**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during a complaint survey, the facility failed to ensure each resident was provided care and treatment in accordance with professional standards of practice for one resident (Resident #9) of 40 sampled residents. Specifically, the facility failed to ensure Resident #9, a resident at risk for dehydration, was monitored for heat related illness and provided with sufficient hydration when temperatures in the building rose above 81 degrees from 4/30/24 until 5/2/24. On the morning of 5/2/24, Resident #9 was found nonresponsive with an elevated temperature and was sent to the hospital where they were treated for heat exhaustion and dehydration. Resident #9 experienced a significant change in condition following this event. This failure resulted in actual harm for Resident #9 that did not rise to the level of immediate jeopardy. Cross reference to F584: safe, clean, comfortable, homelike environment The findings include: According to the Centers for Disease Control and Prevention (CDC) guidance, last updated 6/25/24, retrieved from https://www.cdc.gov/heat-health/risk-factors/heat-and-older-adults-aged-65.html, older adults are at increased risk for heat related illness because they do not adjust as well to sudden changes in temperature, are more likely to have a chronic medical condition that can change normal body responses to heat and are more likely to take prescription medicines that affect the body's ability to control its temperature or sweat. Guidance included that older adults should stay in air-conditioned buildings as much as possible and should not rely on a fan as the main cooling source when it's really hot outside; should drink more water than usual, wear loose/ lightweight clothing and take cool showers or baths to cool down. Use of fans was indicated only if indoor temperatures were less than 90 degrees. In temperatures above 90 degrees, a fan could increase body temperature. The Procedure titled Code Purple: Severe Hot Weather with Loss of Cooling, last revised 2/1/15, documented action steps to be taken in the event of a Code Purple which included the following: move patients/residents to another air-conditioned part of the facility if available, encourage patients/residents to take in more fluids and keep hydrated, to force fluids if necessary, record fluid intake, provide cold wash clothes as needed, continuously evaluate patients/residents to ensure their safety and welfare are not being jeopardized and monitor body and environmental temperatures. Review of facility's Code Purple timeline and documentation revealed on 4/29/24 the cooling tower which serviced the A and B wings was taken out of service for scheduled maintenance and which impacted Resident #9's unit (3A). On 4/30/2024, outside temperatures rose and portable cooling units were unable to keep up with the demand to keep the building cool. After temperatures above 81 degrees were recorded for more than four hours, a Code Purple was enacted at 4:00 PM on 4/30/24. Upon request, the facility could not provide temperature monitoring/logs from 4/30/24 and prior to 4:30 PM on 5/1/24. From 4:30 PM on 5/1/24 until 10:30 AM on 5/2/24, hourly temperatures were recorded during 18 opportunities on unit 3A; of the 18 recorded temperatures, 16 of the temperatures recorded to be above 81 degrees. On 5/1/24 temperatures in the evening hours on Unit 3A reached over 90 degrees. Review of staff education provided on 4/30/24 and 5/1/24 revealed staff were educated to look for the following signs of heat related illness: high body temperature, red/hot/damp skin, fast pulse, headache/dizziness, nausea or vomiting and confusion/loss of consciousness. Actions for staff to take included: place cool, wet clothes on the skin, encourage light clothing, move to a cool area as able, offer plenty of fluids to drink and notify the provider of any change in a resident's condition. Resident #9 was admitted to the facility with diagnosis which included Parkinson's Disease, dementia, and dysphagia (swallowing disorder). The Minimum Data Set (an assessment tool) dated 4/14/24 documented the resident was assessed with a Brief Interview for Mental Status (BIMS) score of 3/15 which was indicative of impaired cognition. Resident #9 was assessed as being dependent on staff to complete most activities of daily living. The Nutrition Care Plan, initiated 7/27/23, documented the resident was at risk for dehydration. Interventions included staff were to observe for signs and symptoms of dehydration. The goal of the care plan was for Resident #9 to remain adequately hydrated as evidenced by good skin turgor, pink and moist mucous membranes and sufficient fluid intake. A Dietary Order dated 1/10/24 ordered the resident to receive honey thick liquids. A Physician Order dated 3/12/24 ordered staff to encourage thickened water intake during every shift. A Provider Note dated 4/24/24 documented Resident #9 seen by their provider and was assessed to be stable, afebrile and not in any acute distress. The resident was seen for a cough and prescribed Geri-tussin every 12 hours for 5 days. Review of Resident #9's electronic medical record (EMR) documented the resident received 240 millimeters of fluid with breakfast on 4/30/24; no additional fluids were documented. On 5/1/24, the resident was documented to have received 450 milliliters (15.2 ounces) of fluid across all shifts. No fluids were documented to have been provided on 5/2/24. Review of Resident #9's EMR revealed no progress notes were documented for the resident from the time they were seen by their provider on 4/24/24 until the morning of 5/2/24. A Nursing Progress Note dated 5/2/24 documented Resident #9 was found nonresponsive during care rounding. Vitals signs were obtained, and the resident's temperature was found to be 102 degrees. Orders were given to send the resident to the hospital for further evaluation and the resident was transported to the emergency room at 10:30 AM via emergency medical services (EMS). A Hospital Discharge summary dated [DATE] documented Resident #9 was confused at baseline but was usually verbal. EMS staff reported there was no air conditioning at the facility where the resident resided. Resident #9 was given 1.5 liters of fluid from EMS and the emergency room collectively. The resident was admitted to the hospital for further evaluation and management of hyponatremia related to decreased oral intake with dehydration due to heat exhaustion. Resident #9 was treated for dehydration and hyponatremia which was resolved with IV hydration. During an interview on 3/31/25 at 1:16 PM, Registered Nurse Unit Manager (RNUM) #10 stated during the Code Purple, staff were educated to monitor residents for signs of heat exhaustion and dehydration and to round to provide additional hydration. They stated it was an all hands-on deck situation and there were no specific resident assignments to monitor for hydration. They stated fluids provided should be documented in the EMR. RNUM #10 reviewed Resident #9's EMR and stated there were no nursing progress notes throughout the Code Purple. They stated Resident #9 required encouragement and assistance to accept fluids. They stated Resident #9 had mumbled speech and could express some needs, however, would not have been someone who could voice complaint about the heat. They stated Resident #9 was found nonresponsive and with a fever on the morning of 5/2/24 and was sent out to the hospital. They reviewed Resident #9's hospital discharge summary and stated the labs obtained were significant for dehydration. During an interview on 3/31/25 at 1:59 PM, the Director of Nursing (DON) stated that nursing staff were educated during the Code Purple to monitor residents for signs of heat exhaustion or changes in condition and to provide additional fluids. They stated routine charting of hydration was not completed during the code. They stated additional education had not been completed with nursing staff in response to the Code Purple after it was cleared. They stated they had reviewed Resident #9's EMR's and noted there was a lack of documentation. They stated Resident #9 was at risk for dehydration due to their diagnoses. During an interview on 4/1/25 at 9:08 AM, Social Work Case Manager (SWCM) #5 stated they were Resident #9's assigned case manager. They stated Resident #9 had mumbled speech but could express their needs in a limited capacity. They stated they had started calling residents' family members/representatives on the morning of 5/2/24 to inform them of moving residents to another area of the building, however, residents were not moved, and Resident #9 was sent out to the hospital that morning. They stated Resident #9's family expressed concern to them about the resident being impacted by the heat but that by the time the resident returned from the hospital, the cooling system was functional again. During an interview on 4/1/25 at 2:04 PM, the Medical Director stated Resident #9 had a diagnosis of advanced Parkinson's Disease and was prescribed thickened liquids to prevent aspiration. They stated staff at the facility monitored the resident's hydration and encouraged fluids. They stated residents who were prescribed thickened liquids were at increased risk for dehydration because they did not receive as much hydration from thickened fluid intake. They stated they had reviewed Resident #9's EMR and noted that there was no nursing progress notes during the time the facility experienced increased temperatures on the unit. They stated it was important to encourage fluids and stay proactive in observing residents for any change that could indicate heat related symptoms. They stated when Resident #9 was sent to the hospital, the labs were indicative of dehydration and hyponatremia. The Medical Director stated Resident #9 had worsening encephalopathy and comorbidities which contributed to the change in their condition. During an interview on 4/2/25 at 1:06 PM, Nurse Practitioner #24 stated they had been the primary care provider for Resident #9. They stated they had seen Resident #9 multiple times prior to the resident's hospitalization and the resident had been stable. They stated Resident #9 was at risk for dehydration and staff were to encourage fluids. They stated they went to assess Resident #9 on the morning of 5/2/24 after the nurse reported the resident had a fever and was nonresponsive. They stated the cooling units in the building had not been working for two days and the resident's room was very hot when they arrived. They stated they immediately called out for a cold compress and gave the order that the resident should be sent to the emergency room. They stated they did not don't recall any additional interventions implemented during the cooling system outage. During an interview on 4/2/25 at 1:25 PM, the Safety and Security Director (SSD) stated they participated in a meeting following the Code Purple. They stated the facility had ample water and Gatorade to disperse to residents during the code, however, it was identified the need for additional need for thickened liquids/residents who required a different consistency was not taken into account. They stated it was identified that thickened liquids needed to be more available on the care units and not kept in storage in the kitchen. It was also identified that fluid intake should be documented in resident medical charts.

Based on staff interview, review of video footage, and review of facility documentation and medical record documentation, the facility failed to protect Resident #3 from neglect when Geriatric Nursing Assistant (GNA) staff were allowed to repeatedly place Resident #3 into restraint with no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation and continuation of restraint. During nine episodes of the noncompliant GNA-initiated restraints between 10/7/22 and 1/6/23 that lasted between approximately 2.5 and 7.5 hours each, staff failed to document increased monitoring of the resident for safety, failed follow orders regarding the use of a soft helmet, failed to allow the resident breaks to stretch, stand or even reposition, and failed to attend to the resident's toileting needs as was care planned. Allowing GNA staff to initiate restraints with no documented clinical rationale, and then failing to meet basic needs of the resident while restrained, constituted neglect under Federal regulations. This was evident for 1 of 3 residents (Resident #3) reviewed for restraints. The findings include: Neglect - is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Physical restraint - is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body. Removes easily means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff. Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as defined at §483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the resident's best interest. Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Person-centered care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1. Three care plans associated with this deficient practice included: 1.1 First, on 2/2/23 review of the medical record revealed that a care plan was initiated on 1/22/21 for Resident #3's risk for impaired skin integrity due to episodes of incontinence. The care-plan goal was that the resident would remain free of impaired skin integrity. Care-plan interventions included but were not limited to, assisting the resident to use the toilet to promote continence, providing incontinence care after each episode [of incontinence], offering additional fluids within diet parameters, and preventative skin care as ordered. The care plan failed to adequately define when and how often the resident required toileting assistance. 1.2 Second, a care plan was open for the risk of gastrointestinal complications due to impaired cognition, a history of colon resection due to cancer, and a history of cholecystectomy. The care-plan goal was that the resident would remain free of constipation and would participate in toilet use with staff assistance to promote continence. Interventions included but were not limited to, assisting the resident to use the toilet and offering additional fluids within diet parameters. This care plan also failed to adequately define when and how often the resident required toileting assistance. 1.3 Third, a care plan was developed to address the resident's inability to comprehend group activity invitations and noted Resident #3 preferred to walk the length of the hallway. The care-plan goal was that the resident would continue to be able to walk within the care center and appear to enjoy socialization with caregivers and peers. The interventions included but were not limited to, walking the resident and talking about the things that were seen during the walk. This care plan also failed to adequately define when, how often, and for how long the resident should or could walk. Neither this care plan nor any other care plan instructed staff that during multi-hour episodes of restraint, staff were not to follow the care plan allowing the resident to walk. Further record review of the medical record revealed that Physician Assistant (PA) #42's conducted a visit on 11/10/22, and documented Resident #3's diagnoses as dementia with behavioral disturbances, repeated falls, and depression. The PA noted that Resident #3 required total care, was severely cognitively impaired, was able to ambulate, and tended to wander (random or repetitive locomotion). Related to the known falls risk, on 7/12/22 the attending physician had entered an order indicating, Resident to wear a soft helmet at all times except during care, remove and check skin Q [every] 2 hours. A second order dated 7/12/22 read, Remove safety helmet every 2 hours for skin checks - notify provider of concerns. 2. On nine separate occasions GNA staff placed Resident #3 into restraint with no clinical justification documented, no notification of the practitioner, no order obtained, no clinical nursing assessment obtained associated with the initiation of restraint, and no documentation of increased monitoring and support. In interview on 2/8/23 at 9:50 AM, Registered Nurse (RN) #41 indicated that, on several occasions, she had witnessed staff sitting Resident #3 in a heavy hospital recliner chair that was reclined and sometimes pushed under a table. RN #41 also reported that she observed Resident #3 in a wheelchair with the wheels locked and pulled up to a table. RN #41 expressed concerned about the length of time Resident #3 had been confined and that s/he had not received care while confined. She reported that although she had brought this to the attention of facility staff including the previous Administrator #44, the facility had failed to report all incidents to the State Agency. 2.1 RN #41 alleged that they observed Resident #3 in restraint on 10/7/22, involving the use of a reclining geriatric chair. A review of the record revealed no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation of restraint on 10/7/22. RN #41 indicated that the prior Director of Nursing (DON: Staff #43) was on the unit and that she verbally notified the DON of the concern. Although allegations were made, the facility did not report the allegations to the state survey agency as required and did not investigate the allegations. Video footage was unavailable for the 3 reported incidents of restraint during October, but the review of the footage for November, December, and January validated the allegations from October by corroborating an ongoing pattern of similar restraint use imposed by facility GNA staff just as was alleged in October. The failure to immediately report, investigate and address the allegations allowed the noncompliant practices to recur eight more times over/during the next three months. 2.2 RN #41 alleged that they observed Resident #3 again in restraint on 10/18/22 involving the use of a reclining geriatric chair. A review of the record revealed no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation of restraint on 10/18/22. RN #41 indicated that on this date she notified the Assistant Administrator (AA) and she then also reported the allegations in an email sent to the previous Administrator #44. Although the allegations were raised, the facility did not report the allegations to the state survey agency as required, did not investigate the allegations, and did not stop the noncompliant practice from recurring. 2.3 On 10/24/22 RN #41 alleged that they observed Resident #3 was again in restraint involving the use of a reclining geriatric chair. Review of the record revealed no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation of restraint on 10/24/22. RN #41 reported an email documentation corroborated that RN #41 reported the allegations to Administrator #44 on 10/24/22. Email documentation revealed also that on 10/26/22, RN #42's Director also reported the allegations to Administrator #44, the AA, and the facility Director of Quality Assurance. Although allegations were made, the facility did not report the allegations to the state survey agency as required, did not investigate the allegations, and still did not stop the noncompliant practice from recurring. 2.4 During the interview with RN #41 on 2/8/23 at 9:50 AM, a review of camera #71 video footage revealed that Resident #3 was brought to the day room by GNA #58 staff at 9:34 AM on 11/17/22 and was confined to a heavy reclining hospital chair by staff pushing the chair under the table. Then, at 9:57 AM, LPN #14 was observed pushing the chair back from the table and reclining the resident in the chair. Resident #3 remained in restraint for 2 hours and 31 minutes before s/he was allowed to stand at 12:05 PM, and this occurred only after staff noticed the resident trying to get up and lowered the reclined chair to allow her to get up. The staff person walked the resident around and left the resident to wander down the hallway in view of camera #71. For the 2 hours and 31 minutes, Resident #3 who otherwise could stand and walk was not able to because s/he was confined by staff using the reclining geriatric chair. A review of the record demonstrated no documented clinical justification, no practitioner notification, no order, and no clinical nursing assessment had been performed associated with the initiation and use of restraint on 11/17/22. For these 2 hours and 31 minutes, staff had not documented increased monitoring of the resident while in restraint, had not toileted the resident, had not provided incontinence care, and had not removed the soft helmet s/he was wearing for relief as ordered. 2.5 A review of the video footage for 11/22/22 revealed that Resident #3 was brought to the day room and placed in the heavy reclining hospital chair at 9:11 AM. When GNA #32 sat down to assist with the resident meal at 9:23 AM, she pushed the chair under the table restricting the resident's ability to move freely. After the meal, Resident #3 remained in this confined position until 12:55 PM when a staff member moved the chair back from the table and the resident immediately stood up without the assistance of staff. However, a staff member responded by making the resident sit back down again for the next meal. A review of the record demonstrated no documented clinical justification, no practitioner notification, no order, and no clinical assessment had been performed associated with the initiation or use of restraint on 11/22/22. For these 3 hours and 32 minutes, staff had not documented increased monitoring for resident safety, had not toileted the resident, had not provided incontinence care, and had not removed the soft helmet she was wearing for relief as was ordered. 2.6 A review of the video footage for camera 71 for 12/10/22 starting at 12:33 PM revealed that Resident #3 was brought to the day room by GNA staff with his/her helmet on. Staff initiated restraint by transferring Resident #3 into a large reclining chair and then reclining it. At 1:21 pm staff put the recliner down and pushed the resident's chair under the table while feeding him/her, and then after the meal they did not move the chair back from the table, which left Resident #3 to continue in restraint. LPN #14 was observed with the resident at 1:39 PM but did not remove him/her from restraint. At 3:11 PM, GNA #15 was sitting in the day room and when the resident was trying to get up, they intervened by pushing the chair further under the table. Resident #3 remained in restraint for 7 hours and 25 minutes until staff finally allowed him/her to exit restraint at 7:58 PM. A review of the record demonstrated no documented clinical justification, no practitioner notification, no order, and no clinical assessment had been performed associated with the initiation and continuation of restraint. For these many hours, staff had not documented increased monitoring of the resident while in restraint, had not toileted the resident, had not provided incontinence care, and had not removed the soft helmet she was wearing for relief as was ordered. 2.7 A review of the video footage for camera 71 for 12/11/22 starting at 4:40 PM revealed Resident #3 was brought to the day room and left sitting in the wheelchair. At 4:43 PM GNA #59 was observed moving the resident's wheelchair under the table and locking both wheels. Resident #3 remained in this position and unable to stand until 7:35 PM. A review of the record demonstrated no documented clinical justification, no practitioner notification, no order, and no clinical assessment had been performed associated with the initiation and use of restraint on this date. For these 2 hours and 52 minutes, staff had not documented increased monitoring of the resident while in restraint, had not toileted the resident, had not provided incontinence care, and had not removed the soft helmet for relief as was ordered. On 12/12/22, the facility reported to the state survey agency that there had been allegations received about restraint use on 12/10/22. This was the first required report the facility submitted. In this report the facility failed to report any of the other six episodes that had been alleged in both verbal and written internal reporting. The facility had also failed to investigate the broader use of restraints imposed by facility GNA staff with no documented clinical justification. This failure to report and investigate was in part causal to the noncompliance, as in failing to report and investigate, the facility administration allowed the resident rights violations to continue. When the facility reported with an update on the findings of the internal review, although aware, they did not report that the 12/10/22 episode was one of seven occurrences where multiple different GNAs were repeatedly restraining Resident #3. The facility did not report that there were no documented clinical justifications, no notifications to the practitioner and that no orders were obtained for any of the many times GNA staff restrained Resident #3. The facility did not report that no nursing assessments were obtained and that increased monitoring for safety during restraint was not documented related to the initiation and extended period of continuation of restraints by facility staff. The facility did not report that the 12/10/22 restraint had lasted more than 7 hours, that the order for the management of the helmet was not followed. Focused on only the one incident, the facility reported that there was no malintent by the staff on 12/10/22 and therefore the facility concluded there was no abuse evident. In interview on 2/10/23 at 10:17 AM, the Assistant Administrator indicated that he had reviewed the video footage for both 12/10/22 and 12/11/22 and had determined abuse was unsubstantiated. The 12/11/23 episode was however never reported to the state survey agency, and no documentation of investigation was provided to the survey team. From the one investigation, the facility did however conclude two GNA staff would not return to work in the facility and the facility reported that they started education for other staff related to the use of restraints in the facility. The education proved ineffective as other GNA staff on the same unit placed Resident #3 into restraint again on both 12/17/22 and 1/6/23. On 2/13/22 at 1:09 PM, review of email documentation provided by RN #41 confirmed that the previous Administrator #44 had been made aware of each of the incidents reviewed for 11/17/22, 11/22/22, 12/10/22, and 12/11/22, to include the incidents that had not been reviewed occurring on 10/7/22, 10/18/22, and 10/24/22. However, he failed to report all allegations of abuse to the State Agency. In fact, many staff were aware of the practice where different GNA staff placed Resident #3 into restraint many times. Multiple GNA staff participated directly in the practices, and multiple management staff were notified of the practices beginning in early October 2022. The failure to meet the minimum requirements to transparently report the concern and to fulsomely investigate the concern contributed to a culture on the unit where GNA staff were empowered to repeatedly, and egregiously violate the rights of Resident #3. 2.8 On 2/9/23 at 12:24 PM, a review of the video footage for camera 71 revealed for 12/17/22 starting at 12:24 PM Resident #3 was ambulating in the day room independently until GNA #33 sat the resident in a regular dining room chair and positioned the chair at the corner of the table. The resident successfully scooted the chair away from the table, but staff was then observed moving the chair back to the table and positioning the chair under the table which restricted the resident from moving about freely. After the staff repositioned the chair resident was observed in the video trying to get up but was unable. This time, Resident #3 was kept in a restraint by multiple facility staff until 7:51 PM (for 7 hours and 27 minutes). GNA #60, who was assigned to Resident #3 that shift, started her shift at 3 pm and had no contact with the resident at all until 7:51. For this episode, no clinical justification was evident, no notification was provided to the practitioner, no order was obtained, and no nursing assessment associated with the extended period of restraints was conducted or documented. Increased nursing monitoring for these many hours was not documented and was not evident in the video reviewed. At 2:45 PM an activity for residents was provided. Resident #3 was not able to participate while he/she remained in restraint. For these 7 hours and 27 minutes in restraint, Resident #3 was not toileted and was not provided incontinence care. The helmet was not removed in accordance with the order to offer breaks and relief and to check the resident's skin and no opportunity to break, stand, stretch or walk were provided. Review of the video revealed that throughout the day the resident was actively trying to get up. 2.9 A review of the video footage for camera 71 for 1/6/23 starting at 9:37 AM revealed Resident #3 was ambulated to the day room by 1 staff member, with no helmet on. The resident was then restrained with the use of a dining room chair by staff pushing it under the table for a half-hour when the resident was assisted by GNA #61 with a meal. When GNA #61 left the table the resident's chair was partially under the table. At 12:12 PM Resident #3 was able to stand. The video revealed that GNA #61 immediately held the resident while pulling the wheelchair behind, and then sat the resident into the chair seat with force sufficient that Resident #3's head went back and his/her left leg to flew up in the air. GNA #61 then locked the left wheel on the chair again. This staff conduct on 1/6/23 met the regulatory definition of abuse. Repeatedly left in restraint for hours at a time without provision of his/her basic care needs, on 1/13/23 PA #42 saw Resident #3 and documented a new sacral pressure ulcer. The PA visualized the wound and described it in some detail. The care plan was too vague to effectively communicate Resident #3's needs regarding prevention of skin damage and over the three months prior, staff had not provided all the necessary care and services that would reduce the risk for pressure ulcers. Review of the medical record revealed that on 1/13/23, Resident #3 was also seen by a wound nurse. The wound nurse also documented concerns with sacral skin integrity. The wound nurse documented that the resident had moisture associated skin damage (MASD). This contradicted the assessment by the PA but nonetheless showed skin integrity was compromised. Based on the video footage review as recent as 1/6/23 the resident had the ability to ambulate with staff assistance and a review of the therapy notes also indicated the resident remained at baseline for mobility. However, staff had placed him/her in positions that restrained the resident for hours at a time increasing the risk for skin damage when the regulations require provision of care and services to protect residents from skin damage. An interview with Geriatric Nursing Assistant (GNA) #31 on 2/9/23 at 9:30 AM revealed that Resident #3 was not able to communicate his/her needs to staff. She reported that the care needs of the resident were to toilet and/or provide incontinence care every 2 hours and remove the resident's helmet when the resident ate a meal, otherwise, the resident sat in the day room with no special needs. GNA #31 reported that she was aware that placing the resident in a position in which they cannot move about freely was a restraint. On 2/9/23 at 9:24 AM an interview with GNA #32 revealed that Resident #3 communicated by way of facial expressions and when the resident would resist that meant s/he did not want to do something. The GNA reported that the resident had a helmet that needed to be removed every 2 hours and required incontinence care every 2 hours. GNA #32 reported that she was aware that restricting a resident's movement against their will was considered a restraint. However, GNA #32 was identified by the facility on the video footage for 11/22/22 as not providing Resident #3 the care s/he needed and restricting the resident's ability to move around freely. During an interview with GNA #33 on 2/9/23 at 9:39 AM it was determined that she had been aware of Resident #3's care including removing the resident's helmet every two hours to check the skin and providing incontinence care every 2 hours. An interview with Licensed Practical Nurse (LPN) #14 on 2/9/23 at 9:13 AM revealed that Resident #3 required total care by staff. LPN #14 reported that she was aware that the resident had a helmet that needed to be removed every 2 hours and required toileting and/or incontinence care every 2 hours. She reported that Resident #3 was not on a restorative program but was walked to his/her room every 2 hours for incontinence care. In addition, she was aware that restricting a resident from moving about freely was considered a restraint. In a subsequent interview with LPN #14 on 2/10/23 at 9:07 AM she was asked how she monitored the GNAs to ensure that they were providing the care and services to meet the needs of each resident. LPN #14 reported that she monitored the residents and staff closely and would tell staff when they needed to provide care if they had not done so already. When asked what had happened on 11/17/22, 11/22/22, and 12/10/22 when she was assigned to Resident #3, it was observed on the video footage that staff had not provided the care that Resident #3 needed. LPN #14 stated she was not sure but that there were times she became overwhelmed with her duties. An interview on 2/13/23 at 1:32 PM with the Administrator, Assistant Administrator, Director of Nursing, Corporate Clinical Consultant #51, and the Director of Quality Assurance Nurse revealed that the Administrator had reviewed the episode of restarting use on 1/6/23. After her review of the video, the Administrator's indicated that she felt the staff had been very interactive with the resident but that they needed to address the restraints. She had not identified the hours that Resident #3 had gone without the care s/he needed. The federal regulations indicate that neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #3 suffered neglect when the facility repeatedly placed him/her into restraint with no clinical justification documented, with no practitioner notified, with no order obtained, with no nursing assessment obtained, and with no additional monitoring for safety and to ensure the resident's needs were met. In 9/9 times Resident #3 was restrained, staff failed to follow the order to remove a helmet from Resident #3 to offer relief. In 9/9 times staff failed to allow Resident #3 breaks to stretch or stand including during two episodes where staff kept Resident #3 in restraint for more than 7 hours. The facility administration was aware of the abusive noncompliant conduct but for more than two months took no actions to report, investigate, or end it. The failure to end the egregious rights violations contributed to a culture on the unit where many staff knew but nonetheless continued to allow the practices of and by several of the facility's GNA staff. The medical record also revealed neglect where the facility failed to ensure everything that should have been done to prevent skin wounds was done. The related care plans noted herein were noncompliant, as were the various episodes where Resident #3 had severely restricted mobility due to inappropriate and unjustified use of restraints. The MASD, and then the pressure ulcer that became evident did not meet the regulatory definition of unavoidable because in its neglect of Resident #3, the facility failed to ensure Resident #3 received the necessary care, treatment and services that might otherwise have prevented the decline in his/her skin integrity. Cross Reference F604, F607, F609, F610, F686, and F835

Based on staff interview, review of video footage, and review of facility documentation and medical record documentation, the facility failed to ensure staff did not impose unjustified restraints on one Resident (Resident #3). Geriatric Nursing Assistant (GNA) staff were allowed to repeatedly place Resident #3 into restraint with no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation and continuation of restraint. During nine episodes of the noncompliant GNA-initiated restraints between 10/7/22 and 1/6/23 that lasted between approximately 2.5 and 7.5 hours each, staff failed to document increased monitoring of the resident for safety, failed follow orders regarding the use of a soft helmet, failed to allow the resident breaks to stretch, stand or even reposition, and failed to attend to the resident's toileting needs as was care planned. This was evident for 1 of 3 residents (Resident #3) reviewed for restraints. The findings include: Neglect - is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as defined at §483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the resident's best interest. Physical restraint - is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body. Removes easily means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff. Convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the resident's best interest. Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Person-centered care: means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. MDS (Minimum Data Set) - is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. 1. Three care plans associated with this deficient practice included: 1.1 First, on 2/2/23 review of the medical record revealed that a care plan was initiated on 1/22/21 for Resident #3's risk for impaired skin integrity due to episodes of incontinence. The care-plan goal was that the resident would remain free of impaired skin integrity. Care-plan interventions included but were not limited to, assisting the resident to use the toilet to promote continence, providing incontinence care after each episode [of incontinence], offering additional fluids within diet parameters, and preventative skin care as ordered. The care plan failed to adequately define when and how often the resident required toileting assistance. 1.2 Second, a care plan was open for the risk of gastrointestinal complications due to impaired cognition, a history of colon resection due to cancer, and a history of cholecystectomy. The care-plan goal was that the resident would remain free of constipation and would participate in toilet use with staff assistance to promote continence. Interventions included but were not limited to, assisting the resident to use the toilet and offering additional fluids within diet parameters. This care plan also failed to adequately define when and how often the resident required toileting assistance. 1.3 Third, a care plan was developed to address the resident's inability to comprehend group activity invitations and noted Resident #3 preferred to walk the length of the hallway. The care-plan goal was that the resident would continue to be able to walk within the care center and appear to enjoy socialization with caregivers and peers. The interventions included but were not limited to, walking the resident and talking about the things that were seen during the walk. This care plan also failed to adequately define when, how often, and for how long the resident should or could walk. Neither this care plan nor any other care plan instructed staff that during multi-hour episodes of restraint, staff were not to follow the care plan allowing the resident to walk. Further review of the medical record revealed that Physician Assistant (PA) #42 conducted a visit on 11/10/22, and documented Resident #3's diagnoses as dementia with behavioral disturbances, repeated falls, and depression. The PA noted that Resident #3 required total care, was severely cognitively impaired, was able to ambulate, and tended to wander (random or repetitive locomotion). Related to the known falls risk, on 7/12/22 the attending physician had entered an order indicating, Resident to wear a soft helmet at all times except during care, remove and check skin Q [every] 2 hours. A second order dated 7/12/22 read, Remove safety helmet every 2 hours for skin checks - notify provider of concerns. 2. On nine separate occasions GNA staff placed Resident #3 into restraint with no clinical justification documented, no notification of the practitioner, no order obtained, no clinical nursing assessment obtained associated with the initiation of restraint, and no documentation of increased monitoring and support. In interview on 2/8/23 at 9:50 AM, Registered Nurse (RN) #41 indicated that, on several occasions, she had witnessed staff sitting Resident #3 in a heavy hospital recliner chair that was reclined and sometimes pushed under a table. RN #41 also reported that she observed Resident #3 in a wheelchair with the wheels locked and pulled up to a table. RN #41 expressed concern about the length of time Resident #3 had been confined and that s/he had not received care while confined. She reported that although she had brought this to the attention of facility staff including the previous Administrator #44, the facility had failed to report all incidents to the State Agency. 2.1 RN #41 alleged that on 10/7/22 they observed Resident #3 in restraint involving the use of a reclining geriatric chair. A review of the record revealed no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation of restraint on 10/7/22. RN #41 indicated that the prior Director of Nursing (DON: Staff #43) was on the unit and that she verbally notified the DON of the concern. Although allegations were made, the facility did not report the allegations to the state survey agency as required and did not investigate the allegations. Video footage was not available for the 3 reported incidents of restraint during October, but the review of the footage for November, December, and January validated the allegations from October by corroborating an ongoing pattern of similar restraint of the same resident on the same unit imposed by facility GNA staff just as was alleged in October. The failure to immediately report, investigate and address the allegations allowed the noncompliant practices to recur eight more times over/during the next three months. 2.2 RN #41 alleged that they observed Resident #3 again in restraint on 10/18/22 involving the use of a reclining geriatric chair. A review of the record revealed no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation of restraint on 10/18/22. RN #41 indicated that on this date she notified the Assistant Administrator (AA) and she then also reported the allegations in an email sent to the previous Administrator (Administrator Staff #44). Although the allegations were raised, the facility did not report the allegations to the state survey agency as required, did not investigate the allegations, and did not stop the noncompliant practice from recurring. 2.3 On 10/24/22 RN #41 alleged that they observed Resident #3 again in restraint involving the use of a reclining geriatric chair. Review of the record revealed no documented clinical justification, no practitioner notification, no order, and no clinical assessment performed associated with the initiation of restraint on 10/24/22. RN #41 reported an email documentation corroborated that RN #41 reported the allegations to Administrator #44 on 10/24/22. Email documentation also revealed that on 10/26/22, RN #41's Director sent a follow up email to Administrator #44, the AA, and the facility Director of Quality Assurance that requested them to look into the allegations as they were a violation of federal regulations. Although allegations were made, the facility did not report the allegations to the state survey agency as required, did not investigate the allegations, and still did not stop the noncompliant practice from recurring. 2.4 During the interview with RN #41 on 2/8/23 at 9:50 AM, a review of camera #71 video footage revealed that Resident #3 was brought to the day room by GNA #58 staff at 9:34 AM on 11/17/22 where s/he was confined to a heavy reclining hospital chair by staff pushing the chair under the table. Then, at 9:57 AM, LPN #14 was observed pushing the chair back from the table and reclining the resident in the chair. Resident #3 remained in restraint for 2 hours and 31 minutes before s/he was allowed to stand at 12:05 PM, and this occurred only after staff noticed the resident trying to get up and lowered the reclined chair to allow her to get up. The staff person walked the resident around and left the resident to wander down the hallway in view of camera #71. When allowed, Resident #3 was able to stand and walk. For the 2 hours and 31 minutes, Resident #3 who otherwise could stand and walk was not able to because s/he was confined by staff using the reclining geriatric chair. A review of the record demonstrated no documented clinical justification, no practitioner notification, no order, and no clinical nursing assessment had been performed associated with the initiation and use of restraint on 11/17/22. For these 2 hours and 31 minutes, staff had not documented increased monitoring of the resident while in restraint, had not toileted the resident, had not provided incontinence care, and had not removed the soft helmet s/he was wearing for relief as ordered. 2.5 A review of the video footage for 11/22/22 revealed that Resident #3 was brought to the day room and placed in the heavy reclining hospital chair at 9:11 AM. When GNA #32 sat down to assist with the resident meal at 9:23 AM, she pushed the chair under the table restricting the resident's ability to move freely. After the meal, Resident #3 remained in this confined position until 12:55 PM when a staff member moved the chair back from the table and the resident immediately stood up without the assistance of staff. However, a staff member then responded by making the resident sit back down again for the next meal. A review of the record demonstrated no documented clinical justification, no practitioner notification, no order, and no clinical assessment had been performed associated with the initiation or use of restraint on 11/22/22. For these 3 hours and 32 minutes, staff had not documented increased monitoring for resident safety, had not toileted the resident, had not provided incontinence care, and had not removed the soft helmet she was wearing for relief as was ordered. 2.6 A review of the video footage for camera 71 for 12/10/22 starting at 12:33 PM revealed that Resident #3 was brought to the day room by GNA staff with his/her helmet on. Staff initiated restraint by transferring Resident #3 into a large reclining chair and then reclining it. At 1:21 pm staff put the recliner down and pushed the resident's chair under the table while assisting him/her with a meal. After the meal they did not move the chair back from the table, which left Resident #3 to continue in restraint. LPN #14 was observed with the resident at 1:39 PM but did not remove him/her from restraint. At 3:11 PM, GNA #15 was sitting in the day room and when the resident was trying to get up, they intervened by pushing the chair further under the table. Resident #3 remained in restraint for 7 hours and 25 minutes until staff finally allowed him/her to exit restraint at 7:58 PM. A review of the record demonstrated no documented clinical justification, no practitioner notification, no order, and no clinical assessment had been performed associated with the initiation and continuation of restraint. For these many hours, staff had not documented increased monitoring for safety of the resident while in restraint, had not toileted the resident, had not provided incontinence care, and had not removed the soft helmet she was wearing for relief as was ordered. 2.7 A review of the video footage for camera 71 for 12/11/22 starting at 4:40 PM revealed Resident #3 was brought to the day room and left sitting in the wheelchair. At 4:43 PM GNA #59 was observed moving the resident's wheelchair under the table and locking both wheels. Resident #3 remained in this position and unable to stand until 7:35 PM. A review of the record demonstrated no documented clinical justification, no practitioner notification, no order, and no clinical assessment had been performed associated with the initiation and use of restraint on this date. For these 2 hours and 52 minutes, staff had not documented increased monitoring of the resident while in restraint, had not toileted the resident, had not provided incontinence care, and had not removed the soft helmet for relief as was ordered. On 12/12/22, the facility reported to the state survey agency that there had been allegations received about restraint use on 12/10/22. This was the first required report that the facility submitted. In this report the facility failed to report any of the other six episodes that had been alleged in both verbal and written internal reporting. The facility had also failed to investigate the broader pattern use of restraints imposed by facility GNA staff with no documented clinical justification. This failure to report and investigate was in part causal to the noncompliance, as in failing to report and investigate, the facility administration allowed the resident rights violations to continue. When the facility reported with an update on the findings of their completed internal review, although aware, they did still not report that the 12/10/22 episode was one of seven occurrences where multiple different GNAs were repeatedly restraining Resident #3. The facility did not report that there were no documented clinical justifications, no notifications to the practitioner and that no orders were obtained for any of the many times GNA staff restrained Resident #3. The facility did not report that no nursing assessments were obtained and that increased monitoring for safety during restraint was not documented related to the initiation and extended period of continuation of restraints by facility staff. The facility did not report that the 12/10/22 restraint had lasted more than 7 hours, that the order for the management of the helmet was not followed. And focused on only the one incident, the facility reported that there was no malintent by the staff on 12/10/22 and therefore the facility concluded there was no abuse evident. In interview on 2/10/23 at 10:17 AM, the Assistant Administrator indicated that he had reviewed the video footage for both 12/10/22 and 12/11/22 and that he had determined abuse was unsubstantiated. The 12/11/22 episode was however never reported to the state survey agency, and no documentation of investigation was provided to the survey team for the restraint episode on that date. From the one investigation, the facility did however conclude two GNA staff would not return to work in the facility and the facility reported that they started education for other staff related to the use of restraints in the facility. The education proved ineffective as other GNA staff on the same unit placed Resident #3 into restraint again on both 12/17/22 and 1/6/23. On 2/13/22 at 1:09 PM, review of email documentation provided by RN #41 confirmed that the previous Administrator #44 had been made aware of each of the incidents reviewed for 11/17/22, 11/22/22, 12/10/22, and 12/11/22, to include the incidents that had not been reviewed occurring on 10/7/22, 10/18/22, and 10/24/22. However, he failed to report all allegations of abuse to the State Agency. The failure to meet the minimum requirements to transparently report the concern and to fully investigate the concern contributed to a culture on the unit where GNA staff were empowered to repeatedly, and egregiously violate the rights of Resident #3. 2.8 On 2/9/23 at 12:24 PM, a review of the video footage for camera 71 revealed for 12/17/22 starting at 12:24 PM Resident #3 was ambulating in the day room independently until GNA #33 sat the resident in a regular dining room chair and positioned the chair at the corner of the table. The resident successfully scooted the chair away from the table, but staff was then observed moving the chair back to the table and positioning the chair under the table which restricted the resident from moving about freely. After the staff repositioned the chair, Resident #3 was observed in the video trying to get up but was unable. This time, Resident #3 was kept in a restraint by multiple facility staff until 7:51 PM (for 7 hours and 27 minutes). GNA #60, who was assigned to Resident #3 that shift, started her shift at 3 pm and had no contact with the resident at all until 7:51. For this episode, no clinical justification was evident, no notification was provided to the practitioner, no order was obtained, and no nursing assessment associated with the extended period of restraints was conducted or documented. Increased nursing monitoring for these many hours was not documented and was not evident in the video reviewed. At 2:45 PM an activity for residents was provided. Resident #3 was not able to participate while he/she remained in restraint. For these 7 hours and 27 minutes in restraint, Resident #3 was not toileted and was not provided incontinence care. The helmet was not removed in accordance with the order to offer breaks and relief and to check the resident's skin; and no opportunity to break, stand, stretch or walk were provided. Review of the video revealed that throughout the day the resident was actively trying to get up. 2.9 A review of the video footage for camera 71 for 1/6/23 starting at 9:37 AM revealed Resident #3 was ambulated to the day room by 1 staff member, with no helmet on. The resident was then restrained with the use of a dining room chair by staff pushing it under the table for a half-hour when the resident was assisted by GNA #61 with a meal. When GNA #61 left the table the resident's chair was partially under the table. At 12:12 PM Resident #3 was able to stand. The video revealed that GNA #61 immediately held the resident while pulling the wheelchair behind, and then sat the resident into the chair seat with force sufficient that Resident #3's head went back and his/her left leg to flew up in the air. GNA #61 then locked the left wheel on the chair again. This staff conduct on 1/6/23 met the regulatory definition of abuse. Based on the video footage review as recent as 1/6/23 the resident had the ability to ambulate with staff assistance and a review of the therapy notes also indicated the resident remained at baseline for mobility. However, staff had placed him/her in positions that restrained the resident for hours at a time. An interview with Geriatric Nursing Assistant (GNA) #31 on 2/9/23 at 9:30 AM revealed that Resident #3 was not able to communicate his/her needs to staff. She reported that the care needs of the resident were to toilet and/or provide incontinence care every 2 hours and remove the resident's helmet when the resident ate a meal, otherwise, the resident sat in the day room with no special needs. GNA #31 reported that she was aware that placing the resident in a position in which they cannot move about freely was a restraint. On 2/9/23 at 9:24 AM an interview with GNA #32 revealed that Resident #3 communicated by way of facial expressions and when the resident would resist that meant s/he did not want to do something. The GNA reported that the resident had a helmet that needed to be removed every 2 hours and required incontinence care every 2 hours. GNA #32 reported that she was aware that restricting a resident's movement against their will was considered a restraint. However, GNA #32 was identified by the facility on the video footage for 11/22/22 as not providing Resident #3 the care s/he needed and restricting the resident's ability to move around freely. During an interview with GNA #33 on 2/9/23 at 9:39 AM it was determined that she had been aware of Resident #3's care including removing the resident's helmet every two hours to check the skin and providing incontinence care every 2 hours. An interview with Licensed Practical Nurse (LPN) #14 on 2/9/23 at 9:13 AM revealed that Resident #3 required total care by staff. LPN #14 reported that she was aware that the resident had a helmet that needed to be removed every 2 hours and required toileting and/or incontinence care every 2 hours. She reported that Resident #3 was not on a restorative program but was walked to his/her room every 2 hours for incontinence care. In addition, she was aware that restricting a resident from moving about freely was considered a restraint. In a subsequent interview with LPN #14 on 2/10/23 at 9:07 AM she was asked how she monitored the GNAs to ensure that they were providing the care and services to meet the needs of each resident. LPN #14 reported that she monitored the residents and staff closely and would tell staff when they needed to provide care if they had not done so already. When asked what had happened on 11/17/22, 11/22/22, and 12/10/22 when she was assigned to Resident #3, it was observed on the video footage that staff had not provided the care that Resident #3 needed. LPN #14 stated she was not sure but that there were times she became overwhelmed with her duties. An interview on 2/13/23 at 1:32 PM with the Administrator, Assistant Administrator, Director of Nursing, Corporate Clinical Consultant #51, and the Director of Quality Assurance Nurse revealed that the Administrator had reviewed the episode of restarting use on 1/6/23. After her review of the video, the Administrator's indicated that she felt the staff had been very interactive with the resident but that they needed to address the restraints. She had not identified the hours that Resident #3 had gone without the care s/he needed. The federal regulations indicate that neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Resident #3 suffered neglect when the facility repeatedly placed him/her into restraint with no clinical justification documented, with no practitioner notified, with no order obtained, with no nursing assessment obtained, and with no additional monitoring for safety and to ensure the resident's needs were met. In 9/9 times Resident #3 was restrained, staff failed to follow the order to remove a helmet from Resident #3 to offer relief. In 9/9 times staff failed to allow Resident #3 breaks to stretch or stand including during two episodes where staff kept Resident #3 in restraint for more than 7 hours. The facility administration was aware of the abusive noncompliant conduct but for more than two months took no actions to report, investigate, or end it. The failure to end the egregious rights violations contributed to a culture on the unit where many staff knew but nonetheless continued to allow the practices of and by numerous facility GNA staff. Cross Reference F600, F607, F609, F610, F686, and F835

Based on video footage review, record review, and staff interview, it was determined that the facility failed to provide the care needed to avoid the development of skin breakdown. This was evident for 1 (#3) of 3 residents reviewed for restraints. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 2/2/23 review of the medical record revealed that Resident #3 had a care plan initiated on 1/22/21 for the resident's risk for impaired skin integrity due to episodes of incontinence. The goal was that the resident would remain free of impaired skin integrity. The interventions included but were not limited to assisting the resident in using the toilet to promote continence, providing incontinence care after each episode [of incontinence], offering additional fluids within diet parameters, and preventative skin care as ordered. The interventions were not specific and did not provide information for staff to know when or how often Resident #3 should be toileted, checked, or provided other activities of daily living (ADL) care, treatment, and services. A care plan was developed to address the resident's inability to comprehend group activity invitations and noted Resident #3 preferred to walk the length of the hallway. The care-plan goal was that the resident would continue to be able to walk within the care center and appear to enjoy socialization with caregivers and peers. The interventions included but were not limited to, walking the resident and talking about the things that were seen during the walk. This care plan also failed to adequately define when, how often, and for how long the resident could or should be able to walk. A medical record review for Resident #3 on 2/2/23 at 2:35 PM revealed Physician Assistant (PA) #42's progress notes for a visit on 11/10/22, where s/he documented Resident #3's diagnoses as dementia with behavioral disturbances, repeated falls, and depression. Further noted was that Resident #3 required total care, was severely cognitively impaired, was able to ambulate, and tended to wander (random or repetitive locomotion). A review of Resident #3's physical therapy notes revealed that on 5/4/22 the resident had been discharged from therapy. The goal was that the resident would be able to ambulate 1000 feet independently with an assistive device with a good gait pattern and safety to achieve his/her prior level of function. At discharge, it was noted the resident was able to ambulate 1000 feet but required constant cuing for posture, balance, gate pattern, and safety. On nine occasions GNA staff placed Resident #3 into restraint with no notification to the practitioner, no order obtained, and no resident assessment associated with the initiation of restraints (10/7/22, 10/18/22, 10/24/22, 11/17/22, 12/10/22, 12/11/22, 12/17/22, and 1/6/23). In these various episodes of noncompliance, Resident #3 was left in restraint between 2 and 7.5 hours at a time. In each one of these nine episodes of restraint, Resident #3 was not allowed any break(s) to stand or stretch, and a soft helmet in use was not removed for relief and to check for concerns with skin integrity. There was an order dated 7/12/22, that required staff to remove the helmet for relief and to check his/her skin. On 1/13/23, the resident was seen by Physician Assistant PA #42, who diagnosed him/her with a new sacral pressure area and she further noted that staff had reported that Resident #3 had not been as active. On 1/13/23, the facility wound nurse Licensed Practical Nurse (LPN) #57 noted in another assessment that Resident #3 had developed Moisture Associated Skin Damage (MASD). It was unclear in the wound nurse's note if this was in addition to the visualized pressure ulcer that the PA documented or if the wound nurse was contradicting the description of what the PA described in their observation of the wound. A review of the wound nurse LPN #57's wound assessment report dated 2/13/23 revealed the wound had advanced to a cluster of wounds on the right buttocks/coccyx area that was unstageable. Unstageable meant the wound by then was at least a stage III. The facility failed to ensure all care, treatment and services were provided that could have minimized the risk for the development of skin wounds. Cross Reference: F600 and F604.

Based on observations, review of video footage, record review, and staff interview, it was determined that the facility's administration failed to protect Resident #3 from egregious rights violations where facility GNA staff repeatedly placed Resident #3 into restraint with no documented clinical justification. The facility administration was aware of the noncompliant practices and related rights violations but failed to promptly take required steps to report, investigate and end the abusive conduct of its staff. This was evident for 1 of 3 residents (Resident #3) reviewed during survey. The findings include: Neglect - is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Physical restraint - is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body. Removes easily means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff. Abuse, is defined at §483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as defined at §483.5 in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the resident's best interest. As detailed beginning on 10/7/22, facility GNA staff repeated placed Resident #3 into restraint. In nine different episodes between 10/7/22 and 1/6/23, GNA staff initiated restraint with no clinical rationale documented, without notifying the practitioner, without obtaining an order, and without obtaining a nursing assessment associated with the initiation or continuation of restraints. None of the nine episodes lasted less than 2 hours and in two of the nine episodes, the staff kept resident #3 in restraint with no break for more than seven hours. Staff violated interventions in care plans by failing to allow the resident to walk, failing to provide incontinence checks, and failing to provide for toileting needs during the extensive periods of restraint. Staff violated an order requiring the removal of a helmet which was employed to mitigate risk for injury in the event of a fall, The order provided that staff were to remove the helmet every 2 hours for relief and to check for skin concerns. During nine out of nine episodes of restraint this was not done. Administration was notified that Resident #3 was observed in restraint with the use of a geriatric chair on 10/7/22. Administration subsequently received verbal and written notification about the concern. Administration received more allegation regarding the successive events that followed. The Administrator, Assistant Administrator, Director of Nursing, and Quality Assessment staff were all made aware. For more then two months the facility failed to report, investigate, and end the egregious rights violations where staff repeatedly restrained Resident #3 for extended periods of time without any documented clinical rationale, without notifying the practitioner, without obtaining an order, and without obtaining a nursing assessment associated with the initiation or continuation of restraints. The administration failure to report, investigate, and address the staff conduct was at least in part causal because it contributed to a culture on the unit where the administration allowed the egregious rights violations to continue unabated for more than two months. After the seventh occurrence, on 12/12/22, the facility reported that there had been allegations received about restraint use on 12/10/22. This was the first required report the facility submitted and on this date the facility failed to report any of the other six episodes that had been alleged with both verbal and written internal reporting. When the facility reported with an update on the findings of the internal review, they did not report that the 12/10/22 episode was only one of seven known occurrences where multiple different GNA were restraining Resident #3 in an ongoing pattern. The facility did not report that there was no documented clinical justification, no notification to the practitioner, and that no order was obtained for any of the many times GNA staff restrained Resident #3. Specifically on the 12/10/22 date, the facility did not report that no nursing assessment was obtained and documented related to the initiation and extended period of continuation of restaurants by the facility staff. The facility did not report that the 12/10/22 restraint had lasted more than 7 hours, that the order for management of the helmet was not followed, and/or that increased monitoring was not documented. Instead, the facility briefly reported that there was no malintent by the staff across multiple shifts who maintained the restraint and therefore the facility concluded with their stated opinion that there was no abuse evident. This was not accurate. Under the regulatory definition of abuse, staff intent is not relevant to a determination of whether any particular staff conduct constitutes abuse. The facility did however conclude two GNA staff would not return to work in the facility and the facility reported that they started education for other staff related to the use of restaurants in the facility. No investigation or education was provided however, regarding the culture on the unit or in the building where this conduct was both known and allowed. Additionally, the limited education focused only on restraints proved ineffective as within the same continuing culture on the same unit, other GNA staff placed Resident #3 into restraint again on 12/17/22 and on 1/6/23. The administration failure to transparently report the concern as required and to fully investigate the concern contributed to a culture on the unit where, with the full knowledge of facility administration, staff were empowered to repeatedly and egregiously violate the rights of Resident #3. Cross Reference F600, F604, F607, F609, F610, and F686

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident record review, and staff and resident interviews, it was determined that the facility failed to: 1) ensure that residents were free from abuse (Resident #17); 2) ensure that residents were free from neglect (Resident #10); 3) maintain adequate supervision of residents with documented histories of aggressive behavior with care planned interventions in place including to perform routine checks to prevent potential 'inappropriate,' and 'aggressive' behavior (Resident #187); and 4) prevent abuse occuring from an employee towards a resident (Resident #235). This was found to be evident for 4 out of 49 residents reviewed for abuse and neglect. As a result of this failure, actual harm was identified for Resident #17. The findings include: 1) A review of the nurse's notes for Resident #17 was conducted on 08/09/2022 at 9:00 AM. The nurses note stated on 05/27/2022 at approximately 4:20 PM the Unit Manager # 42 was told by Resident #17 and his/her roommate Resident # 148 that Geriatric Nursing Assistant (GNA) #74 bent Resident #17's right thumb back. The Unit Manager #42 assessed the resident's right thumb and concluded the thumb appeared abnormal. A Physician's order was obtained, the Resident's representative was notified, and the resident was sent out to a community Hospital Emergency Room. A review of the hospital discharge summary on 08/09/2022 at 9:10 AM revealed Resident #17 was diagnosed with a dislocation of the right thumb in 05/27/2022. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively at the moment. It is a required screening tool used in nursing homes to assess cognition. The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. During an interview conducted on 08/09/2022 at 9:25 AM, Resident #17 with a Brief Interview of Mental Status (BIMS) of 8 stated GNA # 74 came into the resident's room and questioned what he/she was doing with the pillows. The resident stated he/she wanted to have someone to put his pillows in the closet. According to the resident, the GNA began to yell at him/her because the resident did not want the pillows on the bed. The resident further stated the GNA was very mad and grabbed the resident's right thumb, twisted, and pulled his/her thumb back. During an interview conducted on 08/09/2022 at 9:32 AM, Resident #148 (Resident #17's roommate) with a BIMS of 15 stated he /she witnessed GNA #74 yell at Resident#17 and bend the resident's right thumb all the way back. An interview conducted on 08/09/2022 at 10:27 AM, the Unit Manager #42 stated she was told by Resident #17 and Resident #148 on 05/27/2022 that GNA #74 bent Resident #17's right thumb back. The Unit Manager stated she assessed the resident's thumb, obtained a physician order to send the resident to the emergency room because the thumb appeared abnormal. During an interview conducted on 08/10/2022, the Administrator stated GNA #74 was suspended on 05/27/2022 pending an investigation and terminated as result of the facility's investigation. On 08/09/2022 a review of the facility's investigation confirmed the facility suspended GNA #74 pending the facility's investigation and then terminated the GNA based on the results of the investigation. The facility reported the GNA to the Board of Nursing for the abuse of the resident. 2) During an interview conducted on 07/25/2022 at 10:00 AM, Resident #10 stated he/she was left alone in the whirlpool bathtub by GNA #88. The resident stated he/she was fearful that he/she would have slid under the water because of his/her lack of muscle strength. The resident stated he/she yelled for help, the staff came and removed him/her from the whirlpool bathtub. The surveyor asked if the resident had slid under the water, the resident stated no; the resident was asked if he/she received whirlpool baths since the incident, the resident stated no and that he/she never liked a whirlpool bath. The resident further stated the incident did not cause him/her to be fearful of a whirlpool bath or any other type of bath. An interview conducted on 07/25/2022 at 10:22 AM, the Unit Secretary #8 stated she was present at the time of the incident. The Unit Secretary stated the resident is a transfer by Hoyer lift. On the day of the incident the GNA [NAME] the resident to the whirlpool bath in his/her wheelchair. The GNA Hoyer lifted the resident out of the wheelchair and into the whirlpool bathtub. The resident remained on the Hoyer lift with the Hoyer lift pads under him/her. The GNA#88 left Resident #10 inside the whirlpool bathtub on the Hoyer lift. Several minutes later the resident yelled for help and several staff ran into the whirlpool bathtub room. The resident was Hoyer lifted out of the whirlpool and assessed. Friedreich ataxia is a genetic condition that affects the nervous system and causes movement problems. People with this condition develop impaired muscle coordination (ataxia) that worsens over time. Other features of this condition include the gradual loss of strength and sensation in the arms and legs; muscle stiffness (spasticity); and impaired speech, hearing, and vision. On 07/25/2022 at 1:27 PM a review of the Resident #10's medical record revealed the resident had a diagnosis of Friedreich's Ataxia and has a Brief Interview of Mental Status of 15. On 07/29/2022 at 1:22 PM a review of the facility's investigation revealed the facility suspended GNA #88 pending the investigation on the day of the incident 03/15/2022. After viewing camera footage, the facility determined GNA #88 left Resident #10 in the whirlpool bathtub for 8 minutes and the GNA was immediately terminated. On 08/01/2022 at 7:15 AM review of Resident #10's Psychiatric note dated 03/16/2022 stated resident anxious and tearful following being left in the whirlpool bath for an extended period of time. On 08/01/2022 at 7:16 AM review of Resident #10's psychiatric note 03/24/2022 stated/noted the resident was back to baseline and stated/noted that he was doing fine. Resident stated he wishes to get showers instead of baths. On 08/01/2022 at 10:50 AM the Surveyor advised the Administrator of the concern. The Administrator stated she recalled the incident. The Administrator stated that GNA #88 was first suspended immediately and after viewing the camera footage the GNA was immediately terminated. The facility immediately conducted bathtub safety in-services, and competency for mechanical lift and the resident's physician placed a new order for a shower chair and 2 caregiver assistants. On 08/01/2022 at 1:00 PM the Administrator provided the Surveyor with supportive documentation of the interventions implemented. Based on medical record review, interview, and observation of residents, it was determined that the facility failed to: 1. maintain adequate supervision of residents with documented histories of aggressive behavior with care planned interventions in place including to perform routine checks to prevent potential 'inappropriate,' and 'aggressive' behavior and 2. failed to prevent abuse occuring from an employee towards a resident. This was evident during the review of an abuse allegation between 2 residents (#187 and #235) and observations during tour. The findings include: 3) Surveyor reviewed the facility reported investigation into the resident-to-resident altercation between Resident #187 and #235 on 8/2/2022 at 7:25 AM that occurred on 5/26/2021. The report documented that the Charge Nurse, staff #18, was alerted to an altercation between 2 residents by another resident. Staff #18 responded and observed Resident #235 'stomping' on the head of Resident #187. The residents were separated, and Resident #187 was sent to the hospital for evaluation. Review of Resident #187 and #235 care plans both included interventions related to a history of aggressive behaviors documented towards staff and other residents requiring routine checks and monitoring, however, no staff were aware of either residents' status at the time of the incident according to the interviews provided in the facility investigation. Review of the medical record on 8/2/2022 at 7:34 AM for Resident #187 revealed diagnosis including dementia with behavioral disturbances. Care plans reviewed revealed identified problems in place from 10/8/2019 for wandering beyond safe limits and the need for staff to perform routine checks on the residents. Additionally, on 10/10/2019 a care plan was initiated for aggressive behavior towards staff, this was reviewed as recent as 4/19/2021 and remained active at the time of the altercation. Resident #185's Brief Interview for Mental Status (BIMS 15-point cognitive screening measure that evaluates memory and orientation) at the time of the incident was not completed, the score was '99' as the resident was not a candidate cognitively to complete the exam. Review of the medical record for Resident #235 revealed diagnoses including Alzheimer's dementia, depression, and adjustment disorder. Care plans reviewed revealed identified problems and goals in place from 3/17/2020 regarding numerous behavior problems such as aggression and territorial behavior with approaches including to perform routine checks on the resident. Social services assessed Resident #235 after the incident that occurred on 5/26/2021 on 5/27/2021 and determined that s/he had a BIMS score of 6/15 meaning that s/he had 'severe impairment' in cognitive functioning. Interview on 8/11/2022 at 9:05 AM with staff #15, the Regional Nurse Consultant, regarding what 'routine checks' was revealed the expectation was that staff would complete their usual 2-hour checks on the residents. In addition, their behaviors, if any, are documented every shift. Regarding Resident #235, on the day of the incident 5/26/2021 at 10:02 AM, staff documented that s/he had exhibited behaviors and rejection of care. There was no additional documentation of monitoring, observations or interventions related to the already documented behaviors exhibited by Resident #235 on the afternoon of 5/26/2021 prior to him/her inflicting aggression on Resident #187 that led to his/her hospitalization. These findings and concerns were reviewed with the facility DON and Administrator throughout the survey and again on 8/11/2022. Cross reference with F610 4) On 8/7/2022 during a tour of the 2C unit at 2:30 PM, Resident #101 was observed sitting in the day room engaging with various activity mats that were available on the table in front of him/her. A female staff member was observed standing to the right of Resident #101. Surveyor continued tour of the facility with observations and interviews with other residents and staff. Upon walking up the hall towards the nursing station surveyor stopped at the day room to continue to make observations of Resident #101. The female staff member who is now identified as staff # 71 and also Resident #101's usual 1:1 was then observed aggressively pulling Resident #101 up in the chair by the residents' right arm, then threw the residents' right arm across his/her body and angrily stated 'stop that.' She then looked around and saw the Surveyor watching her. Surveyor approached the staff member to get her name and noted that her badge stated 'student.' Staff #71 stated that she was not a student that she had just graduated. The observed concerns were immediately reported to the nurse on duty, LPN staff #68 , then the facility Administrator who happened on the unit moments later. The Administrator immediately removed Staff #71 off the floor and took statements from her and all the staff present. The facility was notified of the concerns related to the observed abuse and inappropriate interaction between the employee who identified herself as a GNA, staff #71 towards Resident #101.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) The care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Medical record review revealed that Resident #51 was admitted to the facility with diagnoses which included but not limited to Alzheimer's disease (AD) with Dementia and other chronic health conditions which require ongoing treatment. Alzheimer's disease (AD) is a common form of dementia among older people. Dementia is a brain disorder that seriously affects a person's ability to carry out daily activities. People with AD may have trouble remembering what happened recently or names of people they know. The surveyor reviewed of facility reported incident on 11/29/18, it revealed that on 09/25/18 and 10/27/18 Resident #51 had experienced falls. Medical record review revealed a fall care plan with an admission initiation dated 03/06/2018 which included goals and approach interventions for fall prevention. Further review of the medical record revealed that the facility failed to update and revise the care plan that addressed the resident's falls which occurred on 09/25/18 and 10/17/18. On 11/30/18 at 11:30 A.M. during an interview with staff member #6 and the Director of Nursing, it was verified that facility staff did not revise Resident #51's fall care plan after reported falls that occurred on 09/25/18 and 10/17/18. The Administrator, Director of Nursing with Corporate Representatives were informed of the concerns prior and during the survey exit. Based on medical record review and interview of facility staff it was determined the facility staff failed to ensure that care plan interventions were implemented: 1) the facility failed to intervene and revise Resident #175's care plan related to tobacco use. This failure occurred when Resident #175 showed signs of decline in cognitive status and activities of daily living, indicating that the resident was not safe to smoke without supervision. It was determined that the facility's failure to revise Resident #175's care plan interventions resulted in an actual harm to the resident from a smoking related accident with injury, and 2) the facility failed to revise and update the care plan that addressed Resident #51's care after a change in condition. This was evident for 2 out of 12 residents reviewed during the survey process. The findings include: 1) Resident #175's medical record was reviewed on 11/30/18. Medical record review revealed that Resident #175 has resided at the facility since February 2018. The resident has diagnoses that include nicotine dependence and a history of a cerebral vascular accident resulting in left sided weakness. Medical record review revealed that on 2/16/18 a smoking screen was completed by the Certified Dementia Practitioner, Staff #11, who determined that the resident was safe to smoke unsupervised. Medical record review revealed that on 2/16/18 the facility staff initiated a care plan related to Resident #175's tobacco use on a regular basis with the goal that the resident would be safe and free of injury. Interventions initiated on 2/16/18 included: Inform resident of appropriate smoking areas and redirect as needed; encourage residents not to have lighters, cigarettes or other smoking materials in their room; encourage resident to smoke with staff and/or family present; place smoking apron on resident following ADL (activities of daily living) if needed; assess for safety per policy; notify Administration of non-compliance. Review of Resident #175's Minimum Data Set (MDS), an assessment tool, dated 2/22/18 revealed that the resident required supervision with the assistance of 1 staff member for eating. The resident had no functional range of motion impairment according to the MDS. Medical record review revealed that on 7/5/18 at 10:25 P.M. the nurse documented in the progress notes that the resident was reported to be in the basement attempting to smoke a cigarette. The nurse further documented that the resident was alert and oriented x 3 (to person, place and time) upon return to the unit. The resident stated that he/she was aware that he/she was in the basement. Medical record review revealed that on 7/6/18 at 11:10 A.M. the nurse documented that burn holes were noted on the resident's shorts. The cushion next to his/her right leg had burn holes from cigarettes. Next to the resident's leg a cigarette had burned and was stuck to the cushion. The nurse further documented that a smoking apron was ordered for the resident to use at all times. The care plan was revised at that time and an intervention was added to place a smoking apron on the resident prior to smoking. Also, on 7/6/18 a physician's order was entered for the resident to use a smoking apron at all times when out to smoke. Medical record review revealed that on 7/10/18 at 3:40 P.M. the nurse documented that a medication review was completed due to a significant change noted to the resident's condition secondary to cognitive status and mobility decline. Medical record review revealed that on 7/11/18 the resident was certified by the attending physician that he/she was unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment and is unable to make a rational evaluation of the burdens, risks, and benefits of treatment. On 7/19/18, a second physician concurred with the attending physician's certification of 7/11/18. Medical record review revealed that on 7/14/18 at 1:43 P.M. the nurse documented that the resident is unsteady smoking by himself/herself, and that cigarettes were found still lit in the resident's chair. On 7/14/18 at 11:56 P.M. the nurse documented that the resident was found by the Geriatric Nursing Assistant (GNA) and the nurse in the basement. Medical record review revealed that on 7/22/18 at 3:46 P.M. the nurse documented that the resident was found in bed with scissors and pieces of his/her smoking apron. The resident stated he/she was trying to get the smoking apron off. Medical record review revealed that on 7/23/18 at 6:00 A.M. and 2:00 P.M. the nurse documented in the Treatment Administration Record (TAR) that the resident did not wear a smoking apron. There was no documentation in the medical record to indicate the reason the resident did not wear a smoking apron on those dates. Medical record review revealed that on 7/24/18 at 6:00 A.M. and 2:00 P.M. the nurse documented in the TAR that the resident did wear a smoking apron. However, on 7/24/18 at 7:32 P.M. the nurse documented that the resident's smoking apron was unavailable, and the resident was outdoors to smoke with staff assistance. Medical record review revealed that on 9/15/18 at 10:44 P.M. the nurse documented that the resident was noted with dry cigarette burns to the left upper thigh. The physician and responsible party were notified. The physician gave no new orders. The responsible party stated that he/she would like to bring a caretaker for the resident to assist him/her during the day by taking him/her outside to smoke and to ensure that he/she is getting his/her meals. Medical record review revealed that on 9/22/18 at 3:41 P.M. the nurse documented in the medical record that the resident was propelling self on and off the unit, was very confused and non-compliant and was found on the third floor hitting and banging on a locked door. The nurse further documented that the resident was unable to hold his/her cups without spilling the fluid and was found outside in the rain just sitting there. The resident had to be redirected most of the day and was unable to follow a direction such as can you take your arm out of your jacket. Medical record review revealed that on 9/23/18 at 10:02 P.M. the nurse documented that the resident was out of bed to smoke cigarettes in the courtyard with assistance from the nursing staff and ate 75% of dinner with assistance because his/her hands were shaking and could not hold a spoon. Medical record review revealed that on 9/25/18 at 4:11 P.M. the nurse documented that the resident had to be redirected several times during the day and was not sure where he/she was going. Medical record review revealed that on 9/27/18 at 3:59 P.M. the nurse documented that the resident was assisted to smoke in the court yard by nursing staff. Medical record review revealed that between 9/27/18 through 10/19/18 there was no documentation in the nursing progress notes that the resident was assisted with smoking. Review of the October 2018 TAR revealed that staff documented that the resident did not use a smoking apron on 10/1/18 at 2:00 P.M., 10/4/18 at 10:00 P.M., and 10/6/18 at 6:00 A.M., 2:00 P.M. and 10:00 P.M. There was no documentation in the medical record to indicate the reason the resident did not wear a smoking apron on those dates. Review of Resident #175's Minimum Data Set (MDS) dated [DATE] revealed that the resident required extensive assistance of 1 staff member for eating. That represented a decline in the resident's ability to eat compared to the MDS dated [DATE] in which it was documented that the resident required supervision with the assistance of 1 staff member for eating. Additionally, the MDS dated [DATE] reflected that the resident had a functional range of motion impairment to 1 side of both the upper and lower extremities. Medical record review revealed that on 10/17/18 a smoking screen was completed by the Certified Dementia Practitioner, Staff #11, and it was determined that the resident was safe to smoke despite documented evidence on 7/5/18 through 9/27/18 that the resident exhibited indicators that he/she was not safe to smoke unsupervised. Interview of Staff #11 on 11/30/18 at 2:00 P.M. revealed that nursing had never reported a concern regarding the resident's cognitive and physical decline or other indicators that the resident may not be safe to smoke unsupervised. Staff #11 further stated that she became aware that the resident required a smoking apron when the resident asked for one at the nurses station, and prior to 7/9/18, she had not observed the resident with a smoking apron. Although Resident #175 had experienced a decline in his/her physical and cognitive abilities, as evidenced by the aforementioned incidents, the facility staff failed to revise the resident's care plan after 10/14/18 to ensure that safeguards were in place to guarantee that the resident was compliant with safe smoking interventions. Medical record review revealed that on 10/20/18 at 6:00 A.M. the nurse documented in the TAR that the resident used the smoking apron. Medical record review revealed that on 10/20/18 at 10:38 A.M. the nurse documented the following entry in the progress notes: Resident is alert and oriented with moments of confusion but [verbally] able to make needs known. Multiple nurses reported to this nurse [writer] that the [patient] was outside in the courtyard smoking a cigarette and [his/her] clothing caught on fire at 9:30 A.M. Activities aid attempted to put the fire out by patting with her hands, but a nurse arrived with blanket/towel and put the fire out. The patient was then [transferred] in [his/her] wheelchair from the courtyard to [his/her] room and [transferred] to bed for first aid (clothes cut off and cold towels applied) and skin assessment completed: Burns/discolorations noted to Left thigh, left abdomen, left wrist, left inner elbow, left chest, bilateral sides of neck and back of [his/her] neck. [Nurse practitioner] notified new order to send out via 911. [Responsible party] notified and made aware that patient will be going to [name of hospital] via helicopter . The resident was subsequently admitted to the hospital and treated for burns to the anterior neck, left upper extremity and left trunk. Interview of the Director of Nursing on 11/30/18 at 1:30 P.M. revealed that charge nurses are responsible for implementing care plan interventions related to smoking safety. The resident was not wearing a smoking apron when the resident's clothing caught fire on 10/20/18. The smoking apron was found in the resident's room. On 10/20/18, the resident had been given cigarettes which were kept at the nurses' station. Further interview of the DON revealed that the resident went outside to smoke multiple times a day. As of 10/20/18, there was no supervision once residents went outside to the facility courtyard to smoke. The courtyard was open for residents to smoke 24 hours a day, 7 days a week.