Based on closed medical record review, review of a facility self-reported incident (SRI), review of facility policy, and interview the facility failed to ensure Resident #52 was free from physical restraints. Actual Harm occurred on 03/08/25 at approximately 7:00 A.M. when Resident #52 was physically restrained and tied to his wheelchair with a bed sheet by Licensed Practical Nurse (LPN) #526 in an attempt to address Resident #52's behaviors and to prevent Resident #52 from standing from the chair. Resident #52 was found by visiting Hospice LPN #603 tied to his wheelchair with a bed sheet knotted behind him. The resident was unattended, seated in his wheelchair, agitated, and reported a pain rating of a 10 on a one-to-ten scale (with ten indicating the worst possible pain). Other interventions in place and available at the time of the incident, including as-needed (PRN) medications for pain, anxiety, and agitation, were not utilized by the nurse prior to Resident #52 being restrained. Hospice LPN #603 released Resident #52's restraint and hospice staff stayed one-on-one with the resident until his transfer out of the facility. This affected one resident (#52) of one resident reviewed for restraints. The facility census was 52. Findings include: Review of the closed medical record for Resident #52 revealed an admission date of 02/27/25. Medical diagnoses included congestive heart failure (CHF), anxiety disorder, and obstructive and reflux uropathy. Resident #52 received hospice services with Hospice #600 since his admission to the facility. Resident #52 discharged from the facility on 03/09/25. Review of Resident #52's physician orders revealed an order dated 02/27/25 to call Hospice #600 with any changes or concerns. Resident #52 had an additional order dated 02/27/25 for Oxycodone HCL (a narcotic pain reliever used to treat moderate to severe pain) 10 milligrams (mg) by mouth every two hours as needed (PRN) for pain. Review of the admission note dated 02/27/25 at 5:10 P.M. completed by LPN #526 revealed Resident #52 was alert and oriented to person, place, and time. Resident #52 communicated verbally, his speech was clear, and he was able to understand and be understood when speaking. Resident #52's mood was pleasant, and he had no unwanted behaviors. The resident had an indwelling catheter in place due to urinary retention. Resident #52's skin was warm and dry, his skin color was within normal limits, and skin turgor was normal. The note indicated Resident #52 sleeps through the night. Review of the Fall Risk evaluation dated 02/27/25 at 5:36 P.M., completed by LPN #526, revealed Resident #52 had one to two prior falls in the last three months. Resident #52 was noted to be ambulatory and continent. His fall risk score was 2.0 Review of the care plan dated 02/28/25 revealed Resident #52 was at risk for episodes of anxiety related to altered breathing and a terminal diagnosis. Listed interventions included addressing reasons for anxiety, social withdrawal, and crying, administering medications as ordered, monitor for medication side effects and effectiveness, and providing a quiet room or area for Resident #52 to go to when anxiety increases. Additional interventions included providing relaxation techniques as needed, removing excess stimulation as able, spending time talking with the resident, and allowing the resident to express their feelings. Further review of Resident #52's care plan dated 02/28/25 revealed the resident was at potential risk for falls related to age, decreased physical function, history of falls, and medication use. Listed interventions included to assist with transfers as needed, and an additional intervention added on 03/08/25 noted Resident #52 was to be one-on-one with hospice staff until transferred to an inpatient hospice facility. Further review of the care plan dated 02/28/25 and revised on 03/14/25 (after the resident's discharge) revealed Resident #52 had the potential for mood and behavioral issues related to depression, anxiety, terminal diagnosis, and insomnia. Resident #52 was combative with care, called emergency services at times, screamed out frequently, and had hallucinations. Listed interventions included administering medications as ordered, observing medication effectiveness and adverse reactions, attempting to provide a calm environment during acute phases, and approaching the resident in a calm and soothing manner. Additional interventions noted if the resident was demonstrating socially inappropriate behaviors, attempting to redirect the behavior. If the resident was unable to redirect, remove the resident from a public area. If the resident is resistive to care, leave the resident and return later if safety was not a concern. Review of the progress note for Resident #52 dated 02/28/25 at 8:47 A.M. completed by Assistant Director of Nursing (ADON) #519 included Resident #52 was pleasant and cooperative during assessment. Resident #52 denied urination since Foley (indwelling urinary catheter) was removed. The note indicated the resident was educated the Foley may need replaced if he was unable to void. Resident #52 verbalized understanding. Review of the Skilled Evaluation dated 02/28/25 at 7:17 P.M. completed by LPN #549 revealed Resident #52 followed commands. Resident #52 denied weakness, tremors, numbness or tingling. He was alert and oriented to person, place and time. Resident #52 communicated verbally, his speech was clear, and he was able to understand and be understood when speaking. Resident #52's mood was pleasant and there were no unwanted behaviors witnessed. Resident #52's urinary catheter was noted to be intact. Review of a nursing note dated 03/01/25 at 6:46 P.M. revealed Resident #52 was seated on his buttocks with his legs extended into the hallway. The resident reported he slid down the door frame and sat on the floor. Resident #52 had denied injury but was yelling at staff to call the police. Resident #52 was noted to be very combative with staff while he was being assessed. Review of the Skilled Evaluation dated 03/02/25 at 3:31 P.M. completed by LPN #509 revealed Resident #52 followed commands. Resident #52 denied weakness, tremors, numbness or tingling. He was alert and oriented to person, place and time. Resident #52 communicated verbally, his speech was clear, and he was able to understand and be understood when speaking. Resident #52's mood was pleasant and there were no unwanted behaviors witnessed. Further review of Resident #52's physician's orders revealed an order dated 03/02/25 at 4:15 P.M. for Ativan (an anxiolytic medication used to decrease anxiety) one mg every two hours as needed for anxiety. Review of the Brief Interview for Mental Status (BIMS) evaluation completed on 03/04/25 at 12:29 P.M. revealed Social Worker (SW) #529 completed the evaluation. Resident #52 was recorded to have a BIMS score of 13, indicating the resident was cognitively intact. Review of a nursing note dated 03/07/25 at 5:50 P.M. authored by LPN #526 revealed Resident #52 was very combative. The note referenced the resident's behaviors began around 8:00 A.M. with the resident hitting, biting, and pulling on his indwelling urinary catheter. Blood was noted in the urinary drainage bag. Resident #52's hospice provider, Hospice #600, was notified and medication changes were made. Resident #52 was given Haldol (an antipsychotic medication) by intramuscular route. The note referenced Resident #52 calmed down for 20 to 30 minutes. Resident #52 was noted to be very paranoid and hallucinating. Review of Resident #52's physician's orders revealed an order dated 03/07/25 at 1:45 P.M. for Haldol Lactate (Immediate release) injection five mg by intramuscular route, one-time only. Record review of the Medication Administration Record (MAR) revealed the one-time dose of Haldol Lactate was administered at on 03/07/25 4:27 P.M. Review of Resident #52's additional physician's orders revealed an order dated 03/07/25 at 7:15 P.M. for Haldol Lactate injection five mg by intramuscular route every six hours as needed for agitation. Review of Resident #52's MAR for March 2025 revealed the Haldol order (from 03/07/25 at 7:15 P.M.) was to be used as needed and was never recorded as administered. Review of a nursing note dated 03/08/25 at 1:35 A.M. authored by LPN #538 revealed Resident #52 was seen by an (unnamed) visiting hospice nurse and new orders were received for Haldol and Ativan due to agitation. Resident #52 was very restless and was tugging at his Foley catheter all night. The note stated Resident #52 was unable to be redirected. Resident #52 was transferring himself to the wheelchair without assistance, was wandering up and down the hallways, and was in and out of other residents' rooms. Resident #52 was difficult to redirect. Resident #52 was recorded as having been medicated with new orders without effectiveness. Resident #52 pulled his Foley catheter out with the balloon inflated and refused to allow the nurse to reinsert the catheter. Review of a nursing note dated 03/08/25 at 7:00 A.M. authored by Registered Nurse (RN) #550 revealed Resident #52 was propelling his wheelchair in the hallway. When Resident #52 reached the treatment cart, he held onto it and attempted to stand unassisted. Resident #52 lost his balance and fell with his right side against the wall before staff could reach him. He then slid down to the floor. Resident #52 denied any pain or discomfort following the incident. Review of the Self-Reported Incident (SRI) tracking number 257988 dated 03/08/25 at 12:44 P.M. revealed the SRI report was created by Regional Director of Clinical Services (RDCS) #557 and completed on 03/11/25 at 5:48 P.M. The SRI reported an allegation/suspicion of neglect or mistreatment abuse by LPN #526. The brief description noted on 03/08/25 at 7:00 A.M., in an attempt to prevent Resident #52 from standing unassisted or falling out of his wheelchair, an employee placed a sheet over his lap and secured it behind the back of the wheelchair by tying it. The sheet was untied, and the resident was assessed for injury. There were no injuries found. The employee, LPN #526, was suspended immediately. The report noted the allegation was investigated by the facility and unsubstantiated, noting the evidence indicated abuse, neglect, or misappropriation did not occur. Review of a witness statement dated 03/08/25 at 7:00 A.M. authored by Housekeeping/Laundry Staff #501 revealed she was coming down the hall and Resident #52 went to get up and fell. The statement noted the nurse tried to catch him, but the resident went down. Resident #52 would not stay in the chair, so the nurse tried to keep him in the chair. The statement sated the nurse did what she needed to do to protect him, she did nothing wrong. At least she tried to protect him. Review of a witness statement dated 03/08/25 at 7:00 A.M. completed by LPN #526 revealed Resident #52 was up walking without a device, grabbing the medication cart. RN #550 tried to get to the patient before he fell. Resident #52's fall was witnessed; the resident did not hit his head or back but fell onto his buttocks to the floor. Resident #52 was put back into his wheelchair and became combative. Resident #52 was trying to get at staff and residents in the hallway. Resident #52 was put at nurse's station. This nurse applied a sheet around the resident's waist, loosely tied behind his back for his safety and other residents. Sheet loose enough he could pull and get out. Review of a witness statement dated 03/08/25 at 7:00 A.M. completed by Certified Nursing Assistant (CNA) #503 revealed Resident #52 was being combative and stood up from his wheelchair and grabbed onto the medication treatment cart and fell while pushing it. Resident #52 was very combative, so the nurse got a sheet and loosely put it around the resident's waist. He was going to hurt himself or others who were in the hallway, so it was tied loosely so he would not go face-first. Resident #52 had been combative since yesterday 03/07/25. The note referenced an unnamed hospice nurse was at the nurse's station with Resident #52. Resident #52 was eating snacks, she (unnamed hospice nurse) was standing beside him doing charting, and she was there for at least 45 minutes. Review of Resident #52's physician's orders revealed an order dated 03/08/25 at 9:00 A.M. for Oxycodone HCL five mg by mouth, a one-time dose, for agitation. Review of Resident #52's MAR for March 2025 revealed the one-time dose of Oxycodone was recorded as administered on 03/08/25 at 9:00 A.M. for a pain level of 10 on a one-to-ten scale, indicating the worst possible pain. The MAR listed the medication had been effective. Further review of Resident #52's MAR revealed the resident received one as-needed dose of Oxycodone on 03/08/25 at 8:59 P.M. Resident #52 additionally received as-needed doses of Ativan on 03/08/25 at 3:19 P.M. and 8:58 P.M., both of which were recorded as effective. There were no additional as needed medications recorded as administered on 03/08/25. Review of a nursing note dated 03/08/25 at 10:46 A.M. authored by LPN #526 revealed Resident #52 was combative in the morning. Resident #52 was kept at the nurse's station for safety. The resident was attempting to hit the staff and trying to hit other residents. Resident #52 had grabbed a hold of a cart and was trying to stand up, almost pulling the cart onto himself and causing himself to fall. Staff were unable to catch the patient before the resident fell. The note referenced staff had tried to redirect the resident with coffee and a snack without success. Resident #52's hospice provider had been called and came for a visit. New orders were obtained. Hospice was performing one-on-one with the resident. Resident #52 was noted to be agitated. Review of Resident #52's physician's orders revealed an order dated 03/08/25 at 11:15 A.M. for Phenobarbital 60 mg, give one tablet by mouth every six hours as needed for agitation/restlessness. Review of a health status note for Resident #52 dated 03/08/25 at 12:30 P.M. authored by ADON #519 revealed it had been reported the resident was sitting up in his wheelchair with a blanket around him, secured loosely behind his chair. Staff reported the resident was still able to move around and could have stood if he tried. ADON #519 and an unnamed hospice nurse assessed Resident #52 for injury. The note referenced there was no injury observed, with the exception of a soft lump to the resident's shoulder. Resident #52 was recorded to have no pain with palpation, and the area was not discolored. An x-ray examination was ordered. Resident #52 denied pain. The note concluded by referencing Resident #52 was resting in bed with hospice staff at the resident's bedside. Review of the progress notes for Resident #52 dated 03/08/25 at 11:57 P.M. authored by LPN #538 revealed Resident #52 was agitated and pulling at his Foley catheter again. PRN medications were referenced as given and effective for a short amount of time. The note concluded by referencing hospice staff remained at the resident's bedside throughout the night. A subsequent note dated 03/09/25 at 1:22 A.M. referenced Resident #52 remained restless and agitated. PRN medications were referenced as given and effective. Resident #52 remained resting in bed. Review of Resident #52's MAR for March 2025 revealed the resident received doses of as-needed Phenobarbital 60 mg on 03/08/25 at 12:42 P.M. and 8:58 P.M. and on 03/09/25 at 4:29 A.M. All three doses were recorded as effective. Review of the Orders Administration note dated 03/09/25 at 3:16 P.M. authored by RN #550 revealed Resident #52 discharged from the facility to an inpatient hospice facility. Review of email correspondence dated 03/12/25 and timed 9:31 A.M., provided to the survey team on 05/14/25 at 5:16 P.M., revealed Hospice LPN #603 emailed her statement and summary of events from 03/08/25 to the DON. The written statement noted Hospice Nurse #603 entered the facility on 03/08/25 at 7:45 A.M. Upon entering the facility, LPN #526 was coming down the hall and stated to Hospice LPN #603 I am not going to lie, I have him in a wheelchair at the nurse's station with a sheet around him and he is tied to the wheelchair. Hospice LPN #603 immediately went to the nurse's station where the resident was observed tied with a sheet. Hospice LPN #603 untied the resident, and Resident #52 stated my belly hurts and pointed to his left lower quadrant of his abdomen. Hospice LPN #603 questioned LPN #526 as to what medications had been provided to Resident #52 and was told to look in the narcotic book. Hospice LPN# 603 noted no intramuscular, as-needed Haldol had been administered even though the order provided on 03/07/25 to be administered as-needed every six hours. Hospice LPN #603 noted there had been no calls to Hospice #600 throughout the night (03/07/25 into the morning of 03/08/25). Hospice LPN #603 requested a dose of Haldol IM be administered. LPN #526 prepared and administered the dose of medication. Resident #52 had no reaction to the injection and was not combative or aggressive. Resident #52 was able to answer short questions appropriately and had intermittent confusion. Hospice LPN# 603 notified the Hospice provider on 03/08/25 at 8:02 A.M. and obtained STAT, one-time doses of Oxycodone 10 mg and Ativan one mg. Hospice LPN #603 also obtained an order for crisis care (around the clock, one-on-one care by a hospice staff member). Hospice LPN #603 communicated the stat orders to LPN #526 and requested they be administered. Hospice LPN #603 stayed with Resident #52 and approximately 20 minutes later the STAT doses of medications were administered by LPN #526. Hospice LPN #603 then assisted Resident #52 to stand, walk to, and sit down in another wheelchair. She later assisted Resident #52 to his room for oxygen to be applied and for administration of a breathing treatment. Hospice LPN #603 remained at the resident's side. A telephone interview on 05/13/25 at 4:19 P.M. with Hospice RN Team Leader #602 revealed resident #52 was supposed to be a long-term resident of the facility. Another nurse, Hospice LPN #603, was the nurse who arrived at the facility on 03/08/25 and saw the resident tied up. Hospice RN Team Leader #602 referenced after the incident; crisis care was provided after that. Hospice LPN #603 talked to Hospice RN Team Leader #602 about what she saw. Hospice LPN #603 reported to her that when she arrived at the facility, she was greeted by LPN #526 as she entered the hallway Resident #52's room was on. LPN #526 stated she was not going to lie, that she had Resident #52 in a wheelchair at the nurse's station with a sheet around him, tied to the wheelchair. Hospice LPN #603 had stated she went immediately to the nurse's station, located Resident #52, and untied the patient. The sheet was tied around Resident #52's waist and tied behind his back in the wheelchair. The sheet was tied under the handlebars (between the armrests), and the resident was unable to release it. As the hospice nurse untied Resident #52, he fidgeted with the sheet and reported abdominal pain in his lower abdomen. Resident #52 was later transferred to an inpatient hospice facility and passed away on 03/13/25. A telephone interview on 05/13/25 at 5:31 P.M. with Hospice LPN #603 revealed she received a phone call on 03/08/25 at 6:47 A.M. from the facility that Resident #52 was agitated and pulled his urinary catheter out. Hospice LPN# 603 confirmed she arrived at the facility on 03/08/25 at 7:45 A.m. When she walked into the facility, LPN #526 walked up the hall and stated to her I am not going to lie, I have him tied to the wheelchair at the nurse's station. Hospice LPN #603 revealed she immediately went to the nurse's station and found Resident #52 seated in the wheelchair at the nurse's station. A sheet was tied around his waist, tied in the back with a traditional knot and tucked in between the armrest so it had him against the chair. Hospice LPN #603 stated Resident #52 could not get up. There were no staff at the nurse's station, there were no staff nearby monitoring the resident. Resident #52 was observed attempting to pull at the sheet, trying to get it loose, but was unsuccessful. Hospice LPN# 603 untied the resident. Hospice LPN #603 was able to get her hand between the sheet and the resident's abdomen, but there was no way the resident could have stood on his own. Resident #52 was complaining of abdominal pain. Hospice LPN #603 further reported staff had stated the resident had been agitated all night, but no phone call had been made to Hospice #600 to request a visit or any intervention. Hospice LPN #603 phoned the hospice provider and obtained new medication orders for a STAT (immediate) dose of Oxycodone and Ativan. At 8:00 A.M., I also gave him Haldol to make him more comfortable. She assisted Resident #52 to his room to help him reposition. Resident #52 was terminally restless and agitated from heart failure with a reduced ejection fraction. Hospice LPN #603 stated Resident #52 was transitioning into dying, and terminal restlessness is common during this period. Hospice LPN #603 additionally obtained an order for crisis care, around the clock hospice care at the resident's bedside. Some of the facility nurses felt the resident was overmedicated and would not administer medications, even though Resident #52 continued to have terminal restlessness. Hospice LPN #603 noted if Resident #52 had been properly medicated, there would not have been a need to restrain the resident. Hospice LPN #603 stated there were multiple medications that were not used prior to the facility staff physically restraining the resident. Hospice LPN #603 stated she was shocked and livid when she saw Resident #52 tied up, her heart broke for the resident as it was so unnecessary when there were unattempted interventions available. Interview on 05/14/25 at 8:33 A.M. with CNA #503 confirmed she was the CNA working on 03/08/25. CNA #503 revealed she saw resident #52 up walking around and revealed before he fell, he had the medication cart and attempted to push it when he fell. Following the resident's fall, CNA #503 stated we put him in his wheelchair by the nurse's station, he was eating snacks, and was standing up by the snacks. LPN #526 asked CNA #503 to get her a sheet. She retrieved the sheet, gave it to LPN #526, and then proceeded to go assist another resident. When she came back from assisting another resident, she saw the sheet tied around resident #52's waist. CNA #503 stated her shift started at 6:00 A.M. She was unsure what time it was when LPN #526 tied up Resident #52. CNA #503 stated after the sheet was tied, Resident #52 was just sitting there. She estimated the hospice nurse arrived approximately an hour or two later and untied the resident when she arrived. After the hospice nurse arrived and untied the resident, she stayed with him. Interview on 05/14/25 at 8:53 A.M. with the Director of Nursing (DON) confirmed the incident with Resident #52 being restrained was on a weekend and confirmed it was a Saturday. The DON confirmed he was not at the facility working that day. The DON revealed nurses absolutely should not tie residents up and believed the sheet was loosely tied so it did not prevent him from standing. The DON stated the nurse involved had a clean record and he felt her intentions were for the best of the resident. Review of LPN #526's personnel record on 05/14/25 at approximately 8:55 A.M. with the DON revealed a date of hire of 10/19/21. LPN #526 did not have an evaluation completed in 2025 or 2025, and there was no evidence the nurse had received behavioral training since being employed at the facility. The DON confirmed LPN #526 remained an active employee of the facility. A follow up phone interview on 05/14/25 at 11:06 A.M. with Hospice LPN #603 confirmed Resident #52 had been tied up using a traditional knot, there was no slip pull on the sheet which restrained Resident #52 to the wheelchair. Hospice LPN #603 stated the resident had been trying to stand while she was attempting to untie the resident but was unable to. She described the knot as having two ties, in a knot which could not be released. After she had found Resident #52 restrained, Hospice LPN #603 called Hospice #600's administration and Hospice RN Team Leader #602 who contacted the facility's management. A follow up phone interview on 05/14/25 at 3:37 P.M. with Hospice RN Team Leader #602 revealed she notified ADON #519 on 03/08/25 at 10:01 A.M. via phone of the incident with Resident #52 being physically restrained. She notified ADON #519 via phone as it was a weekend the facility reported there was no administration present in the facility at that time. Interviews on 05/14/25 at 5:16 P.M. and 05/15/25 at 11:57 A.M. with the DON and RDCS #557 confirmed LPN #526 had not received behavioral training during her employment with the facility. RDCS #557 additionally confirmed the hospice notes or statements, including the emailed statement, were not included in the facility's investigation into the incident with Resident #52. The DON revealed Hospice LPN #603's emailed statement was still in her email. The DON printed and provided the email to the survey team during the interview. RDCS #557 revealed she was unaware of all the information regarding the incident with the restraint. The DON and RDCS #557 confirmed the facility documented in the witness statements that they were aware the nurse tied up Resident #52 at 7:00 A.M. and no staff working at the facility notified facility administration of the event. The DON reported this was part of abuse training which had previously been provided to all staff. RDCS #557 additionally confirmed facility administration was notified of this incident on 03/08/25 at 10:03 A.M. by Hospice RN Team Leader #602. The facility initiated a SRI and began their investigation. The Administrator did not obtain Resident #52's hospice notes or interview the hospice staff, yet submitted the final SRI three days after the initial SRI. Hospice staff emailed a statement to the DON four days after the event, after the final SRI had been submitted. The facility did not wait to ensure a complete investigation was completed. RDCS #557 stated if she had known, the outcome of the SRI could have been different. RDCS #557 revealed she was unsure why the SRI was unsubstantiated. Review of the facility policy titled, Restraint Free Environment revised 06/01/24 revealed it is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definition Physical Restraint refers to any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but not limited to tucking in a sheet tightly so that the resident cannot get out of bed or fastening fabric or clothing so that the resident's freedom of movement is restricted. Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts that the resident cannot remove and prevents the resident from rising. Convenience refers to any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience and not required to treat the resident's medical symptoms. Physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner, unless the resident has previously made a valid refusal of the treatment in question. Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of physical restraints. Before the resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints and determine how the restraint would treat the medical symptom, the length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint and the time and frequency the restraint will be released. The type of direct monitoring and supervision that will be provided during the use of the restraint. This deficiency represents non-compliance investigated under Complaint Number OH00163484.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure safety measures and interventions were implemented to prevent potential accidents and hazards. Actual Harm occurred to Resident #21 on 02/01/25 when the facility failed to ensure Resident #21's smoking apron was in place during smoking and Resident #21 sustained a burn from his cigarette dropping on his right thigh. The burn had full thickness tissue loss with 100 percent (%) slough (dead tissue) in the wound bed, and required debridement. This affected three residents (#21, #28 and #47) and had the potential to affect an additional five additional residents, Residents #3, #33, #40, #42, and #303 who were identified by the facility as being independently mobile, cognitively impaired and able to reach the unsecured box with cigarettes and lighters. The facility census was 54. Findings include: 1. Record review for Resident #21 revealed a readmission date of 07/23/23 with diagnoses including dementia, anxiety disorder, and Alzheimer's disease. Review of the care plan dated 03/25/21 revealed Resident #21 had impaired cognitive process for daily decision making. Resident #21 was at risk for further decline in cognitive status. Interventions included to anticipate needs and keep resident clean, dry and comfortable every shift and provide a stable and supportive environment through consistencies in daily routine as able. Resident #21 also had a care plan related to a potential for safety hazard or injury related to smoking. The care plan revealed Resident #21 was able to smoke with supervision by staff or family. Smoking apron would be provided to Resident #21 during smoking times, effective 12/08/20. The care plan also revealed smoking materials were to be returned to nurse's station after smoke break and while smoking, (resident) would have direct supervision by staff or family member. Review of the Smoking and Safety assessment for Resident #21 dated 12/09/24 completed by Licensed Practical Nurse (LPN) #526 revealed Resident #21 used tobacco, had limited or no range of motion in arms and hands, insufficient fine motor skills needed to securely hold tobacco, marijuana or vape products, and drops ashes on self. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was moderately cognitively impaired. Resident #21 used a wheelchair for mobility, was independent for eating and wheelchair mobility, and was dependent on staff for oral hygiene, upper and lower body dressing, and transfers. Review of the progress note for Resident #21 dated 02/01/25 completed by LPN #549 revealed found cigarette burn on right thigh, and the area was cleaned with normal saline (NS), Xeroform and bordered foam dressing applied. The progress note revealed education was given to wear smoking apron at smoke breaks. Review of an Incident Report (IR) for Resident #21 dated 02/01/25 completed by LPN #549 revealed found burn mark on resident's right thigh. Resident description I dropped my cigarette on my lap. The report revealed educated staff on smoking apron use. The IR included reviewed with interdisciplinary team (IDT) and agree with intervention plan of educating staff on need of wearing apron to smoke dated 02/05/25. Review of the skin grid for Resident #21 dated 02/04/25 at 11:04 A.M. completed by Assistant Director of Nursing (ADON) #519 revealed burn originated on 02/01/25, full thickness tissue loss with 100% slough (dead tissue) in the wound bed, Xeroform used for autolytic debridement. Observation on 05/15/25 at 1:52 P.M. of the North side where Resident #21 resided revealed a smoking box sitting on the counter at the nurse's station. The smoking box had a locking mechanism available on the box but was left unlocked. Observation revealed multiple packs of cigarettes and lighters in the box. Observation revealed no staff were in the vicinity as visitors and residents were nearby until 2:05 P.M. Observation on 05/15/25 at 2:05 P.M. revealed LPN #549 returned to the nurse's station. LPN #549 confirmed the smoking box was unlocked and unsecured and within reach of any residents passing by. The facility identified five additional residents, Resident #3, #33, #40, #42, and #303 who were independently mobile, cognitively impaired and able to reach the unsecured box with cigarettes and lighters creating a potential accident hazard for these residents. Interview on 05/15/25 at 3:27 PM with LPN #549 verified the burn on Resident #21's leg was from a cigarette burn. LPN #549 stated she educated the certified nursing assistants (CNA) to make sure the resident had his smoking apron. However, LPN #549 stated she did not put the education in writing, she just told them stating, They should know, he was always supposed to have one. LPN #549 revealed there were two CNAs that she in-serviced on that day but she could not remember who they were and confirmed she did not in service any other staff. Interview on 05/15/25 at 3:39 P.M. with Director of Nursing (DON) confirmed he was aware of Resident #21 burning his leg with a cigarette and confirmed the intervention was to in-service staff on the need for Resident #21 to wear a smoking apron when he smokes. The DON revealed the in-service was one that was placed at the nurse's station for staff to read and sign. The DON revealed he was unable to find the in-service and confirmed he was unsure if all the staff read and signed the in-service. The DON confirmed the box located at the nurse's station with resident's smoking supplies should be locked when not in use. Review of the facility policy titled Resident Smoking revised 01/16/25 revealed it was the policy of the facility to provide a safe and healthy environment for residents, visitors and employees, including safety as related to smoking. Smoking materials would be maintained by nursing staff. All safe smoking measures would be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who would be responsible for supervising residents while smoking, 2. Record review for Resident #47 revealed an admission date of 01/21/25. Diagnoses included severe protein calorie malnutrition, altered mental status, chronic obstructive pulmonary disease (COPD) and weakness. Review of Resident #47's history of falls for the past 60 days revealed Resident #47 had a fall on 03/26/25, 04/10/25, and 04/26/25. Review of the care plan for Resident #47 dated 04/25/25 revealed Resident #47 was a potential risk for falls related to age, medication, confusion, restlessness, attempting to transfer without assist. Interventions included to ensure the call light was within reach at all times. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was moderately cognitively impaired. Resident #47 was dependent on staff for bed mobility and transfers. Resident #47 had falls since admission. Observation on 05/12/25 at 7:01 A.M. revealed Resident #47 was lying in bed. The call light was located behind the head board at the head of the bed. Observation and interview on 05/12/25 at 7:07 A.M. with LPN #553 verified Resident #47's call light was behind the headboard and verified Resident #47 would not be able to reach the call light to use it. Observation and interview on 05/19/25 at 10:12 A.M. with LPN #509 verified Resident #47's call light was in the top drawer of the night stand with the door closed. Resident #47 confirmed he could not reach the call light. LPN #509 also confirmed Resident #47 could not reach the call light and verified Resident #47 would not have been able to place the call light in the nightstand drawer and close the drawer. LPN #509 stated his CNA #503 must have put it there and stated Resident #47 falls when he tries to get up unattended. Resident #47 does use the call light when he can reach it. Interview on 05/19/25 at 10:19 A.M. with CNA #503 stated she did not put Resident #47's call light in his night stand drawer and said night shift staff must have put in the drawer. CNA #503 confirmed Resident #47 understands how to use the call light. 3. Review of the medical record for Resident #28 revealed an admission date of 01/29/24 with diagnoses including atrial fibrillation, cerebral infarction, mood affective disorder, major depressive disorder, hypertension, cognitive communication deficit, muscle weakness, anxiety disorder, and unsteadiness on feet. Review of the care plan, initiated 02/22/24, revealed Resident #28 had a potential risk for falls related to age, cognitive function, decreased physical function, history of falls, medications, transferring and ambulating without assistance, and buckling his knees at time while staff were providing assistance. Interventions included fall risk assessments to be completed on admission, quarterly, and as needed (initiated 02/22/24), ensure call light within reach (initiated 02/22/24), assist with transfers as needed (initiated 02/22/24), encourage use of assistive devices for transfers or ambulation (initiated 02/22/24), a call don't fall sign for a visual reminder to ask for assistance (initiated 04/17/24), medication review (initiated 11/30/24), and a dycem to recliner (initiated 03/07/25). Review of the fall risk evaluation, dated 01/15/25, revealed Resident #28 scored a three and the evaluation indicated a score of 10.0 or higher was considered high risk. Review of the progress note dated 03/07/25 at 5:15 P.M. revealed Resident #28 slid to the floor from the chair and there were no visible injuries noted. Vital signs were within normal limits, Resident #28 refused to speak about the incident, and the resident was assisted back into the chair with call light within reach. Review of the fall investigation dated 03/07/25 revealed Resident #28 had an unwitnessed fall with no injury. Resident #28 was oriented to person only at the time of the fall. The new intervention was a dycem (non-skid pad) placed in the recliner to help reduce the chance of sliding. Review of the annual Minimum Data Set (MDS) assessment, dated 04/15/25, revealed Resident #28 had moderate cognitive impairment, required substantial/maximal assistance or total dependence for activities of daily living (ADLs), and had one fall without injury since the last assessment. On 05/12/25 at 9:56 A.M., an observation of Resident #28's room revealed there was no dycem in the recliner. Resident #28 was in his recliner and his call light was not within reach. Interview with Certified Nursing Assistant (CNA) #517 verified there was no dycem in the recliner and the call light was within reach of Resident #28. CNA #517 stated the call light was on the opposite side of bed. On 05/12/25 at 1:16 P.M., an observation of Resident #28's room revealed Resident #28 was in his recliner and there was still no dycem in the recliner. Interview at the time of observation with CNA #517 verified there was no dycem in the recliner. On 05/15/25 at 10:31 A.M., an interview with Licensed Practical Nurse (LPN) #549 confirmed Resident #28 had experienced falls. LPN #549 was unable to state what fall interventions were supposed to be in place for Resident #28 and when looking it up in the chart, LPN #549 only looked at physician's orders and stated there were no orders for any fall interventions. LPN #549 was unaware of where to locate the fall interventions in the chart for Resident #28. Review of the facility policy titled Fall Prevention and Management, dated 01/08/24, revealed residents would be assessed for fall risk on admission, quarterly, after a fall, and as needed. Individualized interventions would be implemented based on the assessment and risk factors, interventions would be monitored for effectiveness, and the plan of care would be revised as needed. In the event of a fall, an intervention aimed to prevent further falls would be implemented, the interdisciplinary team would review the fall and new interventions that were identified or implemented, and discuss any new interventions that may help prevent further falls. This deficiency represents non-compliance investigated under Complaint Number OH00161001.