated 1/22/24 at 1:29 p.m. documents Resident admitted for short term rehab d/t (due to) generalized weakness, pleural effusion, bronchitis. Resident also has DX (diagnosis) of chronic pancreatitis, hypotension, hyperbilirubinemia, chronic complex fluid collection in pancreatic head. Resident alert and orientated x 3, able to make needs known. Resident expressed being upset this AM (morning) regarding not being able to go out and smoke. Writer discussed nicotine patch with resident vs gum - states she wants to stick with the gum and understands she can not go outside to smoke. Cigarettes locked in med room. Labs drawn this AM, copy for NP (nurse practitioner) in binder. Colostomy patent, functioning properly. Resident states at home she manages own ostomy and does not have any questions regarding this. Intakes have been adequate, no issues chewing or swallowing noted. Transfers with 1 assist and wheeled walker. Resident has +2 pitting edema to BLE (bilateral lower extremities). Education done with resident about elevating legs, states understanding. Encouraged to lay down after meals. Added daily weight starting tomorrow. No SOB (shortness of breath) noted, remains on RA (room air), O2 (oxygen) sat 95% on RA. No coughing noted. BS (bowel sounds) active. Incontinent of urine at times. Cont (continue) to work with PT (physical therapy) and OT (occupational therapy) towards goal to return home. This nurses note was written by RN-F. The nurses note dated 1/22/24 at 5:10 p.m. documents Called to resident room by CNA (Certified Nursing Assistant) d/t (due to) smell of cigarettes' smoke, strong odor noted upon entering room. Resident admitted to taking 2 puffs, CNA and writer searched room and lighter and cigarettes put in med room, resident stated she knows better but just can't help it. Offered nicotine gum, resident agreeable, given at this time. Writer also explained risks of smoking in building and why is not allowed, states understanding. This nurses note was written by RN-F. The nurses note dated 1/23/24 at 4:17 a.m. documents Per CNAs, they had smelled cigarette smoke coming from resident's room. This writer found resident not in her room as her door was open. Resident out in lounge area eating. Had discussion regarding smoking is not allowed in her room or in the building. Resident did not admit to smoking in her room at this time. This nurses note was written by RN-G. The nurses note dated 1/23/24 at 8:55 a.m. documents Resident admitted to [Facility's Name] for short term rehab d/t generalized weakness, pleural effusion, bronchitis. Resident is A&Ox3, and able to make needs known. Education provided to resident on smoking within facility, and that we are a smoke free facility. Resident stated understanding of education. Has nicotine gum PRN (as needed). Does not want a nicotine patch at this time. Colostomy patent, functioning properly. Has managed her own prior to stay at [Facility's Name]. Incont. (incontinent) of bladder. LSC (lung sounds clear) bilat, heart rate is good. Denies SOB and chest pain at this time. Intakes have been adequate, no issues chewing or swallowing noted. Diet: regular diet, thin liquids. Transfers with 1 assist and wheeled walker. +2 pitting edema to BLE. Education provided on importance of elevating BLE to reduce edema. Resident is a daily weight. Resident cont (continue) to work with therapy to reach goals of returning home. This nurses note was written by RN-C. The admission SNF (skilled nursing facility) initial visit dated 1/23/24 under social history includes documentation of Patient is a current smoker never used vapes not currently using alcohol and uses cannabinoids. The nurses note dated 1/24/24 at 12:47 p.m. documents CNAs brought several cigarettes to writer, some half smoked and let writer know there was a smell of cigarettes' smoke in resident's room. Strong odor noted upon entering room. Resident told writer she did not light any and does not even have a lighter to do so. Room was searched and all cigarettes were removed and brought to office. Writer educated resident on risk of smoking in building and why is not allowed, states understanding and thanked staff for helping quit the bad habit. This note was written by NHA (Nursing Home Administrator)-A. The 5 day MDS (minimum data set) with an assessment reference date of 1/26/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R3 was discharged home on 1/28/24. During R3's record review Surveyor was unable to locate a smoking assessment for R3. On 1/31/24 at 10:15 a.m. Surveyor asked CNA (Certified Nursing Assistant)-I if R3 smoked. CNA-I replied yes. CNA-I informed Surveyor R3 smoked a few times in her room and they had to take the cigarettes away. CNA-I informed Surveyor R3 would blatantly lie about smoking. Surveyor asked how many times R3 was caught smoking in her room. CNA-I replied probably at least three times. CNA-I informed Surveyor one time they did take R3's cigarettes away and R3 had been hiding them in a Kleenex box. Surveyor inquired if R3 used oxygen as Surveyor observed an oxygen sign on the doorframe where R3 resided. CNA-I informed Surveyor that was for a previous resident. On 1/31/24 at 2:29 p.m. Surveyor asked CNA-P if R3 smoked in her room. CNA-P informed Surveyor she didn't see R3 smoke but could smell it. CNA-P stated R3's roommate complained to people about R3 smoking. Surveyor asked if R3 could have her own cigarettes. CNA-P informed Surveyor she thinks R3 ordered them from door dash. Surveyor asked CNA-P when R3 smoked in her room what would happen to R3. CNA-P informed Surveyor she wasn't sure, the nurses were told but it never stopped. On 1/31/24 at 2:31 p.m. Surveyor asked CNA-J if R3 smoked in her room. CNA-J explained she never saw R3 smoking but could smell the smoke. CNA-J informed Surveyor her partner told the nurse, DON (Director of Nursing)-B was told and she would talk to her. Surveyor asked CNA-J if R3 used oxygen while at the Facility. CNA-J replied no. Surveyor asked CNA-J if R3 could go outside the Facility to smoke. CNA-J informed Surveyor R3 could go out with family but they were not allowed to go with R3. On 1/31/24 at 3:04 p.m. Surveyor asked NHA-A if smoking assessments are completed. NHA-A informed Surveyor if we do one they are under the observation tab. NHA-A informed Surveyor they don't do assessments because they are smoke free and can't smoke on their property. Surveyor asked about a smoking assessment for R3. NHA-A informed Surveyor they had a smoking assessment for a previous stay explaining they made an agreement with R3 she could go on the sidewalk and smoke Surveyor noted R3 was previously at the Facility from 10/2/23 to 10/8/23. NHA-A informed Surveyor this stay she didn't want to go and do that and was trying to quit. NHA-A informed Surveyor they gave R3 an option of a nicotine patch. NHA-A informed Surveyor they did catch her trying to smoke & confiscated her cigarettes & lights. NHA-A informed Surveyor she knows there is a smoking assessment for R3's previous stay but not this one. On 1/31/24 at 3:18 p.m. Surveyor asked RN (Registered Nurse)-K about R3's smoking. RN-K informed Surveyor she didn't have R3 as she starts at the next room, [room number] but could smell the smoke. RN-K explained the nurses would go in and tell R3 not to smoke. RN-K informed Surveyor R3 was encouraged to go outside to smoke and saw R3 smoking right outside the front door. On 2/1/24 at 9:43 a.m. Surveyor asked LPN (Licensed Practical Nurse)-L who would complete a Resident's smoking assessment. LPN-L informed Surveyor the admitting nurse would if they are aware the Resident smokes. LPN-L explained it's not a normal part of their admission process. On 2/1/24 at 10:05 a.m. Surveyor asked LPN-M who is responsible for completing a Resident's smoking assessment. LPN-M informed Surveyor she assumes it would be the admitting nurse. LPN-M explained it doesn't happen very often that they have a Resident who smokes or if they smoke they don't smoke here. LPN-M informed Surveyor she has never admitted a Resident who smokes. Surveyor asked LPN-M if a Resident didn't have a smoking assessment and was caught smoking would an assessment be done. LPN-M replied absolutely. On 2/1/24 at 11:37 a.m. Surveyor asked LPN/CM (Licensed Practical Nurse/Clinical Manager)-N if she is responsible for Resident's care plans. LPN/CM-N replied yes. Surveyor asked LPN/CM-N to explain the Facility's process. LPN/CM-N explained if she is here when a Resident is admitted she usually puts in a baseline care plan and if she's not at the Facility the admitting nurse will put a baseline care plan in within the first 48 hours. LPN/CM-N explained she will go back check the care plan and update as needed. LPN/CM-N informed Surveyor the comprehensive care plan has to be done 7 days from the CAA (care area assessment) but usually has the care plans done sooner. LPN/CM-N explained the care plans would then be reviewed quarterly, annually and as needed. Surveyor asked about Resident's smoking care plan. LPN/CM-N informed Surveyor if she knows the Resident is a known smoker then will add a smoking care plan. LPN/CM-N informed Surveyor she knew R3 from her last stay and knew she had a history of smoking so she did a smoking care plan. LPN/CM-N informed Surveyor she knew R3 had a history of smoking in her room from her last admission so she kept the same approaches from R3's prior admission. Surveyor asked LPN/CM-N why R3's smoking care plan wasn't revised after staff smelled cigarette smoke multiple times in her room. LPN/CM-N informed Surveyor she wasn't aware of R3 smoking until she was basically gone. LPN/CM-N informed Surveyor she never saw or smelled the cigarette smoke. LPN/CM-N informed Surveyor if she had known she would have updated the care plan. LPN/CM-N informed Surveyor the nurse on the floor can update care plans but they have had some agency nurses and she wasn't sure if they know how to update care plans. LPN/CM-N informed Surveyor she tries her best to keep on top but doesn't always know everything. Surveyor inquired who would complete a Resident's smoking assessment. LPN/CM-N replied the nurse and explained they are pretty good at keeping this a smoke free facility. LPN/CM-N indicated they have never had a problem and this is new to them. On 2/1/24 at 1:38 p.m. Surveyor met with DON-B to discuss R3's smoking. Surveyor inquired why a smoking assessment was never completed. DON-B informed Surveyor they never actually saw R3 smoke only smelled the cigarette smoke. DON-B explained they didn't see her so they didn't do an assessment. DON-B informed Surveyor they took R3's cigarettes from her room but R3 would call an Uber and go out. DON-B informed Surveyor they would ask R3 if she was smoking in her room and she would deny smoking every time. Surveyor informed DON-B a smoking assessment should have been completed. Surveyor informed DON-B Surveyor had noted a smoking care plan with approaches all dated 1/19/24 but R3's care plan was not revised. DON-B replied sorry, should have done that. On 2/1/24 at 2:08 p.m. Surveyor asked SSD (Social Service Director)-O if she had any contact with R3. SSD-O replied just to do her discharge with her. Surveyor asked SSD-O if she spoke to R3 about smoking in her room. SSD-O replied no. 2. On 1/31/24 at 8:01 a.m. Surveyor asked NHA (Nursing Home Administrator)-A for a list of Residents who smoke. On 1/31/24 at 9:17 a.m. Surveyor was provided with a list of Residents who smoke. Surveyor noted there was only one Resident, R2, on the list. R2 was admitted to the facility on [DATE]. Diagnoses includes bilateral osteoarthritis of knee, alcoholic cirrhosis of liver with ascites, diabetes mellitus, anxiety disorder and depression. R2's face sheet for smoking status documents Current some day smoker. The admission MDS (minimum data set) with an assessment reference date of 1/17/24 has a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. On 1/31/24 Surveyor reviewed R2's care plans and noted the following care plans: * Contact isolation. Start date & edit date 1/10/24. * Requires oxygen therapy. Start date & edit date 1/10/24. * At risk for alteration in nutrition. Start date & edit date 1/10/24. * Wishes to be a full code. Start date & edit date 1/10/24. * Dressing & grooming. Start date & edit date 1/10/24. * Limited in ability to transfer self. Start date & edit date 1/10/24. * At risk for constipation. Start date & edit date 1/10/24. * At risk for pain. Start date & edit date 1/10/24. * At risk for skin breakdown, pressure injury, skin tears. Start date & edit date 1/10/24. * At risk for incontinence. Start date & edit date 1/10/24. * At risk for falls. Start date 1/10/24 & edit date 1/17/24. * Potential risk for self care deficit or needs assistance with ADLs (activities daily living). Start date & edit date 1/10/24. * At risk for psycho-social well being. Start date & edit date 1/10/24. * To be discharged from facility. Start date & edit date 1/10/24. Surveyor did not note a smoking care plan for R2. On 1/31/24 at 1:13 p.m. Surveyor observed R2 awake in bed. Surveyor asked R2 if she smokes. R2 replied I do. R2 informed Surveyor right now she doesn't have any cigarettes so she's not smoking. R2 indicated if a family member comes they can take her out. On 1/31/24 at 1:20 p.m. Surveyor asked RN (Registered Nurse)-R where Surveyor would be able to locate smoking assessments. RN-R informed Surveyor she wasn't sure. Surveyor informed RN-R Surveyor had asked the Facility for a list of Residents who smoke and was provided with R2's name. RN-R informed Surveyor R2 is the only one that smokes. Surveyor asked what happens if a Resident smokes in their room. RN-R informed Surveyor they would have to talk to the Resident that it's not appropriate, would have to give their cigarettes to us. On 1/31/24 at 3:04 p.m. Surveyor asked NHA-A if smoking assessments are completed. NHA-A informed Surveyor if we do one they are under the observation tab. Surveyor inquired if there is a smoking assessment for R2 who is identified as smoking on the list provided to Surveyor. NHA-A informed Surveyor she didn't believe they did one. NHA-A informed Surveyor R2 attempted to smoke in the courtyard and NHA-A told R2 to put out the cigarette. NHA-A informed Surveyor she told R2 they are smoke free and R2 has not made any other attempts to smoke. NHA-A informed Surveyor they don't do assessments because they are smoke free and can't smoke on their property. On 2/1/24 at 9:43 a.m. Surveyor asked LPN (Licensed Practical Nurse)-L who would complete a Resident's smoking assessment. LPN-L informed Surveyor the admitting nurse would if they are aware the Resident smokes. LPN-L explained it's not a normal part of their admission process. On 2/1/24 at 10:05 a.m. Surveyor asked LPN-M who is responsible for completing a Resident's smoking assessment. LPN-M informed Surveyor she assumes it would be the admitting nurse. LPN-M explained it doesn't happen very often that they have a Resident who smokes or if they smoke they don't smoke here. LPN-M informed Surveyor she has never admitted a Resident who smokes. Surveyor asked LPN-M if a Resident didn't have a smoking assessment and was caught smoking would an assessment be done. LPN-M replied absolutely. On 2/1/24 at 11:37 a.m. Surveyor asked LPN/CM (Licensed Practical Nurse/Clinical Manager)-N if she is responsible for Resident's care plans. LPN/CM-N replied yes. Surveyor asked LPN/CM-N to explain the Facility's process. LPN/CM-N explained if she is here when a Resident is admitted she usually puts in a baseline care plan and if she's not at the Facility the admitting nurse will put a baseline care plan in within the first 48 hours. LPN/CM-N explained she will go back check the care plan and update as needed. LPN/CM-N informed Surveyor the comprehensive care plan has to be done 7 days from the CAA (care area assessment) but usually has the care plans done sooner. LPN/CM-N explained the care plans would then be reviewed quarterly, annually and as needed. Surveyor asked about Resident's smoking care plan. LPN/CM-N informed Surveyor if she knows the Resident is a known smoker then will add a smoking care plan. Surveyor asked LPN/CM-N why there wasn't a smoking care plan for R2. LPN/CM-N informed Surveyor she wasn't aware R2 was currently smoking. Surveyor informed LPN/CM-N R2's face sheet indicates she smokes and NHA-A informed Surveyor she caught R2 smoking in the court yard and told her to put out the cigarette. LPN/CM-N informed Surveyor she has never seen R2 smoke. Surveyor inquired who would complete a Resident's smoking assessment. LPN/CM-N replied the nurse and explained they are pretty good at keeping this a smoke free facility. LPN/CM-N indicated they have never had a problem and this is new to them. On 2/1/24 at 1:48 p.m. Surveyor asked DON (Director of Nursing)-B why a smoking assessment was not completed for R2. DON-B informed Surveyor she didn't know R2 was smoking and didn't know she was a smoker. Surveyor informed DON-B that NHA-A had informed Surveyor R2 attempted to smoke in the courtyard and she told R2 to put out the cigarette. Surveyor informed DON-B a smoking assessment was not completed for R2 and a smoking care plan was not developed. The Falls Clinical Protocol from 2001 Med Pass Inc. (Revised March 2018) under cause identification documents; 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. If the cause of a fall is unclear, of if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. a. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. b. Many categories of medications and especially combinations of mediations in several of those categories, increase the risk of falling. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified or it is determined that the cause cannot be found or is not correctable. Falls: 3. R1 was admitted to the facility on [DATE]. Diagnoses includes fracture of right femur s/p ORIF (status post open reduction internal fixation), hypertension, diabetes mellitus, and dementia. The at risk for falling care plan with a start date of 12/19/23 & edited on 1/25/24 documents the following approaches: * Assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair if indicated. Start date 12/19/23 & edit date 12/21/23. * Assure the floor is free of glare, liquids, foreign objects, and clutter. Start date 12/19/23 & edit date 12/21/23. * Educate resident on safety measures and approaches. Start date 12/19/23 & edit date 12/21/23. * Encourage resident to assume a standing position slowly. Start date 12/19/23 & edit date 12/21/23. * Give resident verbal reminders not to ambulate/transfer without assistance. Start date 12/19/23 & edit date 12/21/23. * Keep call light in reach at all times. Start date 12/19/23 & edit date 12/21/23. * Keep personal items and frequently used items within reach. Start date 12/19/23 & edit 12/21/23. * Leave night light on in room as desired. Start date 12/19/23 & edit date 12/21/23. * Low-high risk: Falling star. Start date 12/19/23 & edit date 12/21/23. * Obtain PT/OT (physical therapy/occupational therapy) consult for strength training, toning, positioning, transfer training, gait training, mobility devices. Start date 12/19/23 & edit date 12/21/23. * Orient resident to environment, room, and call light upon admission and as needed. Start date 12/19/23 & edit date 12/21/23. * Orient resident when there has been new furniture placement or other changes in environment. Start date 12/19/23 & edit date 12/21/23. * Provide proper, well-maintained footwear. Start date 12/19/23 & edit date 12/21/23. * Provide resident an environment free of clutter. Start date 12/19/23 & edit date 12/21/23. * Resident is cognitively and physically unsafe to be left alone on toilet for privacy with call light in reach and reminders not to self transfer until cleared by therapy. Start date 12/19/23 & edit date 12/21/23. * Review fall prevention information and contract with resident. Post signed contract in resident room within 24-72 hours of admission. Start date 12/19/23 & edit date 12/21/23. * Pad alarm implemented, placed on at all times to chair & bed. Start date 12/30/23 & created 1/2/24. * Sent to ER (emergency room) for eval (evaluation) and admitted . Resident had been toileted 1 hour prior, resting in recliner with call light in reach, gripper socks on feet, and pad alarm on and functioning. Start bladder diary, recently started new seroquel for dementia with behaviors, restlessness, impulsiveness, agitation. To be in supervised areas when out of bed. Start date & create date 1/4/24. * Keep recliner remote in side pocket. Start date 1/22/24 & created 1/25/24. * Dycem to recliner to reduce the risk of sliding down. Start date 1/22/24 & created 1/24/24. The John Hopkins fall risk assessment dated [DATE] has a score of 13 which indicates moderate fall risk. The admission MDS (minimum data set) with an assessment reference date of 12/24/23 has a BIMS (brief interview mental status) score of 7 which indicates severe cognitive impairment. R1 is assessed as having no behavior including refusal of care. R1 is assessed as requiring substantial/maximal assistance for toileting/hygiene, mobility roll left to right, sit to lying, chair/bed to chair, and toilet transfer. R1 is occasionally incontinent of urine & bowel. Yes is answered for the question did resident have falls anytime in last month prior to admission. Yes is answered for question does resident have any fractures related to fall in last 6 months prior to admission/entry or reentry. The fall CAA (care area assessment) dated 1/1/24 under analysis of findings documents Resident has triggered for this CAA r/t (related to) her fall at home prior to admission. She is also at risk for fall per the antidepressant she is on. She is working with PT/OT to improve her strengthening and independence. She has had no falls while at the facility. She is at moderate risk for falls per the fall observation. Facility protocols are in place. Staff to ensure that all her needs are met with all encounters. The nurses note dated 1/4/24 at 5:50 a.m. documents Writer heard resident's chair/bed alarm while getting out from other's resident's room. Writer rushed thru resident's room and observed resident in front of reclining chair with head down/right side on the floor, with both knees in fetal position gripper socks on. Resident able to lift her head up herself. Asked resident what happened; states she was trying to go to the bathroom. Noted a quarter size bump, raised to right side of head/upper temple states discomfort kind a crying saying I hit my head Resident able to do active ROM (range of motion) to upper and lower extremities, WNL (within normal limits) per resident usual no deformity or shortening noted. BP (blood pressure) 159/8, T (temperature) 97.5 P (pulse) 98 R (respirations) 18 O2 (oxygen) 93% RA (room air. Bilateral hand grasps firm/strong and equal. Left side PERRLA (public equal round reactive light accommodation), right side not able to assess d/t (due to) treatment. Speech is clear answering questions appropriately. Transferred with 2 assist back to reclining chair per her choice without difficulty. Resident got toileted an hour prior of the fall. Resident's pan cake call light to her left side by her table where she wants it was in reach pad alarm was functioning. This nurses note was written by LPN (Licensed Practical Nurse)-S. The nurses note dated 1/4/24 at 6:30 a.m. documents Updated provider via hucu. Received order from [Name], APNP (advanced practice nurse prescriber) to send to ER (emergency room) for evaluation d/t (due to) resident is taking eliquis. Called POA (power of attorney) son [Name] and updated in regards of residents fall; ok to what ever providers recommendation. Informed son that resident will be sent out to ER at [Hospital initials] for evaluation and voiced understanding. Requesting to keep him updated as resident has an appt (appointment) with ortho today and suppose to meet resident up to her appointment. This was passed on to AM (morning) nurse & will update son. Ambulance were called/[name]. Called ER nurse at [hospital initials] gave report in regards of resident to [name] RN (registered nurse). Ambulance came and left at 0615 (6:15 a.m.). DON (Director of Nursing) [Name] aware of fall. This nurses note was written by LPN-S. Surveyor reviewed R1's fall investigation and noted the Facility conducted a thorough investigation but did not determine the root cause of R1's fall on 1/4/24 to help prevent future falls. On 1/31/24 at 8:52 a.m. Surveyor observed R1 sitting in a personal type recliner in R1's room with her eyes closed. R1's legs were extended and was wearing yellow gripper socks. The call light pad is on the over bed table to the left of R1 and there is an alarm cord noted on the left arm going down to the seat of the chair. On 1/31/24 at 10:19 a.m. Surveyor observed R1 continues to be sitting in the personal type recliner with her legs down. The blue blanket is on the floor by R1's feet and R1 is rubbing her forehead. On 1/31/24 at 10:37 a.m. Surveyor observed CNA (Certified Nursing Assistant)-H leaving R1's room, the room door is almost closed and CNA-H pushed the round light device on the door frame. Surveyor asked CNA-H what the device was that she just pushed to turn the lights on. CNA-H replied so we know she is in the bathroom. On 1/31/24 at 10:43 a.m. Surveyor observed CNA-H leave the unit. On 1/31/24 at 10:49 a.m. Surveyor observed R1 sitting on the toilet in the bathroom with her pants down to her knees. On 1/31/24 at 10:49 a.m. Surveyor observed CNA-H back on the unit. On 1/31/24 at 10:51 a.m. Surveyor observed CNA-H enter R1's room and into the bathroom. CNA-H assisted R1 to stand, lowered R1's pants & assisted R1 to sit on the toilet. CNA-H indicated R1 must have at one point pulled up her pants and sat on toilet as R1 had her pants down when she (CNA-H) left her. CNA-H stated she was glad R1 didn't fall. CNA-H placed an incontinence product on R1 and asked R1 if she wiped good. R1 replied I wiped good. CNA-H asked R1 to stand up, assisted R1 to stand [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure residents have the right to voice grievances to the facility and receive a resolution to their grievance for 1 (R1) of 4 residents reviewed for grievances. R1's family voiced multiple concerns to the facility that were not documented, fully investigated and had no resolution. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that included Encounter for Aftercare - Left Knee Arthroplasty, Coronary Artery Disease, Diabetes Mellitus 2 and Edema. At the time of survey on 10/4/23 R1 was still a resident at the facility. Surveyor reviewed R1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/13/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired. R1 had an activated Power of Attorney (POA)-Q. On 10/3/23 Surveyor entered R1's room and Power of Attorney (POA)-Q was seated besides her. Surveyor asked if she had any concerns with the facility and R1's care. POA-Q stated yes and explained concerns such as her immobilizer causing blisters, the immobilizer being put on wrong, a delay in being seen by ortho in August and a delay in receiving antibiotics just to name a few. Surveyor asked if she had expressed these concerns to the facility. POA-Q stated yes. Surveyor reviewed facility's Grievance Log for July 2023 through October 2023. There were no grievances for R1. On 10/4/23 at 12:20 PM Surveyor interviewed Registered Nurse (RN)-R. Surveyor asked if R1 ever expressed any concerns to her. RN-R stated she has concerns, we just talk it over and address it. RN-R stated she does not think there is anything that has not been addressed. Surveyor asked if she reports these concerns to anyone or documents them. RN-R stated they discuss in morning meeting and sometimes she will discuss with Nursing Home Administrator (NHA)-A or Director of Nursing (DON)-B but they are both in morning meeting as well. RN-R stated she is also sure that NHA-A and DON-B have had some sort of meetings with R1 and POA-Q but she is not sure what they are about. On 10/4/23 at 12:20 PM Surveyor interviewed NHA-A. Surveyor asked if POA-A ever had any concerns or Grievances. NHA-A stated in July of 2023 she interviewed POA-A for a Quality Assurance project. NHA-A stated she wanted to get to the root of her issues. NHA-A stated POA-A stated she does not feel the facility is compassionate and were not educating her on discharging R1 and the possibility of private pay at the facility. NHA-A stated they had educated her and given her forms to fill out but they were never returned. NHA-A stated she also gave her outside referrals such as the ADRC (Aging and Disability Resource Center) for help with financial's. Surveyor asked if any of this was documented on a Grievance Form. NHA-A stated no. Surveyor stated that since July there are no Grievances from POA-Q and if she has so many concerns why are there no Grievances with investigations and resolutions. NHA-A stated that Former NHA-C would have been in charge at that time but even with her interview there should have been. NHA-A stated POA-Q has called and spoke to her about R1's pain management and her concerns. NHA-A stated that should have been in a Grievance as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview & policy review, the Facility did not ensure 1 (R2) 1 allegations of abuse were reported to the Administrator and State Survey Agency. R2 alleged that staff were rough when giving her a bed bath on 9/19/23. The allegation was not reported to the state survey agency immediately and no longer than 2 hours from the allegation. Findings include: R2 was admitted to the facility on [DATE] with diagnoses that included Fibromyalgia and Depression, R2's Initial Minimum Data Set (MDS) dated [DATE] indicated R2 was assessed to have a Brief Interview for Mental Status score of 15 which indicated fully intact cognitive function. On 10/3/23 a grievance for R2 dated 9/20/23 reported by R2's family member was reviewed and indicated concerns that Certified Nursing Assistants (CNA) were being rough during a bed bath. R2 could not explain how the CNA's were rough with her. R2 indicated she was treated like an animal. The CNA's were interviewed and indicated R2 was scared to roll in bed and siderails were added after the grievance. No other staff or residents were interviewed as part of the investigation. On 10/3/23 at 10:00 AM R2 was interviewed and indicated that CNAs were previously rough with her while giving her care. R2 indicated it only happened once and the facility fixed the problem. R2 indicated she didn't want to be treated like that again. R2 did not remember who the CNA's were and could not elaborate on the incident. Positioning bars were observed on R2's bed. On 10/3/23 at 1:30 PM Former Nursing Home Administrator-C (who completed the investigation) was interviewed and indicated she did not report R2's allegation of rough treatment to the state because she ruled it out within 2 hours. Former Nursing Home Administrator-A indicated she did not interview any additional staff or other residents and should have. On 10/3/23 the facility's policy titled Reporting and Investigating Allegations of Caregiver Misconduct dated 11/2022 was reviewed and read: All alleged violations involving resident abuse are reported immediately to the Division of Quality Assurance. Department of Health Services requires the reporting of allegations of abuse immediately, but within 2 hours of the allegation. The allegation by R2 was not reported to the state agency. On 10/3/23 at 3:00 PM Nursing Home Administrator (NHA-A) and Director of Nursing (DON)-B were informed of the above findings. Additional information was requested if available. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview & record review, the Facility did not ensure that 1 resident (R2) of 1 allegation an incident of physical abuse were thoroughly investigated, and the results of the investigation reported to the State Agency. R2 alleged that staff were rough when giving her a bed bath on 9/19/23. The investigation was not thoroughly investigated as no other staff were interviewed and other residents were not interviewed to see if they had similar concerns. Findings include: R2 was admitted to the facility on [DATE] with diagnoses that included Fibromyalgia and Depression, R2's Initial Minimum Data Set (MDS) dated [DATE] indicated R2 was assessed to have a Brief Interview for Mental Status score of 15 which indicated fully intact cognitive function. On 10/3/23 a grievance for R2 dated 9/20/23 reported by R2's family member was reviewed and indicated concerns that Certified Nursing Assistants (CNA) were being rough during a bed bath. R2 could not explain how the CNA's were rough with her. R2 indicated she was treated like an animal. The CNA's were interviewed and indicated R2 was scared to roll in bed and siderails were added after the grievance. No other staff or residents were interviewed as part of the investigation. On 10/3/23 at 10:00 AM R2 was interviewed and indicated that CNAs were previously rough with her while giving her care. R2 indicated it only happened once and the facility fixed the problem. R2 indicated she didn't want to be treated like that again. R2 did not remember who the CNA's were and could not elaborate on the incident. Positioning bars were observed on R2's bed. On 10/3/23 at 1:30 PM Former Nursing Home Administrator-C (who completed the investigation) was interviewed and indicated she did not report R2's allegation of rough treatment to the state because she ruled it out within 2 hours. Former Nursing Home Administrator-A indicated she did not interview any additional staff or other residents and should have. On 10/3/23 the facilities policy titled Reporting and Investigating Allegations of Caregiver Misconduct dated 11/2022 was reviewed and read: The administrator shall interview all employees who have had contact with the resident or individuals who may have been working at that time when the allegation was said to have occurred. The minimum timeframe shall include the 24 hours prior to the alleged abuse. The administrator or designee shall interview a sample of residents and staff regarding any concerns they may have which might indicate the extent of potential abuse. Interviews shall be documented. The only interviews as part of the investigation involving R2 on 9/19/23 were the 2 CNA's involved, R2 and R2's family member. On 10/3/23 at 3:00 PM Nursing Home Administrator (NHA-A) and Director of Nursing (DON)-B were informed of the above findings. Additional information was requested if available. No additional information was provided.