Every finding on record at Belle Teche Nursing & Rehab Center

Based on observations and interviews, the facility failed to distribute, store, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. The food service area remained in a sanitary condition during the meal prep process; and 2. Residents' dishware consisting of plates, plate warmer covers and saucers were stored inverted or covered. This deficient practice had the potential to affect the 93 residents who were served food from the kitchen. Findings:On 07/06/2026 at 9:20 a.m., an observation of the kitchen was conducted with S3DM which revealed two uncovered rectangular pans of cornbread sitting on top of the serving table. Closer observations of the ceiling tiles and vent positioned above the uncovered cornbread revealed the ceiling tiles and ceiling vent had small amounts of visible dust particles covering them. An immediate interview was conducted with S4AC, who stated the cornbread was hot and could not be covered at that time. An interview was conducted with S3DM, who stated there were visible dust particles on the ceiling tiles and vent. She further stated that the ceiling tiles and vents were supposed to be cleaned weekly by kitchen staff. S3DM confirmed the cornbread should have been covered near ceiling tiles and vents that were dust filled. On 07/06/2026 at 9:25 a.m., further observation was made of dishware sitting in the plate warmer stored facing upward and was not covered. Further observation revealed saucers on the shelf below the service line that were facing upward and were not covered and plate covers sitting on the top of the counter that were stored right side up. An immediate interview was conducted with S3DM who confirmed the dishware consisting of plates in the plate warmer, saucers, and plate covers should have been stored inverted and were not.On 07/06/2026 at 3:55 p.m. and again on 07/07/2026 at 12:48 p.m., the facility's policy for storage of dishware and food preparation was requested from S3DM. On 07/07/2026 at 1:22 p.m., S7AA provided the facility's policy and procedure titled, Cleaning Procedures Item: Plastic storage Containers- NFS, which failed to address the deficient practice that was observed of preparing food under unsanitary conditions and the improper storage of dishware. On 07/07/2026 at 3:38 p.m., S1ADM provided the facility's policies and procedures titled, Storage of Cooked Food and Cleaning Procedures Item: Pots and pans, which failed to address the deficient practice that was observed of preparing food under unsanitary conditions and the improper storage of dishware.

Based on observations, interviews and policy review, the facility failed to appropriately store medications in Med Cart B for Resident #23. Findings:On 07/06/2026, a review of the facility's policy titled Medication Storage in the Facility with a last reviewed date of 01/19/2026, read in part: Policy Statement: The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. Procedure: Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication room, carts, and medication supplies are locked or attended by persons with authorized access.On 07/06/2026 at 9:15 a.m., an observation was made of Med Cart B on Hall E. Med Cart B was observed as unattended for 3 minutes. Three unsecured blister cards containing pills were observed on top of Med Cart B. On 07/06/2026 at 9:18 a.m. an interview was conducted with S6LPN. S6LPN returned to Med Cart B and confirmed that she had left the three blister cards of medication belonging to Resident #23 on top of Med Cart B and left it unattended. S6LPN confirmed these medications were accessible to unauthorized personnel and residents. S6LPN confirmed that the following medications were left on top of Med Cart B and accessible to anyone who walked by: Olanzapine 5mg (milligrams), 3 pills were in the blister card; Citalopram 40mg, 1 pill was in the blister card; Levothyroxine 50 mcg (micrograms), 3 pills were in the blister card. S6LPN stated that she should have placed the medications inside Med Cart B and locked it before leaving it unattended. 07/06/2026 at 9:52 a.m., an interview was conducted with S2DON. S2DON confirmed that medications should not be left on top of medication carts when they are unattended. S2DON confirmed that the nurse should have placed the medications inside the cart and locked it before leaving the cart unattended.

Based on interviews and record reviews, the facility failed to notify the Responsible Party (RP), immediately after a change in the resident's physical condition for 1(Resident #91) of 36 sampled residents.Findings:On 07/08/2026, a review of the facility's policy titled Resident and Family Notification Guidelines with a last reviewed date of 01/19/2026, read in part: Notification of resident and the resident representative of changes in the resident's condition is the primary responsibility of the nurse assigned to the resident. Listed below are scenarios of when such notification is to occur and be documented as occurring in the nurses notes .2. Any order change, addition or discontinuance .3. Any significant change in the resident's condition (i.e.changes in condition).Review of Resident #91's clinical records revealed he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, metabolic encephalopathy, unspecified protein-calorie malnutrition, and abnormality of albumin.Review of the nurses' progress notes revealed that on 06/11/2026 at 10:41 p.m., S8LPN wrote in part, Resident noted sitting at the main nursing station sitting in wheelchair slumped over with brown emesis falling out of mouth. Alert to physical stimuli, not to verbal stimuli. Resident transferred into bed, vitals taken. 114/63, P (pulse) 90, 97.1, O2 (oxygen) 95% RA (room air), R (respirations) 18. Writer listened to bowel sounds, no bowel sounds noted. Abdomen soft, not distended. Writer informed S9NP. New orders for Zofran 4mg (milligram) ODT (orally disintegrating tablet) sublingual, 1st dose now and then q6h (hour) prn (as needed) x (times) 7 days. STAT (immediately) KUB (kidneys, Ureters, and Bladder test) and STAT (immediate) CBC (Complete Blood Count). Further review of the nurses' progress notes did not reveal Resident #91's RP was notified of the change in the resident's condition, or the new orders. On 07/06/2026 at 1:09 p.m., an interview was contacted with Resident #91's RP. The resident's RP stated that about two weeks ago on a Sunday, he visited the resident in the facility and was informed by his assigned nurse that he had not been feeling well since Friday. He stated that he asked why no one had notified the family and she could not give an answer. On 07/07/2026 at 3:22 p.m., an interview was conducted with S8LPN who confirmed that she did not notify the family of the change in Resident #91's physical condition or the new orders by S9NP. She further confirmed that she was aware of the facility's policy to immediately notify the resident's RP for changes in physical condition and new orders at all times. On 07/07/2026 at 3:30 p.m., an interview was conducted with S1ADM and S2DON. They both confirmed that it was the facility's policy to immediately notify the family when there is a change in a residents' condition or new orders, and S8LPN should have immediately notified Resident #91's RP.

Based on observations, interviews and record review, the facility failed to ensure a person-centered care plan was implemented for each resident, by failing to implement fall interventions for 1 (Resident #55) of 2 residents investigated for accidents of 36 sampled residents. Findings:On 07/08/2026, a review of the facility's policy titled Fall Prevention Program with a last reviewed date of 01/19/2026, read in part: It is the policy of this facility to promote safety, dignity, and overall quality of life for residents. A safe and hazard free environment, as possible, will be provided as well. It is our goal to prevent falls by enabling staff to recognize those residents who have been identified as high risk for potential falls so appropriate interventions can be implemented .g. Plan of Care: Based on the nursing assessment, preventive measures will be implemented and care planned for residents identified at high risk for falls .Resident #55 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, history of falling, and restlessness and agitation.Review of incident reports for Resident #55 revealed he had an un-witnessed fall with no injury on 05/04/2026. The resident stated he was going to smoke. Further review revealed another un-witnessed fall with no injury on 05/10/2026. The resident stated he was trying to get to his wheelchair and fell.Review of Resident #55's current care plan revealed a focus area initiated on 09/12/2023 and revised on 06/10/2026 which read in part: At high risk for falls.Further review revealed the following interventions, in part: Place resident's wheelchair outside of room when resident is in bed per family request, and to keep call light in reach and respond in a timely manner.On 07/06/2026 at 10:11 a.m., an observation was made of Resident #55 in his bed. The resident's call light was placed on his night stand which was at the foot of his bed and outside his reach. On 07/06/2026 at 10:17 a.m., an observation and an interview was conducted with S13LPN. She confirmed Resident #55's call light was on his night stand and outside his reach. S13LPN stated that the resident was at risk for falls and stated his call light should have been within his reach. On 07/08/2026 at 8:08 a.m., an observation was made of Resident #55 in his room. The resident was in his bed having breakfast and his wheelchair was at his bedside.On 07/08/2026 at 8:14 a.m., an observation of Resident #55's room and an interview was conducted with S12LPN/CNA Sup. She confirmed Resident #55's wheelchair was at his bedside and stated that it should have been placed outside his room.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident who required assistance with personal care received assistance with activities of daily living (ADLs) to maintain good grooming for 1 (Resident #67) of 3 residents investigated for ADL care.FindingsOn 07/09/2026, a review of the CNA (Certified Nursing Assistant) skills training hire packet dated 01/26, read in part, CNA skill Resident Basic Care Review.Shaving: . If your resident needs a shave you are to assist or shave the person regardless of the time of day or shift.On 07/09/2026, a review of the facility's policy titled, Hygiene and Grooming with a last reviewed date of 01/19/2026, read in part, Policy: . Staff will provide resident with whatever assistance is necessary to keep their facial hair properly groomed. Essential Points: . 4. Staff members should be conscious of female hygiene, like shaving legs and underarms when desired by resident as well as chin hair. A Review of Resident #67's electronic health record (EHR) revealed that she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to sequelae of other cerebrovascular disease, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, and primary generalized osteoarthritis. A review of Resident #67's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Section C: Cognitive Patterns - BIMS (Brief Interview for Mental Status) was 10, indicating the resident's cognition was moderately impaired. Section GG: Functional Abilities - Personal Hygiene . including combing hair, shaving . was scored 2, indicating the resident required substantial/maximal assistance. A review of Resident #67's current comprehensive care plan initiated on 01/09/2015, read in part, the resident needs assist with bathing, hygiene, dressing, and grooming. On 07/06/2026 at 9:44 a.m., an interview and observation of Resident #67 was conducted. Resident #67 was lying in bed and stated she was waiting for the staff to get her ready for the day. Overgrown facial hair that was long and curled was observed on her chin. A review of Resident 67's task documentation report failed to reveal that Resident #67 was shaved from 06/20/2026 to 07/07/2026. On 07/06/2026 at 11:01 a.m., an interview and observation of Resident #67 was conducted. Resident #67 was sitting up in her wheelchair in her room. Overgrown facial hair was still observed on her chin. She stated staff got her ready for the day, and the last time her facial hair was shaved was months ago. She stated she did not like her facial hair and wanted it shaved. On 07/07/2026 at 10:53 a.m., an observation was conducted of Resident #67 in her room, and overgrown facial hair was still observed on her chin. On 07/07/2026 at 2:15 p.m., an observation was conducted of Resident #67 sitting in her wheelchair in the dining room, and overgrown facial hair was noted on her chin. On 07/07/2026 at 2:47 p.m., an interview and observation of Resident #67 was conducted with S11CNA. S11CNA stated her responsibility was grooming the resident which, consisted of bathing, shaving, and combing her hair. S11CNA stated that even if it was not Resident #67's bath day or time, she should always be groomed. She confirmed Resident #67 was dependent on staff with ADL care. At this time, an observation of Resident #67 was conducted with S11CNA, and she confirmed the resident had overgrown, long, and curled facial hair on her chin, and it should have been shaved. On 07/07/2026 at 3:00 p.m., an interview and observation of Resident #67 was conducted with S12LPN/CNA Sup. S12LPN/CNA Sup. stated residents were to be groomed by their designated CNA every day. S12LPN/CNA Sup. stated if a resident's facial hair was long, it should be shaved right away. At this time, an observation of Resident #67 was conducted with S12LPN/CNA Sup., and she confirmed Resident #67 had overgrown, long, and curled facial hair and it should have been shaved.

Based on observations, interviews, and record review, the facility failed to ensure nurses followed the facility's policy to accurately document the count of controlled medications in Med Cart A for Resident #38 out of 2 medication carts reviewed. Findings: A review of the facility's policy titled, Controlled Medication with a last review date of 01/19/2026, read in part, Policy: In accordance with federal and state laws, medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility. Procedure:. 2. When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record; a. date and time of administration. b. amount administered. c. signature of nurse administering the dose, immediately after the medication is actually administered, d. amount remaining.A review of Resident #38's electronic medical record revealed he was admitted to the facility on [DATE] with a diagnosis that included in part, encounter for other orthopedic aftercare. A review of Resident #38's physician orders revealed an order dated 06/24/2026 for Hydrocodone Acetaminophen Oral Tablet 7.5-325 mg (milligram), give 1 tablet by mouth every 6 hours as needed for pain related to encounter for other orthopedic aftercare. On 07/07/2026 at 3:15 p.m., a narcotic count was performed on Med Cart A with S5LPN which revealed the following inaccurate narcotic count: Resident #38's Individual Narcotic Record for medication hydrocodone acetaminophen 7.5-325 mg revealed a count of 18 tablets with last dose documented on 07/06/2026 at 8:00 p.m. The current count of tablets observed and counted was 17 tablets. A review of Resident #38's MAR (Medication Administration Record) with S5LPN for July 2026 revealed that the last dose of Hydrocodone Acetaminophen 7.5-325 mg, 1 tablet was administered on 07/07/2026 at 11:55 a.m. A review of the facility's form, labeled Individual Narcotic Record for Resident #38, failed to reveal the administration of Hydrocodone Acetaminophen Oral Tablet 7.5-325 mg on 07/07/2026 at 11:55 a.m. S5LPN confirmed that she gave Resident #38 Hydrocodone Acetaminophen 7.5-325 mg at 11:55 a.m. S5LPN confirmed that she did not document the administration of the narcotic medication immediately on the Individual Narcotic Record and she should have. On 07/07/2026 at 3:30 p.m. an interview was conducted with S2DON. S2DON confirmed that the nurse should have documented administration of the narcotic medication on the Individual Narcotic Record immediately after it was given.

Based on interview and record review, the provider failed to transmit MDS (Minimum Data Set) Assessments within 14 days after completion for 3 (#34, #50, #71) out of 3 residents triggered for resident assessment review in a sample of 36 residents. Findings:Review of the facility's policy titled Resident Assessment Instrument (RAI) Policy, with a last reviewed date of 01/19/2026, read in part: Within seven (7) days after completing the resident assessment, the data will be encoded for transmittal to the state. Electronic transmittals will occur weekly, when possible, but at least monthly. Review of Resident #34's electronic clinical record revealed a quarterly MDS assessment, with an ARD (Assessment Reference Date) of 03/07/2026, was completed on 03/21/2026. Review of the facility's CMS (Center for Medicare Services) transmittal validation report indicated Resident #34's quarterly MDS assessment with the ARD of 03/07/2026 was transmitted on 04/06/2026 and was more than 14 days late.Review of Resident #50's electronic clinical record revealed a quarterly MDS assessment, with an ARD of 06/06/2026 was completed on 06/19/2026. Review of the facility's CMS transmittal validation report indicated Resident #50's quarterly MDS assessment with the ARD of 06/06/2026 was transmitted on 07/07/2026 and was more than 14 days late. Review of Resident #71's electronic clinical record revealed a quarterly MDS assessment, with an ARD (Assessment Reference Date) of 06/06/2026 was completed on 06/19/2026. Review of the facility's CMS transmittal validation report indicated Resident #71's quarterly MDS assessment with the ARD of 06/06/2026 was transmitted on 07/06/2026 and was more than 14 days late. On 07/08/2026 at 10:48 a.m., an interview and record review was conducted with S10MDS. S10MDS reviewed Resident #34, #50, and #71's electronic clinical records and CMS transmittal validation reports. S10MDS confirmed that each resident's MDS assessment had been submitted greater than 14 days after completion and were late.

Based on interviews and record reviews, the facility failed to ensure a resident who required assistance with activities of daily living (ADLs) received good grooming and personal hygiene for 1 (Resident #1) of 4 sampled residents.Findings:Review of Resident #1's electronic health record (EHR) revealed she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic nephropathy, morbid (severe) obesity due to excess calories, chronic obstructive pulmonary disease with (acute) exacerbation, muscle wasting and atrophy left and right hand, and need for assistance with personal care.Review of Resident #1's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/13/2026, revealed the following:-In Section C, the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact.-In Section GG, the resident required substantial maximal assistance to shower/bathe. Review of Resident #1's care plan revealed the following focus areas in part:03/17/2025 Self-care deficit: resident will receive person-centered care; needs assist with bathing, hygiene, dressing and grooming.Interventions in part. Bathe per schedule, staff to assist as needed to complete task.On 06/01/2026 at 9:50 a.m., an interview was conducted with Resident #1. The resident stated that she was supposed to receive a full bed bath on 05/05/2026, 05/07/2026 and 05/09/2026. Resident #1 stated she was not sure why she did not receive her scheduled baths. Review of Resident #1's task documentation report revealed she received a partial bath on 05/05/2026 and 05/07/2026, and no bath on 05/09/2026. On 06/02/2026 at 8:17 a.m., an interview and review of Resident #1's May 2026 task documentation report was conducted with S4CNASup. She confirmed the above findings on the report and stated the resident should have received her scheduled baths.On 06/02/2026 at 10:08 a.m., an interview and review of Resident #1's task documentation was conducted with S1ADMIN. He stated he had conducted an investigation, and confirmed the findings on the documentation report. S1ADMIN stated the resident should have received her scheduled full baths.

Based on interviews and record reviews, the facility failed to ensure there was a sufficient number of Certified Nurse Aides (CNAs) to provide services in accordance with resident care plans for 1 (Resident #1) of 4 sampled residents.Findings:On 06/02/2026, a review of the CNA (Certified Nursing Assistant) skills training hire packet dated 01/2026, read in part: Incontinent Care: Any of the residents on your assigned set who are incontinent of their bowel and/or bladder need to have incontinent care completed by you at least every 2 hours.You need to check all residents on your set for incontinence every 2 hours.Review of Resident #1's electronic health record (EHR) revealed she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, type 2 diabetes mellitus with diabetic nephropathy, morbid (severe) obesity due to excess calories, chronic obstructive pulmonary disease with (acute) exacerbation, personal history of urinary (tract) infections, muscle wasting and atrophy left and right hand, and need for assistance with personal care.Review of Resident #1's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/13/2026, revealed the following:-In Section C, the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact.-In Section GG, the resident required partial/moderate assistance with toileting hygiene.-In Section H, the resident was always incontinent of urine.-In Section N, the resident was on a diuretic (a medication that causes increased urination).Review of Resident #1's current physician's orders revealed an order dated 01/20/2026 for Lasix Oral Tablet 20 mg (milligram) (Furosemide) Give 20 mg by mouth one time a day related to generalized edema.Review of Resident #1's care plan revealed the following, in part:03/16/2025 Toileting deficit: Needs assist r/t (related to) dx (diagnoses) morbid obesity.Interventions in part.Incontinence care check for incontinence at least every 2 hours. On 06/01/2026 at 9:50 a.m., an interview was conducted with Resident #1. The resident stated that S9CNA who worked the 11:00 p.m. to 7:00 a.m. shift kept her a nervous wreck. She stated she was not afraid of S9CNA but she was tired of her rude attitude. Resident #1 stated that S9CNA doesn't like to be called outside of her rounds. She stated she was wet with urine that soaked her bed and gown after 4 1/2 hours on the night of 05/31/2026. She stated she needed to be changed but was waiting for S9CNA to come in on her rounds because when she called S9CNA outside of her rounds she always came in her room with a bad attitude. Resident #1 stated that on Friday night (05/29/2026) she mentioned to S9CNA that she was scheduled for a bath on Saturday (05/30/2026), and S9CNA said in an angry tone, Tell them b****** to bathe you before I get here. Because them b****** don't have nothing else to do. If it ain't done by the time I'm here; I'm not doing it. She stated when S9CNA did not round on her on Sunday (05/31/2026) between 7:00 p.m. and 11:00 p.m. She didn't call because she was tired of her attitude. Resident #1 stated she discovered later that S9CNA did not start her shift until 11:00 p.m. Review of the facility's staffing schedule revealed S9CNA was scheduled to work on Hall B from 7:00 p.m. to 7:00 a.m. on the following dates: 05/28/2026; 05/29/2026, 05/31/2026, and 7:30 p.m. to 7:00 a.m. 05/30/2026. Review of the Condensed Employee Time Detail (clock in and out) for S9CNA revealed the following:-05/28/2026, S9CNA clocked in at 8:05 p.m. and out at 7:00 a.m.-05/29/2026, S9CNA clocked in at 7:56 a.m. and out at 7:00 a.m.-05/30/2026, S9CNA clocked in at 7:47 p.m. and out at 7:00 a.m.-05/31/2026, S9CNA clocked in at 10:55 p.m. and out at 7:01 a.m.Three calls were made to S9CNA throughout the survey on 06/01/2026 and 06/02/2026 with no response. On 06/01/2026 at 2:25 p.m., an interview and review of the facility's schedule from 05/28/2026 to 05/31/2026 with S2DON and S4CNASup. They both confirmed the times on the schedule were the times S9CNA was supposed to work. S2DON and S4CNASup acknowledged the times S9CNA clocked in and confirmed that she had clocked in late. S2DON was asked if that was normal and she stated, That is a big issue. S2DON further stated that if a CNA was clocking in late, the nurse on the unit was supposed to report to her supervisor that the staff member was not at work. S2DON and S4CNASup both stated that they were not aware S9CNA had been clocking in late. S2DON stated S3ADON was the nurse in charge on 05/31/2026.On 06/01/2026 at 2:28 p.m., an interview was conducted with S3ADON. She stated that she left the facility before 7 p.m. on 05/28/2026 and 05/29/2026 and did not work on 05/30/2026. S3ADON confirmed she worked on Hall B on 05/31/2026 from around 5:00 p.m. to 10:15 p.m. She confirmed that she was aware that S9CNA did not show up for her scheduled shift. She stated S4CNASup stayed over a little and did not confirm if she was able to reach S9CNA. When asked if she had reported it to her supervisor, S3ADON stated S2DON was on vacation. S3ADON was asked if she reported it to the administrator and she stated she did not.On 06/02/2026 at 8:05 a.m., a follow-up interview was conducted with S2DON. She stated that there was a chain of command from S4CNASup - S3ADON - S2DON - S1ADMIN. She stated that S4CNASup and S3ADON were both at work on 05/31/2026, and S4CNASup was responsible for ensuring S9CNA was there for her scheduled shift. S2DON then stated that she had been aware of CNAs clocking in late and had done some retraining, but confirmed that she had not been monitoring the behavior and should have been monitoring.

Based on interviews and record review, the facility failed to protect the resident's rights to be free from neglect evidenced by staff failing to lower the bed of a resident who was a high risk for falls for 1 (#3) resident out of 9 (#1, #2, #3, #R1, #R2, #R3, #R4, #R5 and #R6) sampled residents. This deficient practice resulted in an actual harm for Resident #3 on 03/13/2026 at 6:50 a.m., when S3CNA observed Resident #3's bed was not in the lowest position and failed to intervene by lowering the bed. S3CNA admitted she was aware the resident's bed should have been in the lowest position, but did not lower the bed nor inform the nurse or other staff that resident's bed was not in the lowest position. Resident #3 was found on the floor, 9 minutes after S3CNA identified Resident #3's bed was not in the lowest position. Staff and a visitor observed Resident #3 yelling out, complaining of left hip/leg pain. Resident #3 was sent to the emergency room (ER) via emergency medical services. ER x-rays revealed the resident sustained a left femoral intratrochanter fracture requiring surgery (open reduction internal fixation/intramedullary nail placement) that was performed on Monday 03/16/2026. Resident #3 was discharged back to the facility on [DATE].The facility implemented corrective action plan on 03/13/2026 which was completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings:On 03/24/2026 review of the facility's undated policy titled, Fall Prevention Program revealed, in part:It is the policy of this facility to promote safety, dignity, and overall quality of life for residents. A safe and hazard free environment, as possible, will be provided as well.Protocol: I. Identification of High Risk Residents: A. Fall Risk Assessment will be completed on all residents within the first 24 hours of admission and with each MDS (Minimum Data Set assessment).Residents with a score of 10 or greater will be considered at high risk.II. Preventative Protocol.c. Elimination of Environmental Hazards: Another key factor in preventing falls is identification and elimination of environmental hazards when possible. Several areas to address include the following: .4. Bed Height: When the resident is seated at the edge of the bed, feet should be flat on the floor.h. Falling Star Program: Any resident who is identified at high risk by the previous criteria will be placed on the Falling Star Program. The purpose of the falling star program is to promote easy recognition of residents who have been identified as being high risks for falls.Review of the facility's policy titled, Abuse/Neglect with a last revision date of 04/03/2025 revealed, in part: This facility will not condone any form of resident abuse or neglect.Each resident has the right to be free from neglect.Definitions:.G. 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,.I. Serious bodily injury is defined as an injury involving extreme physical pain. or requiring medical intervention such as surgery, hospitalization. Review of the medical records for Resident #3 revealed the resident was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, bradycardia, dementia, bipolar disorder, long term use of aspirin major depressive disorder.Review of Resident #3's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/28/2025, revealed the following, in part:BIMS (Brief Interview for Mental Status) score of 06 which indicated the Resident had severe cognitive impairment; and was dependent on staff when performing bed mobility and chair/bed to chair transfers.Review of Resident #3's March 2026 physician's orders revealed an order entry dated 07/23/2024-Resident is high risk for falls and is on the Falling Star Program. Review of Resident #3's fall risk assessments dated 11/28/2025 revealed a score of 17 and assessment on 03/19/2026 revealed a score of 19.Review of Resident #3's current care plan revealed the following, in part: initiated 09/02/2021 .Problem: The resident will remain free from falls and will have no falls with injuries.Approaches: keep bed in the lowest position with the wheels locked.Review of Resident #3's Unwitnessed fall Incident Report dated 03/13/2026 revealed the following, in part: Nurse summoned to room and informed that resident was noted lying on the floor on his back, nurse assessed resident and noted bruising to left temple, complaining of pain to left hip, once hip pain noted resident was left in still position and DON (Director of Nursing) was notified. Emergency medical service was contacted. Resident taken to hospital. Other information included: bed not in lowest position. Review of Resident #3's hospital records revealed an x-ray report dated 03/13/2026 at 8:52 a.m. which noted the resident had a left femoral intertrochanteric fracture with displacement and surrounding soft tissue swelling. Resident #3 underwent surgery; intramedullary nailing of the left femur on 03/16/2026. Review of the facility's Investigative Report revealed the following, in part: on 03/13/2026, S1ADM reviewed facility's video footage (not available at time of survey) from earlier in the morning and identified S3CNA on Resident #3's hall making rounds and looked in Resident #3's room, but did not enter. S3CNA did state when she made rounds at 6:50 a.m., she did see Resident #3's bed was not in a low position. S3CNA was counseled on making sure resident beds remain in the low position.Review of S3CNA's personnel file revealed Certified Nursing Assistant job description duties and responsibilities, in part: 22.Provide maximum resident-care services to assure well- being of resident to greatest degree.24.Assist with execution of resident assessment and plan of care.27.Detect and correct situations that have a probability of causing accidents or injuries to residents.signed by S3CNA on 10/09/2025.On 03/25/2026 at 8:45 a.m., a phone interview was conducted with S3CNA. S3CNA verified she came on shift at 6:50 a.m. on 03/13/2026 and was assigned to provide care to Resident #3. S3CNA explained she conducted a quick round on the hall Resident #3 resided. As she walked down the hallway she observed Resident #3's door was opened and observed his bed was not in its lowest position. S3CNA confirmed she continued walking toward the dining room for breakfast meal service duties and failed to lower Resident #3's bed to the lowest position. When asked why she did not go into Resident #3's room to lower his bed, S3CNA stated she thought other staff were going to get Resident #3 up out of bed. S3CNA confirmed S1ADM reviewed the facility's video surveillance footage with her that showed S3CNA looking in Resident #3's room from the hallway and not entering the resident's room after identifying his bed was not in the lowest position. On 03/23/2026 at 9:20 a.m., an interview was conducted with S1ADM who was responsible for managing the facility. S1ADM confirmed Resident #3 had been hospitalized [DATE] until 03/18/2026 as a result of an unwitnessed fall resulting in a leg fracture that required surgical repair on 03/16/2026. S1ADM explained he immediately reviewed the facility's video footage with S2DON and S6ADON four hours prior to the resident falling at 6:59 a.m. He identified per the video at 6:50 a.m., S3CNA was seen making a round down Resident #3's hall and had looked in Resident #3's room from the hallway. Then at 6:59 a.m., a visitor was seen walking down the hall and heard Resident #3 hollering and when the visitor looked in the room, he saw Resident #3 on the floor near his bed and immediately notified S4HSK who was on the hall. S4HSK then notified S5LPN who immediately notified S2DON. At 7:00 a.m., S2DON and S5LPN entered Resident #3's room. Emergency medical services were notified and Resident #3 was transported to the hospital on [DATE] after complaints of left hip pain and left leg shortening. S1ADM then interviewed S3CNA and pointed out that he observed her on the hall in front of Resident #3's room around 6:50 a.m. S3CNA confirmed she stopped and looked in Resident #3's room and observed his bed was not in its lowest position, but failed to intervene. S1ADM stated he immediately began in-servicing all clinical staff which included: a verbal discussion covering resident bed positions-All resident beds should remain in low position, unless care planned otherwise. After providing care of leaving a resident's room, the bed needs to be lowered. S1ADM also in serviced non clinical staff on 03/13/2026 and discussed resident bed positions to include if any resident's bed is seen in the high position, immediately alert the nurse and/or CNA (Certified Nursing Assistant) down the hall so they can lower it. Remain with the resident until the bed is lowered. S1ADM explained on 03/13/2026 at 8:00 a.m., S2DON completed an audit on all residents' beds to ensure each bed was in low position unless otherwise care planned. S1ADM stated the facility started a QAPI (Quality Assurance Performance Improvement) meeting on 03/13/2026 to begin investigations and initiate corrective actions. S1ADM reported the facility's monitoring began 03/13/2026 and was ongoing. He denied any negative findings with the monitoring and stated there had been no further incidents regarding facility staff intervening to ensure residents' bed were in the lowest position, unless care planned otherwise. S1ADM reported he and S2DON conducted random monitoring and in-servicing staff on Saturday 03/14/2026 and Sunday 03/15/2026 with negative findings. S1ADM stated he had in-serviced all staff by 03/16/2026 and the administrative staff reviewed all residents' care plans and Fall Risk Assessments to ensure residents with a score greater than 10 included accurate safety interventions. Multiple Nurses and CNAs were interviewed on 03/23/2026, 03/24/2026 and 03/25/2026 about ensuring residents beds were kept in the lowest position unless care planned otherwise. Other non-clinical staff were interviewed, such as housekeeping and maintenance who confirmed the recent in-services to ensure resident beds were kept in the lowest position and if identified a bed not in the lowest position to immediately notify the nurse and/or CNA as well as to stay with the resident until the bed was lowered. Multiple observations of residents care planned for beds in lowest position conducted on 03/23/2026- 03/24/2026. Beds were observed in the lowest position. No issues were identified. On 03/24/2026 at 10:30 a.m., an observation of two CNAs and one CNA in training demonstrated proper use of transferring Resident #3 from his wheelchair to his bed using a lifter. After Resident #3 was positioned to comfort, the CNAs lowered the resident's bed in its lowest position prior to exiting the room. No concerns were identified. The facility implemented the following actions to correct the deficient practice: 03/13/2026- Continuous Quality Assessment and Improvement Corrective Action Plan:I. Immediate baseline monitor to check all bed heights in the facility was initiated at 8:00 a.m. by Administrative Staff to ensure resident safety.II. Immediate reeducation of clinical staff focusing on resident bed height and if not care planned, they need to be kept in a low position to prevent any injuries, should a fall occur. Non nursing staff were educated that when making rounds and they find a resident's bed elevated, they need to stay with the resident and alert the resident's nurse/CNA.III. Nursing Facility Administrator (NFA) and DON performed in-services off hours (night and early am staff) on Saturday 03/14/2026 and on Sunday 03/15/2026 and rounds made to checks if any beds were not in the low position; none were found.IV. A rounding monitor was initiated on Friday 3/13/2026 and delegated to Nursing Administrative staff focusing on making room rounds and checking to make sure that beds were kept in low position. Any noncompliance found needs to be addressed at that time. Monitors are to be turned in to NFA weekly for review.V. Monitoring currently ongoing in facility 3x (times)/weekly for 6 weeks and monthly thereafter until compliance is achieved. 03/16/2026- All clinical staff have received re-education; monitoring conducted and documented with ongoing trainings continued. No immediacy was identified after monitors were complete. All resident in the facility were found to be safe.

Based on interviews and record review, the facility failed to maintain accurately documented medical records in accordance with accepted professional standards and practices. The facility's CNA (Certified Nursing Assistant) staff failed to accurately document in a resident's electronic medical record for 1 (#1) out of 3 (#1, #2, and #3) sampled residents. The facility's total census was 95.Findings: On date of review, a review of the facility's undated policy titled, Documentation Guidelines read in part,.Documenting information on the resident in the medical record provides: 4. A way to record the care received by the resident.Essential Points: Charting will be done on all residents to maintain a complete and accurate medical record. Review of a facility document titled CNA Orientation-Healthstream and PCC Information read in part, 3. As a CNA employed by this facility you are required to document the tasks in the facility kiosks you performed on each resident in your care everyday if you work a partial shift, a full shift or even an entire double shift. Prior to leaving the facility accurate kiosk documentation is to be completed on the residents you cared for. 4. Kiosk documentation is not an option or a if I have time action. This is mandatory.Kiosk Charting Requirements: Turn and Reposition Resident #1: Review of the resident's electronic medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to: pressure ulcer of sacral region, stage 4 hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; non-pressure chronic ulcer of skin of other sites with unspecified severity; chronic embolism and thrombosis of left femoral vein; right and left leg contractures; and Type 2 DM (diabetes mellitus). Review of Resident #1's February and March 2026 CNA task record revealed no documentation for turn and position for the following:February 2026: 7 a.m.-3 p.m. shift: 02/01/2026; 02/04/2026 through 02/06/2026; 02/09/2026 through 02/12/2026; 02/14/2026 through 02/15/2026; 02/17/2026 through 02/18/2026; 02/21/2026 through 02/27/2026. 3 p.m. -11p.m. shift: 02/04/2026 through 02/06/2026; 02/08/2026; 02/10/2026 through 02/17/2026; and 02/20/2026 through 02/28/2026.11 p.m.-7 a.m. shift: 02/28/2026.March 2026:7 a.m.-3 p.m. shift: 03/01/2026 through 03/02/2026; and 03/04/2026 through 03/16/2026.3 p.m.-11p.m. shift: 03/01/2026 through 03/02/2026; 03/04/2026; 03/06/2026; 03/08/2026 through 03/09/2026; 03/11/2026 through 03/12/2026; and 03/14/2026 through 03/16/2026. An interview was conducted on 03/16/2026 at 12:45 p.m. with Resident #1. He stated that the CNAs did offer to turn him, but often refused as he preferred to remain on his back. An interview was conducted on 03/17/2026 at 11:00 a.m. with S3CNA. S3CNA stated that she was working with Resident #1 and was familiar with him. She stated that the resident refused to let the CNAs turn/reposition him when he is in bed. She stated they let the resident know how important it is for him to turn to avoid skin breakdown, but he still refused most of the time. She stated that they notify the nurse when the resident refuses to be turned, and are to document it in the Kiosk under the turn/position task. An interview was conducted on 03/17/2026 at 4:30 p.m. with S2DON who directed nursing services. She confirmed the above CNA's task records for turning/repositioning was missing documentation on multiple days for each month. She confirmed that the CNAs were supposed to place their initial on the task every shift, and confirmed that the CNA task records did not reflect when the resident refused to be turned/repositioned on the above dates. An interview was conducted on 03/18/2026 at 9:15 a.m. with S1ADM who oversaw the day to day operations of the facility. He confirmed that the above CNA task records for turning/repositioning were missing documentation on multiple days. He stated that all the CNAs received training on documenting in the Kiosk during orientation. He stated that the CNAs should be documenting their completed tasks at the end of every shift, even when the resident refused care.

Based on observations, record reviews, and interviews, the facility failed to implement a person-centered care plan for 3 (#11, #65, and #86) out of a total sample of 47 residents as evidenced by: 1. Failing to ensure Resident #11 and #86 wore the appropriate footwear while out of bed. 2. Failing to ensure Resident #65 was provided a [NAME] No Spill 360 Grip and Sip cup at the bedside. Findings: Resident #11 Review of Resident #11's record revealed an admitted [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #11's Minimum Data Set (MDS) Annual assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 07, suggesting the resident's cognition was severely impaired. Review of Resident #11's care plan dated 03/21/2025 read in part .at high risk for falls related to personal history of falls. Intervention - ensure appropriate footwear is worn. On 05/19/2025 at 9:00 a.m., an observation of the resident in the dining room revealed she was wearing white socks, which were not non-skid socks. On 05/20/2025 at 2:48 p.m., an observation and interview was conducted with S7LPN (Licensed Practical Nurse) who was the nurse on the unit where the resident resided. She confirmed that staff should have ensured the resident had appropriate footwear on at all times. Did she confirm that the resident did not have the appropriate footwear? Resident #86 Review of Resident #86's record revealed an admitted [DATE] and had diagnoses with diagnoses that included, but not limited to, of flaccid hemiplegia affecting left non-dominant side, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident's 86's MDS Quarterly assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 07, suggesting the resident's cognition was severely impaired. Review of Resident #86's care plan dated 3/20/2025 read in part at high risk for falls related to personal history of falls. Intervention - ensure appropriate footwear was worn. On 05/19/2025 at 10:18 a.m., resident was observed in the dining room with white socks on both feet, which were not non-skid socks. On 05/20/2025 at 8:10 a.m., a follow-up observation of the resident was conducted during breakfast meal, which revealed the resident still had non-skid socks on both feet. On 05/20/2025 at 2:48 p.m., an observation and interview was conducted with S7LPN who was the nurse on the unit where the resident resided. She confirmed that the staff should have ensured the resident had appropriate footwear on at all times. 47540 Resident #65 A review of Resident #65's record revealed she was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Cerebral Palsy, Other Lack of Coordination, Spastic Hemiplegia affecting Right Dominant Side, and Contracture Right Wrist. A review of Resident #65's Quarterly MDS (Minimum Data Set) dated 03/28/2025 revealed a BIMS (Brief Interview for Mental Status) of 8, indicating her cognition was moderately impaired. Under Section GG: Functional Abilities revealed the resident had impairment one side of her upper extremities, and required partial/moderate assistance for eating. A review of Resident #65's physician's orders revealed an order entry with a start date of 08/21/2024 read in part, resident to use [NAME] No Spill 360 Grip and Sip cup at all times while drinking. A review of Resident #65's person-centered plan of care, revealed in part, a focus of altered nutrition and dehydration r/t (related to) vitamin deficiency, moderate PCM (protein-calorie malnutrition) with an intervention of . resident to use [NAME] No Spill 360 Grip and Sip cup at all times while drinking. A review of Resident #65's EHR (Electronic Health Record) header read in part, special instructions: right-sided weakness, resident to use [NAME] No Spill 360 Grip and Sip cup at all times while drinking. On 05/19/2025 at1:38 p.m., an observation and interview were conducted with Resident #65 in her room. Resident #65 does not have a [NAME] No Spill 360 Grip and Sip cup at the bedside. The resident stated it is only kept in the dining room. On 05/20/2025 at 11:16 a.m., a second observation was conducted of the resident's room. There was a gray drinking cup noted at the bedside with a straw in it. Resident #65 does not have a [NAME] No Spill 360 Grip and Sip cup at the bedside. On 05/20/2025 at 2:26 p.m., a third observation was conducted of Resident #65 in her room. There was a gray drinking cup noted at the bedside with a straw in it. Resident #65 was sitting in her wheelchair and contracture to her right wrist was noted. Resident #65 does not have a [NAME] No Spill 360 Grip and Sip cup at the bedside. An interview was conducted with Resident #65 at this time, and she stated the [NAME] Grip and Sip cup was only given to her during meals and she was told the [NAME] Grip and Sip cup cannot leave the dining room. She stated while she was in her room she had to use the gray drinking cup, and sometimes it was hard to use. On 05/21/2025 at 12:26 p.m., a fourth observation was conducted of the resident's room. There was a gray drinking cup noted at the bedside with a straw in it. Resident #65 does not have a [NAME] No Spill 360 Grip and Sip cup at the bedside. On 05/21/2025 at 12:34 p.m., an interview and observation of Resident #65's room was conducted with S9CN (Certified Nursing Assistant). She stated while the resident was in her room she drank out of the gray drinking cup. She then reviewed a pink sheet above the resident's bed. She stated these listed all of the resident's needs. She stated the pink sheet read the resident is to use [NAME] No Spill 360 Grip and Sip cup at all times while drinking. She confirmed the resident did not have the appropriate drinking cup in her room to drink water out of. On 05/21/2025 at 12:40 p.m., an interview and observation were conducted with S7LPN (Licensed Practical Nurse). She reviewed Resident #65's physician's orders and confirmed the resident should have a [NAME] No Spill 360 Grip and Sip cup, and she does not. She confirmed the resident only has a gray drinking cup in her room to drink out of. On 05/21/2025 at 12:42 p.m., an interview and observation were conducted with S4DM (Dietary Manager). She stated Resident #65 should have a [NAME] No Spill 360 Grip and Sip cup in her room at all times with her to drink out of. She observed her entire room to look for her [NAME] No Spill 360 Grip and Sip cup and stated it was not in the room, and only her gray drinking cup was in her room. On 05/21/2025 at 12:59 p.m., an interview was conducted with S8OT (Occupational Therapist). She stated that Resident #65 was ordered to have a [NAME] No Spill 360 Grip and Sip cup at all times to drink out of due to the spasticity in the arm from her diagnosis of Cerebral Palsy. She stated the [NAME] No Spill 360 Grip and Sip cup allowed better control of drinking water by controlling the rate of flow and preventing the resident from spilling on herself.

Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 5 (#11, #52, #64, #67, #86) of 5 (#11, #52, #64, #67 and #86) residents reviewed for ADLs. The facility failed to comb resident's hair. Findings: Resident #11: Review of Resident #11's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses with diagnoses that included, but not limited to, of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of Resident # 11's care plan dated 03/21/2025 read in part, resident will receive person centered care; needs assist with hygiene, and grooming. Provide set-up assist with ADLs as needed. On 05/19/2025 at 8:07 a.m., an observation of Resident #11 in the dining room during breakfast meal revealed her hair was uncombed, matted, and she had facial hair on her chin. On 05/19/0225 at 2:02 p.m., a follow up observation was conducted which revealed the resident's hair remained uncombed, matted, and she still had facial hair on her chin area. On 05/20/2025 at 8:08 a.m., an observation of Resident #11 in the dining room during breakfast meal revealed her hair still remained uncombed, matted, and had facial hair on her chin area. On 05/20/2025 at 11:50 a.m., a follow up observation of the resident in the dining room revealed her hair was still uncombed, matted, and facial hair on her chin area. On 05/20/2025 at 2:48 p.m., an observation and interview was conducted with S7LPN (Licensed Practical Nurse) who was the nurse on the unit where Resident #11 resided. She confirmed that the staff had not been combing the resident's hair, and they should have. Resident #52: Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses with diagnoses that included, but not limited to, of muscle wasting and atrophy right and left shoulder, left and right hand, and dementia severe with agitation. Review of Resident 52's care plan dated 03/17/2025 read in part, resident will receive person centered care; needs assist with hygiene, and grooming. Provide set-up assist with ADLs as needed. On 05/19/2025 at 12:11p.m., an observation of Resident #52 in the dining room revealed her hair was uncombed. On 05/20/2025 at 2:48 p.m., an observation and interview was conducted with S7LPN who was the nurse on the unit where Resident #52 resided. She confirmed that the staff had not been combing the resident's hair, and they should have. Resident #64: Review of Resident #64's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses with diagnoses that included, but not limited to, of Alzheimer's disease and, dementia. Review of Resident #64's care plan dated 04/02/2025 read in part, resident will receive person centered care; needs assist with hygiene, and grooming. Provide set-up assist with ADLs as needed. On 05/20/2025 at 7:34 a.m., the resident was observed in the dining room with her hair uncombed. On 05/20/2025 at 7:52 a.m., a follow up observation of the resident in the dining room during breakfast meal revealed, and her hair remained uncombed. On 05/20/2025 at 11:39 a.m., another observation of the resident sitting in the dining room revealed her hair still remained uncombed. On 05/20/2025 at 2:48 p.m., an observation and interview was conducted with S7LPN who was the nurse on the unit where the resident resided. She confirmed that staff had not been combing the resident's hair, and they should have. Resident #67 Review of Resident #67's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses with diagnoses that included, but not limited to, of Dementia mild with other behavioral disturbance, muscle wasting and atrophy to right shoulder, left shoulder, right hand, left hand, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #67's care plan dated 03/26/2024 read in part, resident will receive person centered care; needs assist with hygiene, and grooming. Assist with hygiene, and grooming as needed. On 05/19/2025 at 10:22 a.m., Resident # 67 was observed in the dining room with her hair uncombed, and facial hair on her chin. On 05/19/2025 at 12:11 p.m., a follow up observation of the resident revealed her hair remained uncombed, and facial hairs on her chin. On 05/20/2025 at 11:48 a.m., an observation of resident in the dining room revealed her hair still remained uncombed. On 05/20/2025 at 2:48 p.m., an observation and interview was conducted with S7LPN who was the nurse on the unit where the resident resided. She confirmed that the staff had not been combing the resident's hair, and they should have. Resident #86 Review of Resident #86's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses with diagnoses that included, but not limited to, of flaccid hemiplegia affecting left non-dominant side, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #86's care plan dated 01/17/2024 read in part, resident will receive person centered care; needs assist with hygiene, and grooming. On 05/19/2025 at 12:11 p.m., an observation of the resident in the dining room revealed her hair was uncombed. On 05/19/2025 at 2:15 p.m., a follow-up observation of the resident in the dining room revealed her hair remained uncombed. On 05/20/2025 at 2:39 p.m., an observation of the resident was conducted in her room, which revealed her hair remained uncombed. On 05/20/2025 at 2:48 p.m., an observation and interview was conducted with S7LPN who was the nurse on the unit where the resident resided. She confirmed that the staff had not been combing the resident's hair, and they should have.

Based on interviews and record reviews, the facility failed to implement appropriate interventions to prevent falls for 1(#56) of 3 (#11, #56, #86) residents investigated for falls. Findings: Review of Resident #56's Electronic Health Record (EHR) revealed an admitted [DATE], with diagnoses which included, but were not limited to cognitive social or emotional deficit following other cerebrovascular disease, repeated falls, unsteadiness on feet, other lack of coordination, restlessness and agitation, delirium due to known physiological condition. During an interview with Resident #56's representative (RP), she stated that the resident had many falls since his admission to the facility. Review of Resident #56's admission Minimum Data Set (MDS) assessment with an assessment reference date of 02/28/2025, revealed a Brief Interview for Mental Status (BIMS) of 9, suggesting moderate cognitive impairment. Further review revealed the resident had a history of a fall with fracture on admission in section J1700 and was coded yes for having falls since admission in section J1800. Review of Resident #56's Fall Risk assessment dated [DATE] revealed a total score of 21 which indicated the resident was a high risk for falls. The resident had a fall on the following dates: 02/26/2025; 03/01/2025; 03/06/2025; 03/18/2025; 03/19/2025; 03/25/2025; 03/28/2025; 03/31/2025; 04/25/2025; 05/07/2025; 05/13/2025; 05/16/2025; 05/20/2025; and 05/21/25 Review of the facility's investigative reports and plan of care for Resident #56 revealed appropriate interventions were not implemented after the following falls: On 03/25/2025 at 6:23 p.m., the resident had a witnessed fall without injury. Resident was pushing himself around in a slouched position and slid off the seat onto the wheelchair footrests. Review of care plan revealed no intervention was placed to address the fall. On 03/28/2025 at 3:50 p.m., the resident had an unwitnessed fall with no injury. Review of investigative report revealed the resident's roommate notified staff of resident's fall. Immediate action was for fall mat at open side of bed. Review of care plan revealed no intervention to address the fall On 03/31/2025 at 1:45 p.m., the resident had a fall without injury. S15LPN (Licensed practical Nurse) wrote that she was walking down the hallway at 1:45 p.m., and decided to check in on the resident knowing that he was put in bed. She found resident sitting on the floor at his bedside, legs crossed. Review of care plan revealed an intervention was implemented for a fall mat to open side of bed dated 03/31/2025. On 04/25/2025 at 3:11p.m., the resident had an unwitnessed fall. Action taken was were neuro checks and continue plan of care. Review of Care plan revealed no interventions implemented to address the fall. On 05/07/2025 at 12:45 a.m., the resident had an unwitnessed fall. Review of investigative report revealed the resident was found sitting on his left side on the floor with his back towards the back door on Hall W and his wheelchair in front of him. Review of Care plan revealed no interventions to address the fall. On 05/21/2025 at 1:40 p.m., an interview and review of the resident's care plan was conducted with S6CCC/LPN (Clinical Care Coordinator/Licensed practical Nurse) and S19CCC/LPN. S6CCC/LPN was asked about the interventions implemented after the falls. S6CCC/LPN stated that S3ADON (Assistant Director of Nursing) is responsible for conducting the investigations and discussing with the clinical care coordinators through a phone call or morning meeting. S6CCC/LPN and S19CCC/LPN confirmed that for each fall an intervention should have been implemented and was not. On 05/21/2025 at 3:00 p.m., an interview and review of Resident #56's care plan was conducted with S2DON (Director of Nursing). She presented a handwritten report of interventions implemented after the resident's falls. S2DON explained the following hand written report which included the following, in part: 03/25/2025 - continue plan of care 03/28/2025 - no intervention 04/25/2025 - continue plan of care 05/07/2025 - continue plan of care S2DON stated CCCs were responsible for updating care plans. S2DON was unable to provide evidence of appropriate interventions placed after the above falls.

Based on record review and interview, the facility failed to refer a resident with a diagnosed mental disorder to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (#15) of 3 (#15, #32, #49) residents investigated for PASARR in a final sample of 47 residents. Findings: Review of Resident #15's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, bipolar disorder and major depressive disorder. Review of Resident #15's Level I PASARR dated 10/07/2022 revealed in part Section III: Mental illness, Question #1 Do you suspect the applicant has, or has the applicant been diagnosed as having a mental illness? Including mental disorders that may lead to chronic disability . schizophrenia, schizoaffective disorder, delusional disorder, other psychotic disorder, bipolar disorder, major depressive disorder .Bipolar disorder was not checked. Further review of Resident #15's records revealed no evidence that a Level II PASARR had been submitted to the appropriate state-designated authority after Resident #15 had a newly identified mental disorder of bipolar disorder, with an onset date of 10/10/2022. On 05/20/2025 at 3:10 p.m., an interview and record review was conduct with S5SSD. After review of a psychiatric progress note dated 10/09/2022 for Resident #15, S5SSD confirmed the resident had a qualifying Level II diagnosis of bipolar psychosis. S5SSD confirmed a request for a Level II screening was not submitted for Resident #15. She stated the request for a Level II screening should have been submitted.

Based on record review, interviews, and policy review, the facility failed to ensure a resident's comprehensive care plan was revised for 1 resident (#49) and included 1 resident (#68) in reviewing the care plan out of 47 sampled residents. This deficient practice was evidenced by: 1. resident #49's care plan was not revised to reflect the resident no longer required CBG (Capillary Blood Glucose) checks, and 2. resident #68 was not involved in a care plan meeting with the facility's interdisciplinary team Findings: 1. Resident #49 Review of Resident #49's electronic medical record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnosis Type 2 Diabetes Mellitus with hyperglycemia. Review of Resident #49's May 2025 physician's orders revealed an order dated 02/21/2025 for Regular Insulin per sliding scale for two weeks with an end date of 03/07/2025. Review of Resident #49's electronic medical record included a follow-up provider note dated 02/28/2025 per S17NP (Nurse Practitioner) revealed in part: Resident #49 being seen for fu (follow up) after started on CBG checks to ss (sliding scale) for elevated hga1c (blood test for type 2 diabetes that measures an individual's average blood sugar over the past 3 months) through 03/07/2025. Blood sugar checked reviewed .Resident #49 does not like his finger stuck .will continue blood sugar checks through 03/07/2025. Review of Resident #49's May 2025 care plan revealed the Resident has Diabetes Mellitus with an intervention to monitor blood glucose tid (three times a day) x 1 week initiated on 10/02/2024. On 05/21/2025 at 1:47 p.m., an interview and record review were conducted with S3ADON (Assistant Director of Nursing). S3ADON stated Resident #49's blood sugar checks were discontinued on 02/21/2025. When questioned about Resident #49's care plan including blood sugar checks, S3ADON stated S6CCC/LPN (Clinical Care Coordinator/Licensed Practical Nurse) was responsible for revising a resident's care plan. On 05/21/2025 at 1:58 p.m., an interview was conducted with S6CCC/LPN who stated she completed Resident #49's care plan. S6CCC/LPN verified Resident #49's blood sugar checks were discontinued on 03/07/2025. S6CCC/LPN confirmed Resident #49's care plan had not been revised to reflect the resident no longer required blood sugar checks. 44418 2. Resident # 68 On 05/22/2025, a review of the facility's policy titled Comprehensive Resident Care Plans with a review date of 01/15/2025, read in part: Purpose: The resident's comprehensive care plan will be developed utilizing the results of the comprehensive resident assessment instrument (RAI) plus information gained from resident and family interviews, care conferencing and health care professional data to determine daily care needs, and to attain, or maintain the resident's highest functional capacity. Resident # 68 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, polymyalgia rheumatica, osteoarthritis, and fibromyalgia, dependent to wheelchair. A review of Resident #68's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/08/2025 revealed he had a BIMS (Brief Interview for Mental Status) score of 15, suggesting her cognition was intact. On 05/19/2025 at 11:30 a.m., an interview was conducted with Resident #68. The resident stated she has not been invited to a care plan meeting. On 05/20/2025 at 1:34 p.m., an interview was conducted with S5SSD (Social Service Director), she confirmed that she was responsible for notifying the RP (Resident Representative) or resident, if they were their own RP, of scheduled care plan meetings. S5SSD stated if the resident was their own RP, then they were given a hand delivered letter inviting them to attend. She confirmed she was unable to provide documentation to confirm that a letter was given to Resident #68 inviting the resident to a care plan meeting. On 05/20/2025 at 1:55 p.m., an interview was conducted with S6CCC/LPN (Clinical Care Coordinator/Licensed Practical Nurse), she confirmed she was responsible for Resident #68's care plan. S6CCC/LPN confirmed she was unable to provide documentation at this time identifying who attended or the finding of the care plan meeting for Resident #68 that was held on 05/06/2025. She stated there was not a sign-in sheet for staff, residents and RP to sign that they had attended the care plan meeting.

Based on record reviews and interviews, the facility failed to assess/reassess a resident's nutritional needs, monitor for effectiveness of interventions, and ensure coordination of care among the interdisciplinary team for 1 resident (#71) of 4 (#45, #65, #71, #94) residents investigated for nutrition as evidence by: 1. Failing to weigh Resident #71 weekly as ordered, 2. The RD (Registered Dietician) failing to accurately reassess resident #71's nutritional interventions, and 3. Failure of the RD and the facility to coordinate care in response to Resident #71's significant weight loss. Findings: A review of the facility's policy titled, Weight Variance Protocol with a last reviewed date of 01/15/2025 read in part, Policy: All resident weights will be monitored monthly or more often as indicated by the resident's condition or physician orders. Procedure: 1. Gross weight gains or losses will prompt an immediate re-weighing of resident. If weight is confirmed, the MD (Medical Doctor) will be notified immediately. The nurse will also notify the DON (Director of Nursing) and Food Service Director of weight variances. The Registered Dietician will be notified of significant variances as well. 3. Weight Variance-Calculate weight loss or gain every time a resident is weighed. Significant weight loss must be brought to the attention of the DON, FSD (Food Service Director) and Registered Dietitian. Significant weight loss is 5% in one month or 10% in six months. 4. The Registered Dietitian will review the weight information upon her next monthly visit and document recommendations in the medical record. 5. The physician will be called by the nurse regarding Registered Dietitian's recommendations in a timely manner. 7. Before recording each weight in the medical record the nurse will double check that: b. If gross gain or loss had indeed occurred, a Dietitian consult has been requested and the physician and family have been notified. Essential Points: Any weight variations as stated above are to be brought to the attention of the IDT (Interdisciplinary Team), RD (Registered Dietician), Family and Physician. Resident #71 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to unspecified severe protein-calorie nutrition, dysphagia, muscle wasting and atrophy, cognitive communication deficit, chronic obstructive pulmonary disease, and major depressive disorder. 1. A review of Resident #71's care plan read in part: Potential for altered nutrition and dehydration with interventions in part: weekly weights. A review of Resident #71's current Order Summary Report, revealed an order, Weekly weights every day shift every Tuesday with a start date of 01/14/2025. A review of Resident #71's Weights and Vitals Exceptions report, revealed the following weights were not obtained as ordered by the physician: a. January 2025- 01/14/2025, 01/21/2025, and 01/28/2025. b. February 2025- 02/25/2025 c. March 2025- 03/11/2025. d. April 2025- 04/15/2025, and 04/29/2025. e. May 2025- 05/13/2025. On 05/20/2025 at 4:40 p.m., a review of Resident #71's Weights and Vitals Exceptions report and physician orders was conducted with S3ADON (Assistant Director of Nursing). S3ADON confirmed that the resident should have been weighed weekly and had not been. 2. A review of Resident #71's MAR (Medication Administration Record), revealed that he had an order for Boost two times a day for 60 days give 8oz (ounces) by mouth, started 02/03/2025 with and end date of 04/04/2025. A review of a Progress Note dated 04/08/2025 by S16RD (Registered Dietician) for Resident #71 read in part. 3. Continue providing Boost 8oz BID (twice daily) x (times) 60 days due to weight loss as well as Might Shake TID (three times a day). Resident does receive Boost tid and consumes 100%. On 05/21/2025 at 9:18 a.m., a record review and interview was conducted with S2DON (Director of Nursing) and S3ADON. Both confirmed that Resident #71's Boost had been discontinued on 04/04/2025 due to completing 60 days. Both confirmed that the resident was not taking Boost at the time of the RD's assessment on 04/08/2025. On 05/20/2025 at 4:25 p.m., a phone interview was conducted with S16RD. She confirmed that she last assessed Resident #71's nutritional status on 04/08/2025. She stated that on 04/08/2025 she assessed Resident #17 with the thought that Resident #17 remained on Boost. She stated that she was not aware that the Boost had already been administered for the 60 day interval and inaccurately noted on his assessment that he continued to receive Boost. 3. A review of Resident #71's Weights and Vitals Exceptions report, revealed on 05/05/2025, Resident #71 had a weight of 168.4 pounds. The report revealed that the resident had a weight of 217 pounds on 11/04/2024 indicating that the resident had a loss of 49 pounds in 180 days. This is was a 22.6% weight loss. A review of Resident #17's medical record revealed a Progress Note dated 04/08/2025 by S16RD. A review of Referral Form for Consultant Dietician for May 2025 revealed that Resident #71's name was not present on the list of residents to be seen by the Dietician. On 05/20/2025 at 2:51 p.m., an interview was conducted with S3ADON and S4DM (Dietary Manager). S4DM and S3ADON confirmed that the last assessment from S16RD for Resident #17 was on 04/08/2025. S4DM stated that she was unsure of why S16RD had not assessed the resident's significant weight loss for May of 2025 because S16RD accesses the significant weight losses herself. S4DM stated that she provided the RD with a Referral Form for Consultant Dietitian, which is composed of names of residents needing to be assessed in addition to those on the weight report for May of 2025. S4DM confirmed that Resident #71's name was not present on this form for May of 2025. On 05/20/2025 at 4:25 p.m., a phone interview was conducted with S16RD. She confirmed that she last assessed Resident #71's nutritional status on 04/08/2025. S16RD stated that she assesses residents for weight loss based on the report given to her by S4DM. S16RD stated that she does not access a weight report herself. She stated she was not aware of the resident's significant weight loss at her last visit to the facility on [DATE], and would have reassessed the resident had she been aware of it.

Based on record review and interviews, the facility failed to perform laryngectomy care for 1(#14) of 2(#14 and, # 298) residents investigated for Respiratory Care. This had the potential to affect the 1(#14) resident with a laryngectomy in the facility. Findings: Resident #14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to personal history of malignant neoplasm of larynx and acquired absence of larynx. Review of Resident #14's Quarterly MDS (Minimum Data Set) dated 03/01/2025, revealed the resident had a BIMS (Basic Interview for Mental Status) of 13, indicating her cognition was intact. A review of Resident #14's Order Summary Report, revealed the following orders: 1. Laryngectomy Site: Cleanse laryngectomy site with peroxide daily. Every day shift. Start date of 07/09/2024. 2. Laryngectomy Site: Monitor site for s/s (Signs/Symptoms) of increased leaking and secretions. Notify MD (Medical Doctor)/NP (Nurse Practitioner) if s/s of increased leaking and secretions occur. Every day shift. Start date of 07/09/2024. 3. Laryngectomy Tube: Change adhesive dressing to laryngectomy tube every day shift every Friday. Start date of 07/12/2024. 4. Laryngectomy Tube: Change filter to laryngectomy tube every day shift. Start date of 07/09/2024 A Review of Resident #14's MARS (Medication Administration Records) for the months of February 2025, March 2025, and May 2025 revealed missing signatures for the following orders: 1. Laryngectomy Site: Cleanse laryngectomy site with peroxide daily. Every day shift Missing signatures: a. February 2025: 6th, 7th, 12th, and 20th b. March 2025: 5th, 10th 17th, and 31st c. May 2025: 2nd 2. Laryngectomy Site: Monitor site for s/s (Signs/Symptoms) of increased leaking and secretions. Notify MD (Medical Doctor)/NP (Nurse Practitioner) if s/s of increased leaking and secretions occur. Every day shift. Missing signatures: a. February 2025: 6th, 7th, 12th, and 20th b. March 2025: 5th, 10th 17th, and 31st c. May 2025: 2nd 3. Laryngectomy Tube: Change adhesive dressing to laryngectomy tube every day shift every Friday. Missing signatures: a. May 2025: 2nd 4. Laryngectomy Tube: Change filter to laryngectomy tube every day shift. Missing signatures: a. March 2025: 5th, 10th, and 17th b. May 2025: 2nd On 05/21/2025 at 1:25 p.m., a record review and interview was conducted with S2DON (Director of Nursing). She confirmed that the signatures were missing for Resident #14's laryngectomy care on the MAR for the above stated dates for the months of February 2025, March 2025, and May 2025. She stated that she assumed the care was not completed with the signatures missing for these dates. On 05/21/2025 at 1:51 p.m., an interview was conducted with Resident #14. She communicated that some days her laryngectomy care is not performed by staff.

Based on observations, interviews and policy review, the facility failed to ensure dietary staff prepared, distributed and served food in accordance with professional standards for food service safety as evidenced by 2 dietary assistants (S13DA and S14DA) without a beard restraint. Findings: On 05/21/2025 a review of facility's policy titled, Employee Sanitation Practices reviewed on 01/15/2025, revealed in part: 3. Proper Work Attire .b. The food service employee observes the following dress standards: i. Wears a clean hat or other hair restraint. Employees with facial hair wear a beard restraint . On 05/19/2025 at 8:44 a.m., an initial observation was made of S13DA (Dietary Assistant) assisting with prepping sandwiches with his facial hair not covered. On 05/19/2025 at 10:35 a.m., a follow up visit in the kitchen was made. S13DA was observed assisting with food preparation for the lunch meal service with his facial hair not covered. On 05/19/2025 at 10:56 a.m., an observations was made of S14DA assisting with the lunch meal service preparation with his facial hair exposed and not covered. On 05/19/2025 at 11:30 a.m., an observation was made of S13DA and S14DA assisting with preparing the residents' lunch meal on individual plates. S13DA was observed distributing food from the steam table to each resident's plate and S14DA was observed placing the fixed lunch meal individual plates in an insulated rolling cart to be distributed to residents. S13DA and S14DA failed to cover their beards while preparing and distributing food to residents. On 05/19/2025 at 12:20 p.m., an interview was conducted with S4DM (Dietary Manager). S4DM stated male staff should have beard coverings over their facial hair when working in the facility's kitchen.

Based on record reviews and interview, the facility failed to obtain the most recent recertification of terminal illness and most recent hospice POC (plan of care) for 1 (#31) out of 1 (#31) resident reviewed for hospice care. Findings: A review of the facility's agreement with the Contracted Hospice Agency dated 08/26/2015 read in the part, the following, Compilation of Records: Nursing facility and hospice shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient . Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Resident Hospice Patient . Each such record shall be readily accessible and systematically organized to facilitate retrieval by either party. A review of Resident #31's record revealed he was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Encounter for Palliative Care and Parkinson's disease with Dyskinesia. A review of Resident #31's Quarterly MDS (Minimum Data Set) dated 02/12/2025 revealed Section O: Special Treatments revealed the resident was admitted to hospice care. A review of Resident #31's physician's orders revealed an order entry with a start date of 04/18/2024 read in part, Admit to Contracted Hospice for dx (diagnosis): Parkinson's disease. A review of Resident #31's person-centered plan of care, revealed in part, a focus on required hospice services with Contracted Hospice Parkinson's initiated on 04/18/2024. A review of Resident #31's hospice documents in his contracted hospice binder revealed, in part, that the most recent certification of terminal illness by the Contracted Hospice Agency's physician was signed on 04/16/2024 for the certification period of 04/09/2024 through 07/07/2024. A review of Resident #31's hospice documents in his contracted hospice binder revealed, in part, that the most recent POC was dated 04/18/2025 for the certification period of 03/05/2025 through 05/03/2025. On 05/20/2025 at 2:00 p.m. a record review and interview was conducted with S2DON (Director of Nursing). S2DON stated she is responsible for maintaining Resident #31's contracted hospice binder. She stated Resident #31' most recent POC was dated 04/18/2025 for the certification period of 03/05/2025 through 05/03/2025, and his most recent certification was from 04/09/2024 through 0707/2024. She confirmed there was not an updated recertification of terminal illness and POC in Resident #31's contracted hospice binder and should have been.

Based on observations, interviews, and record reviews; the facility failed to protect the residents' right to be free from abuse for 3 (#1, #2, #6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility failed to protect: 1. Resident #1 from physical, verbal, and psychosocial abuse by S8CNA. 2. Resident #2 from physical and psychosocial abuse by Resident #3. 3. Resident #6 from physical and psychosocial abuse by Resident #2. This deficient practice resulted in physical, verbal, and psychosocial harm for Resident #1 on 11/09/2022 at 1:15 pm when S8CNA yelled expletives at him and grabbed him by the shirt collar. Resident #1's face turned red and stated he was choking. Resident #1 was observed crying by staff after the incident. This deficient practice resulted in physical and psychosocial harm for Resident #2 when the resident was hit by Resident #3 on 10/15/2022 near lunch time. Resident #2 was observed by S5WC with a bloody mouth after the incident. This deficient practice resulted in physical and psychosocial harm for Resident #6 on 11/20/2022 at 4:45 p.m. when Resident #2 punched Resident #6 more than once in his face. Resident #6 complained of pain after the incident and was sent to the hospital for evaluation. Findings: A review of the facility's Abuse/Neglect Policy statement read in part: This facility will not condone any form of resident abuse .Each resident residing in the facility has the right to be free from verbal, sexual, mental and physical abuse .Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . Resident # 1 A record review of Resident #1's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses in part: Parkinson's Disease, Vascular Dementia, with other Behavioral Disturbance, MDD (Major Depressive Disorder) Recurrent Severe with Psychotic Symptoms, Presence of Cardiac Pacemaker and Generalized Anxiety Disorder. A record review of Resident # 1's quarterly MDS (Minimum Data Set) dated 10/18/2022 revealed that the resident had a Brief Interview for Mental Status (BIMS) of 08 which indicated he had a moderate cognitive impairment. A review of Resident #1 care plan, with a start date of 02/27/2020, revealed he was care planned for socially inappropriate and disruptive behavior, history of aggression, and threatening to hit another patient. Care planned interventions included to talk in calm voice when behavior is disruptive, do not argue with resident and discuss options for appropriate channeling of anger. Review of form titled Resident Incident Report, dated 11/09/2022 at 1:15 p.m., revealed Resident #1 with incident type of alleged physical abuse-staff that occurred in Resident #1's room involving S8CNA (Certified Nursing Assistant) reported to supervisor on 11/09/2022 at 1:15 p.m. Further review of the incident report, dated 11/09/2022 at 1:15 p.m., revealed section titled Narrative of incident and description of injuries read: Writer-S3LPN (Licensed Practical Nurse) made aware per S7CNA that she witnessed S8CNA holding his hands back behind his head and pulling on his shirt collar where it was choking resident was cursing at resident Writer immediately notified S2DON (Director of Nursing) and S1ADM (Administrator) of what was reported; no injuries noted .Immediate actions taken: Investigation pending per S1ADM. Review of S7CNA's handwritten statement read in part .On 11/09/2022 right before lunch me and S9CNA was getting Resident #1 and his roommate up for their shower and the two residents started fighting. I got the residents to calm down and was going to shower Resident # 1's roommate and then I heard Resident #1 hollering, so I went back in to Resident #1's room and he was swinging at S9CNA. I told him to calm down and he said ok but then he started swinging and I started walking away and he said don't walk away I will get up for you and I told him ok but you can't fight, he said ok and then he started to fight again. S8CNA came running into Resident #1's room to help but she grabbed him by his shirt from the back and he started hollering you're choking and I said no don't do that, he said 'stop' and S8CNA told him to 'shut the f*** up' and he said let me go now b****. On 01/04/2023 at 9:25 a.m., an interview was conducted with S7CNA. S7CNA reported on 11/09/2022 before lunch she was the designated staff for assisting with residents' showers. S7CNA reported she and S9CNA were attempting to get Resident # 1 from his room to the shower, but Resident #1 kept refusing and started swinging at S9CNA. Then S7CNA reported she was asking Resident #1 to calm down and he did but then started swinging again and that's when S8CNA came out of nowhere and grabbed Resident #1 by his shirt collar from behind and was very aggressive with him. S7CNA explained Resident #1 kept saying he was choking and his face was red, so I told S8CNA to stop now and she told Resident #1 to shut the f*** up and let him go and left the room. Resident #1 was upset and crying and wanted me to tell someone about what happened, so I told S1ADM immediately and then I told S2DON and S3LPN. S7CNA further stated that S8CNA quit on 11/09/2022 and S9CNA no longer worked at the facility. On 01/04/2023 at 11:04 a.m., Resident #1 was observed participating in therapy and was observed to be cooperating with the therapy staff. During an observation and attempted interview with Resident #1, on 01/04/2023 at 2:05 p.m., Resident was alert to person and place only. He was observed to be alert and friendly. Resident was unable to recall the incident that occurred when S8CNA grabbed him by his shirt collar on 11/09/2022. Phone calls made to S8CNA on 01/03/2023 at 5:15 p.m., 01/04/2023 at 7:00 a.m., and 01/04/2023 at 12:25 p.m. were not returned and therefore was unable to be interviewed. On 01/04/2023 at 3:04 p.m., an interview was conducted with S3LPN who explained what was reported to her was that S7CNA witnessed S8CNA grab Resident #1's shirt from behind by his collar choking him. S3LPN further stated that on 11/09/2022 around 1:30 pm after S7CNA informed her of what happened, S3LPN filled out an incident report and S1ADM started an investigation. S3LPN denied witnessing Resident #1 crying after the incident and explained that he was a little frustrated but that was about it. On 01/04/2023 at 9:47 a.m., an interview was conducted with Resident #1's responsible party who stated that the resident was okay after the incident. He confirmed that S8CNA resigned and no longer had contact with the resident. He further stated that the resident's dementia was getting really bad and he may not even remember the incident. On 01/04/2023 at 4:00 p.m., S1ADM confirmed he contacted the local police department regarding the alleged physical abuse that happened on 11/09/2022 between Resident #1 and S8CNA. S1ADM reported that S8CNA resigned on the day of the incident on 11/09/2022. 46149 Resident #2 Review of Resident #2's medical record revealed he was admitted on [DATE]. Resident #2's diagnoses included: Alcohol Abuse with Alcohol-induced Psychotic Disorder Schizoaffective Disorder-Bipolar Type, Vascular Dementia, and Chronic Respiratory Failure. Review of the resident's most recent MDS (Minimum Data Set) dated 11/02/2022 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 99, indicating the resident had been unable to complete the interview. Review of Resident #2's care plan with a start date of 07/21/2022 revealed he was care planned for impaired cognition related to dementia with behaviors with interventions that included approach in a calm manner and provide reorientation if needed. The care plan also reflected that he wandered with a potential for elopement with interventions that included do not argue with resident; do not challenge content of behaviors; and visual checks of resident's location every hour. Further review revealed he was care planned for mood disorder and behaviors with interventions that included assess for changes in mood status; assess for effectiveness of medication therapy; monitor behaviors; enjoys following maintenance man; and send medical records to other facilities with a male locked unit. Review of form titled Resident Incident Report dated 10/15/2023 revealed Resident # 2 had an incident type of alleged resident to resident physical altercation that occurred on Hallway B. It was reported to supervisor on 10/15/2022 at 12:46 p.m. Further review of the incident report dated 10/15/2022 revealed the section titled Narrative of incident and description of injuries read: Writer- S3LPN was called to Hall B. S3LPN (Licensed Practical Nurse) found Resident #2 with blood dripping around his mouth. The resident was in an irate mood, and did not allow nurses to assess his lip or injury. The cause of the blood was unknown. Review of nurse's progress notes dated 10/15/2022 at 5:20 p.m. revealed that S1ADM (Administrator) viewed video footage, and observed Resident #3 hitting Resident #2. Review of S5WC's (Ward Clerk) handwritten witness statement read in part .On 10/15/2022, working the front lobby desk today around lunch, I heard a ruckus, and Resident #3 hollering 'swing again'. So I went to see what was going on. I saw Resident #3 and Resident #2 bucked up to each other. When I called Resident #2's name, he turned and I saw his face was bloody. On 01/03/2023 at 11:00 a.m., Resident #2 observed lying in bed. Resident was lying at the bottom half of the bed and stated he was okay. Resident then began speaking and was noted to be confused and his speech was incomprehensible. On 01/04/2023 at 9:15 a.m., an interview with S3LPN. She stated that the resident was very combative, restless, and refused care most days. When he was hit by Resident #3, she was unsure of what escalated the situation, but it is not uncommon for the resident to have negative interactions with others but they occurred mainly with staff. Resident liked to pace the hall and did not like to be in the room. She stated he has been combative with another resident and staff as well. He was recently discharged from a behavior health center with several medication changes. He still continues to have screaming episodes, but his behavior has since improved and he has not had any resident to resident or resident to staff concerns since he returned 2 weeks ago. On 01/04/2023 at 3:00 p.m., an interview was conducted with S5WC. S5WC stated that she was sitting at the desk as she overheard explicit language and Resident #3 saying swing again. She went to Hall B and saw that Resident #2's face was covered in blood. S5WC stated that she notified the nurse immediately. She further stated that the two residents were separated and the administrator was also notified of the incident. On 01/04/2023 at 4:00 p.m., an interview was conducted with S1ADM. He stated that the resident has a history of being combative with staff and was involved in the 2 incidents with the residents, but has not had any other resident to resident altercations. He also stated that they have taken actions such as allowing the resident to be with the maintenance man throughout the day and rounded on him as much as possible. He stated the facility has exhausted all options for Resident #2. He stated the resident needed to be on a locked or supervised unit but they were having difficulty finding placement. He stated that there is a locked unit at the facility, but it was for female residents. He further stated that there is a CNA that sat on the hallway that monitored the smokers and the resident as well that informs staff if Resident #2 required assistance. Resident #6 Review of Resident #6's medical record revealed he was admitted on [DATE]. Resident #6's diagnoses included: Anxiety Disorder, Cognitive communication Deficit, Chronic pain due to Trauma, Muscle Wasting and Atrophy. Review of the resident's most recent MDS dated [DATE] revealed the resident had a BIMS score of 9, indicating the resident had mildly impaired cognition. Review of the form titled Resident Incident Report dated 11/20/2022 at 4:42 p.m. revealed Resident #6 with incident type of alleged resident to resident physical altercation that occurred in Dining Room A. It was reported supervisor on 11/20/2022 at 4:42 p.m. Further review of the incident report dated 11/20/2022 at 4:42 p.m. revealed the section titled Narrative of incident and description of injuries read: Writer- S10LPN was summoned by CNA to Dining Room A, stating Resident #2 punched Resident #6 in the face a few times. The CNA separated both residents stated that Resident #6 was hit by another resident. Resident #6 stated He just stood up and started punching me. S10LPN asked the resident if he was in pain and he stated yes. An order was received to send Resident #6 to the hospital for further evaluation and treatment. Review of S6CNA's handwritten statement signed on 11/20/2022 read in part .On 11/20/2022, Resident #2 and Resident #6 were sitting at the table in Dining Room A. All I saw was Resident #2 saying the word huh and started punching Resident #6 in his face. That is when I jumped across the table and stopped Resident #2 from fighting Resident #6. On 01/04/2023 at 11:30 a.m., an interview with S4LPN was conducted. She stated that the resident was sent to the hospital because he had a history of Traumatic Brain Injury but he did not have any injuries or changes. On 01/04/2023 at 12:30 p.m., an interview was conducted with S6CNA. S6CNA stated that she witnessed Resident #2 punch Resident #6 in the face. S6CNA stated that Resident #2 paced around Dining Room A and then sat at the table where Resident #6 was sitting. S6CNA further stated that she was unsure if Resident #6 said something to Resident #2 because he speaks in a monotone voice. Resident #2 stood up and said What?! and punched Resident #6. Resident #6 told her that he did not say anything Resident #2. She further stated that she separated the residents, notified the nurse, and escorted Resident #2 to the nurse's station. On 01/04/2023 at 12:45 p.m., Resident #6 was observed in the therapeutic dining area. An interview was attempted at this time but the resident could not be heard due to the noise in the dining area. He was observed seated in wheelchair while he waited for his food and did not interact with other residents. On 01/04/2023 at 3:40 p.m., an interview and observation was conducted with Resident #6. He stated that he was doing okay and had a good day. When asked about the incident with Resident #2, he stated that he did not remember anyone hitting him.

Based on record review and interview, the facility failed to ensure that residents assessed as a high risk for elopement receive adequate supervision to prevent elopement out of a door that is not visible by staff. The facility staff failed to notice that two residents (Resident #1,#3) out of 6 residents reviewed (Resident #1,2,3,4,5,6) in a universe of 20 residents assessed as high risk for elopement ( Resident #1 thru #20) , had exited the main lobby door until they were informed by individuals that were not employed by the facility. Review of the facilities investigative report indicated that Resident #1 was found sitting in a wheelchair in the parking lot of the facility on [DATE] at 2:00 pm. According to this report, a visitor to the facility at the time notified the staff of the whereabouts of the resident. Review of the facilities's accident/incident report indicated that Resident #3 was found out in the community on [DATE] at 7:00 pm. According to this report, the facility received a call from the Sheriff's department inquiring if Resident #3 was residing in the facility. The Sheriff's Department at that time informed the facility's staff that the resident had "walked out" of the place he resided in and was being taken to a local hospital for evaluation due to abrasions and possible fall. The lack of supervision and monitoring of residents at a high risk for elopement placed Resident #3 in an Immediate Jeopardy situation. The Immediate Jeopardy sitiuation began on [DATE] after resident #1 eloped from the facility. S1 Administrator was informed of the Immediate Jeopardy on [DATE] at 12:10 pm. The Immediate Jeopardy ended on [DATE] at 9:55 am, when the Administrator provided an acceptable plan of removal. The Plan of Removal read: 1. Increased monitoring will consist of designated staff members to monitor the front lobby q 15 minutes to ensure no high risk residents are in the front lobby not being supervised. 2. At any significant increased visitation, such as parties, church services or highly populated events, the administrator and/or charge nurse will ensure employees supervise all doors, for monitoring all residents at a high risk for wandering to ensure they cannot exit with the visitors. 3. All staff were in serviced on high risk residents which included the elopement binder at the front nurses station and all other stations which is updated as needed to include information and pictures of the deemed high risk wanderers. 4. All staff was in serviced for visual checks of high risk residents and increased monitoring of all doors. 5. All 20 residents deemed high risk for elopement wander guards were visually checked and all doors were rechecked to ensure proper functioning of all wander guard devices. The deficient practice remains at a level or more than minimal harm to all residents (Resident #1 through #20) in the facility at risk for elopement. Findings: 1. Resident #1. Review of the resident's clinical records revealed that the resident was admitted to the facility on [DATE]. Further review of the resident's clinical record revealed that the resident was diagnosed with [REDACTED]. Review of the resident's MDS dated [DATE] revealed that the resident's BIMS score was 8 which meant that the resident was moderately impaired. Review of the resident's physician order's for [DATE] revealed, "......Wander alert bracelet on resident for elopement precautions at all times; Visual check for resident's location q 1 hour; Monitor Wander Guard to ensure working properly q shift; Check wander alert weekly for proper function........". Review of the resident's care plan with an onset date of [DATE] revealed that the resident's care plan addressed, "Potential for elopement, looking for wife, confusion r/t dementia and memory loss". Review of the interventions revealed, "[DATE] wander alert bracelet on resident for elopement precautions at all times; [DATE] visual check for resident's location q 1 hour; [DATE] check wander alert where constant observation is possible; [DATE] place monitoring device on resident that sounds alarms when resident leaves building; ..." Review of resident #1's skilled nurse's notes dated [DATE] at 7:00 pm revealed, "At 2pm summoned to main lobby entrance by visitor to facility. Upon asking where he was going states 'do u have a cigarette' ........(due to diagnosis). Wander guard checked. Noted to not work properly.........." Review of the resident's Resident Incident Report dated [DATE] revealed, "Summoned to main lobby entrance by visitor of facility. Resident noted to be sitting in wheelchair in parking lot. Upon asking him where he was going states 'Do u have a cigarette.' .......Wander guard checked and noted to not work properly........." On [DATE] at 2:55 pm, the resident was observed sitting down in a wheelchair in the dining room. The resident stated that he had to go outside with someone to go smoke. The resident stated that he had a bracelet on his right ankle. The resident stated that he has gone outside and that he has not heard an alarm go off. On [DATE] at 3:05 pm, S2DON confirmed that the resident's wander guard bracelet did not trigger the alarm when he was found outside in the parking lot by a visitor. On [DATE] at 3:15 pm, S3ADON confirmed that resident #1's wander guard bracelet did not trigger the alarm on the door when he was found outside in the parking lot by a visitor. S3ADON stated that she checked the wander guard bracelet and it was not functioning. S3ADON stated that the wander guard bracelet was not expired and that it looked like it was damaged. 2. Resident #3. A review of the clinical record revealed that Resident #3 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the resident's plan of care revealed that Resident #3 had been assessed as a high risk for elopement and the use of the wander guard system had been initiated as one preventative measure for elopement. A review of the MDS on [DATE] revealed a BIMS score of 3 which is severely impaired. A review of the July, 2014 Physician order [REDACTED]. A review of the facility accident/incident log for May, June and July, 2014 revealed that Resident #3 eloped from the facility on [DATE]. A review of the incident report dated [DATE] read : At 7pm, received a call from sheriff department that resident was found out in the community by a bystander. Resident was being taken to hospital for evaluation as was suspected resident fell . A review of the police report dated [DATE] read: item # G-,[DATE] miscellaneous complaint; Officer spoke to bystander who stated he was traveling down________road, near ___restaurant when he observed an elderly black male stumbling near the roadway. Bystander stopped and escorted the male , identified as Resident #3, into his vehicle and brought him to a restaurant parking lot where he called the sheriff's office. Officer spoke to Resident #3 who was talking incoherently. It was learned that resident #3 walked out of the facility where he resides. Resident #3 was transported to local hospital. A review of the ER record for Resident #3 dated [DATE] revealed that resident was treated for [REDACTED]. A review of the Resident's Nurse's Notes revealed an entry dated [DATE] at 11:41pm which read: at 7pm received a call from Sheriff's Department explaining that resident was picked up from around a local restaurant and is being transferred to hospital per ambulance for evaluation due to suspected fall..... Continued review of Nurse's Notes read: [DATE] at 12:35am, resident returned to facility per transportation. Transported from van to room via wheelchair at family request. Resident awake and alert; able to make needs known. Resident has an abrasion above the right eyebrow and on his top lip............... An interview was conducted with S2DON on [DATE] at 12:30pm. During this interview, the incident report and the information provided by the facility regarding this elopement issue were reviewed. S2DON stated that on the day of the elopement ([DATE]) there were a lot of things going on within the facility. S2DON stated that there was a large influx of visitors in and out of the facility all day due to a resident who was passing away. S2DON also stated that on [DATE], she was personally having to help administer medications and work on the floor as the weather had been bad and staff had difficulty getting into the facility as well as helping with the family members that were in the facility. S2DON stated they were not really sure how the resident got out of the facility but they assumed he left the facility through the front door of the main lobby amidst the arrival and departure of visitors. S2DON confirmed that the resident did have a wander guard system in place, but stated that in the interviews of staff, the facility was unable to determine if the system alarmed or not. S2DON confirmed that the resident was found approximately 3 blocks from the facility by a gentleman within the community. After the gentleman's attempt to find the "friend's apartment", that Resident #3 was saying he was going to, was unsuccessful, he then pulled into the parking lot of a restaurant in the area and called 911 for assistance. It was after the Sheriff's department arrived at the scene that is was determined that Resident #3 was probably from the facility. The Sheriff's department called to inquire if the resident resided here and upon confirmation by staff that he did, the facility was notified that the resident had " walked out" of facility, where he lived, and that they were sending him to the local hospital for evaluation.

Based on observation, interview, and record review, the facility failed to ensure that their Wander Guard monitoring system functioned to alarm staff when residents exited the facility with Wander Guard bracelets for 4 (#1, #3, #5, #6) of 5 residents ' Wander Guard bracelets tested at the exit doors out of a total of 14 residents who wore Wander Guard bracelets in the facility. Four (End of Halls 100, 300, 400, and 500) of the eight total exit doors failed to alarm when these residents (#1, #3, #5, #6) exited the facility with Wander Guard bracelets. Findings: During an interview with S2DON on [DATE] at 9:45 AM, she stated that she was in charge of monitoring to ensure that the Secure Care Alarm system was functioning properly with the use of the Secure Care Product, Inc. Treatment 2 equipment Tester 135 box. S2DON added that this was the only testing she conducted to ensure that the residents ' Wander Guard bracelets were functioning properly. A review of the facility's list of residents with Wander Guard bracelets revealed there were 14 residents who wore Wander Guard bracelets. During an interview with S1ADM on [DATE] at 10:31 AM, he confirmed that Resident #1, #3, #5, and #6 wore Wander Guard bracelets and were at risk for elopement. An observation was made on [DATE] at 2:40 PM of the S3ADON checking Resident #4 ' s Wander Guard bracelet with the Tester 135 box. The tester box was noted to be functioning and the tester box read " Tx OK " . Resident #4 was escorted via wheelchair to the exit door on the end of Hall 500 for testing of the wander guard and S3ADON entered the visitor ' s code *234 into the keypad, which unlocked the door. The exit door was opened by S3ADON, she exited with the resident, and an audible alarm was activated. S3ADON stated that this was the proper procedure for visitors, and that each Wander Guard bracelet should set the door alarm off when the resident passed through the door. An observation was made on [DATE] at 2:50 PM of S3ADON checking Resident #5 ' s Wander Guard bracelet with the Tester 135, and the tester box read " Tx OK " . Resident #5 was escorted to the end of Hall 500 exit door, the visitor ' s code *234 was entered into the keypad, and S3ADON opened the door. She then escorted the resident out of the door and closed the door behind them, waiting over 30 seconds and no alarm sounded. She stated that something must have malfunctioned. She repeated the entire procedure 3 times with no alarm sounding. She stated that the door must not have been picking up the signal from the Wander Guard on this resident. An observation was made on [DATE] at 2:55 PM of Resident #1 being escorted to the exit door at the end of Hall 500. Both S2DON and S3ADON were present for this observation. After the visitor ' s code was entered into the keypad, the exit door unlocked and when the resident exited , the alarm did not sound or light up on the keypad. The resident was brought back into the facility, the door automatically locked again and the entire procedure was repeated with the alarm failing to sound again. S2DON stated that she was not certain what was wrong, but that the alarm should have sounded when the resident with a Wander Guard bracelet exited the doors with a visitor ' s code. An observation was made on [DATE] at 2:55 PM and 3:00 PM of Resident #3 being escorted out of the 400 Hall exit after S4LPN entered the visitor ' s code into the keypad. S4LPN and Resident #3 stood outside of the exit door, and the alarm did not sound. S4LPN confirmed that the alarm did not sound, and she stated that the alarm should have sounded when the resident exited the door with the Wander Guard bracelet. An observation was made on [DATE] at 3:07 PM of Resident #6 being escorted out of the 400 Hall exit after S4LPN entered the visitor ' s code into the keypad. S4LPN and Resident #6 stood outside of the exit door, and the alarm did not sound. S4LPN confirmed that the alarm should have sounded when Resident #6 exited the door with the Wander Guard bracelet. An observation was made on [DATE] at 3:15 PM of Resident #3 being escorted out of the 500 Hall exit after S2DON entered the visitor ' s code into the keypad. S2DON and Resident #3 stood outside, and the door closed behind them with no alarm sounding. S2DON confirmed that the alarm did not sound, and she stated that it should have sounded when the resident walked out of the door with the Wander Guard bracelet. An observation was made on [DATE] at 3:18 PM of S2DON exiting the 500 Hall exit door carrying a Wander Guard bracelet after entering the visitor ' s code into the keypad and no alarm sounded. She stated that the Wander Guard bracelet was not expired and that it should have sounded when she walked through the door and went outside. Further observation of the Wander Guard bracelet revealed that the expiration date was [DATE], and the Wander Guard bracelet did not appear damaged. S2DON added that the facility only conducted testing of the residents ' Wander Guard bracelets by use of the tester box, and they did not bring residents through the exit doors to test for functioning. An interview was conducted with S1ADM on [DATE] at 3:20 PM who confirmed that the exit door on Hall 500 should have alarmed when the above residents were escorted outside of the exit door. He stated that a resident could possibly elope if they followed a visitor outside of the door and the Wander Guard bracelet did not trigger the alarm as observed on the above residents. He stated that he was unsure when the system was checked by Secure Care Products Inc., and he was unsure if all the exit doors were tested . An observation was made on [DATE] at 3:21 PM with S4LPN and S3ADON. During the observation, Resident #3 being escorted out of the 300 Hall exit door after S4LPN entered the visitor ' s code into the keypad. S4LPN and Resident #3 stood outside of the exit door, and the alarm did not sound. S4LPN and S3ADON confirmed that the alarm should have sounded when Resident #3 exited the door with the Wander Guard bracelet. An observation was made on [DATE] at 3:27 PM of Resident #6 being escorted out of the 100 Hall exit after S4LPN entered the visitor ' s code into the keypad. S4LPN and Resident #6 stood outside of the exit door, and the alarm did not sound. S4LPN confirmed that the alarm should have sounded when Resident #6 exited the door with the Wander Guard bracelet. During an interview with S1ADM on [DATE] at 3:56 PM, he stated that during the plan of correction period the facility staff did not have random residents that wore Wander Guard bracelets walk through the exit doors to test and see if the alarms were functioning properly.

Based on record review and staff interview, the facility failed to use the results of the comprehensive assessment to develop, review, and revise the resident ' s comprehensive plan of care, by failing to develop a plan of care for 2+ person assistance with bed mobility as identified on the resident ' s MDS assessment for 1 (#3) of 5 sampled records (#1, #2, #3, #4, #5). Resident #3 was care planned on 12/27/11 for at risk for falls with an approach of Bilateral bolsters while in bed. Resident #3 was in immediate jeopardy on 5/13/12 at 10:30 a.m. when S1, CNA, (Certified Nursing Assistant), without appropriate training, knowledge of the resident ' s care needs, or adequate nursing supervision, removed the bilateral bolsters from the resident ' s bed, performed a bed bath which included bed mobility with 1 person physical assistance instead of 2 person physical assistance as identified on the resident ' s MDS (Minimum Data Set) assessments. The resident fell out of bed onto the floor when turned to her side during the bed bath. Resident #3 sustained lacerations to her forehead and a C2 (Cervical) fracture as a result of the fall from the bed during the bed bath. Resident #3 was transferred to the hospital on [DATE] at 10:58 a.m., following the incident which occurred on 5/13/12 at 10:30 a.m. with a [DIAGNOSES REDACTED].. The Immediate Jeopardy for Resident #3 ended at the time of transfer to the hospital on [DATE] at 10:58 a.m. This deficient practice had the potential to affect 18 other residents in the nursing facility currently using bolsters on their beds. The immediate jeopardy continued for all 18 other residents (Resident # ' s 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21) identified by the facility as using bolsters while in bed. Resident # 3 was in immediate jeopardy when she returned to the facility on [DATE] at 9:30 p.m., and the facility had not trained the CNA staff on the proper use of bolsters. The immediate jeopardy ended for resident # 3 when she was sent to the hospital on [DATE] at 10:16 a.m. for an unrelated medical condition. The immediate jeopardy situation continued for the 18 other resident currently identified by the facility as using bolsters in bed. Immediate Jeopardy was called on 5/17/12 at 3:55 p.m. due to the facility failing to accurately train staff regarding the use of bolsters at all times while resident is in bed. The Immediate Jeopardy for Resident # 3 was removed when Resident # 3 returned to the hospital on [DATE] at 10:16 a.m. However, the Immediate Jeopardy continued for the 18 other residents identified by the nursing facility currently using bolsters in bed at the time of the call due to the nursing facility having failed to accurately train staff regarding the use of bolsters and the identified times that bolsters are to be in place. The Immediate Jeopardy was removed 5/18/12 at 10:30 a.m. S4, Administrator presented a plan of removal for the other 18 residents to address all residents in the facility with bolsters. This plan of removal for the other 18 residents dated 5/17/12 included additional in-service held regarding the proper use of bed bolsters; that bed bolsters are to be used at all times while the resident is in the bed per physician's order [REDACTED]. While the immediate jeopardy was removed on 5/18/12, the facility remained out of compliance at Level 3 for Resident #3, and Level 2 for the other 18 residents currently using bolsters. Findings: Resident #3 ' s current [DIAGNOSES REDACTED].Gastrostomy, Depend-Supplement Oxygen, [MEDICAL CONDITION] Reflux, other Psoriasis. Resident #3 ' s record revealed that she had a history (12/20/11 H&P-History & Physical) of [MEDICAL CONDITION], dysphagia, and [MEDICAL CONDITION]. This H&P also indicated that Resident #3 was severely demented. Review of two of Resident #3 ' s MDS assessments with reference dates of 3/25/12 and 4/1/2012, both reflected that Resident #3 was assessed by the nursing facility as: 1. Bed Mobility - 3/3 for bed mobility which included how the resident ...turns side to side, and positions body while in bed ...; meaning she required extensive assistance/2+ person physical assistance.(Resident involved in activity, staff provide weight-bearing support, with two + person physical assistance). 2. Bathing was identified on the 3/25/12 MDS assessment as 3/2; describing how the resident takes a ...sponge bath .... Meaning extensive assistance - resident involved in activity, staff provide weight-bearing support/1person physical assistance. Review of Resident #3 ' s plan of care reflected that the facility care planned the resident at risk for falls as of 12/27/11 with updates to goals and approaches up to 6/29/12. The approaches for 6/29/12 on the care plan included Bilateral bolsters while in bed; Place resident on fall-prevention program High risk for falls, resident on falling star program, star placed on pink sheet on bulletin board; Give resident verbal reminders not to ambulate or transfer without assistance. Review of the nurse ' s notes for Resident #3 dated 5/13/12 reflected documentation by S7,LPN of an incident in which Resident #3 fell out of the bed during a bed bath on 5/13/12 at 10:30 am. S7, LPN documented in the note that she was outside the resident ' s door when S1, CNA yelled for her to come in the room. S7, LPN wrote that she rushed in the room to find Resident #3 lying on her left side with the left side of her " forehead planted on the floor , in a large puddle of blood ... ...two lacerations over her left eyebrow, resident was conscious. " Review of the facility incident and accident report reflected that on 5/13/12 at 10:30 a.m., Resident #3 fell from the bed onto the floor when S1, CNA turned the resident towards her during a bed bath. The report reflected that S1, CNA explained to S7, LPN that she was administering a bed bath to Resident #3, she turned Resident #3 towards her, at the side she was standing, Resident #3 rolled to the end of the mattress, and she noted that Resident #3 was falling. S1, CNA reported that she tried to stop the fall, but Resident #3 fell to the floor. The report reflected that Resident #3 had 2 lacerations above her left eye with blood pouring out of each one. The report reflected that Resident #3 left the facility per ambulance on 5/13/12 at 10:58 a.m. Review of hospital records revealed that the resident presented to 2 hospitals on 5/13/12. The first hospital conducted a CT (Computerized Tomography) Scan on 5/13/12 at 12:09 p.m. The impression noted on the CT scan reflected: " 1. THERE IS A C2 FRACTURE WITH MILD DISPLACEMENT, AS DESCRIBED. NO FRACTURE ELSEWHERE. 2. RELATIVELY MILD [MEDICAL CONDITION] CHANGES OF THE CERVICAL SPINE. 3. OSTEOPENIA/[MEDICAL CONDITION] AND [MEDICAL CONDITION] DISEASE. " Hospital records reflect that Resident #3 was examined at the second hospital on [DATE] at 1700 hours. The physician noted that he/she was called by physician from hospital #1 to see Resident #3 for a neck fracture. The physician noted that the resident had a Stable C2 ant. (Anterior) Column fx (fracture) with a recommendation for a Philadelphia Collar x 6 weeks - can be removed for hygiene, and follow up with this physician in 6 weeks. Review of the nurse ' s notes reflected that Resident #3 returned to the nursing facility on 5/13/12 at 9:30 p.m. Additional approaches were added to the plan of care, after the incident, on 5/13/12 and 5/14/12. The 5/13/12 approach included a statement, " 5/13/12 @ 10:30 a.m ..... Res (Resident) fell from bed onto floor, Noted lying on (L) side, 2 lacerations to (L) eye, bathing res (resident) and when she turned res (resident) she rolled to end of mattress. Cervical fx-C2. " The added approach dated 5/13/12 included - send to ER (emergency room ), neuro (neurological) checks every1hour. The additional approaches added on 5/14/12 included " 2 person assistance (with) bed mobility, transfers, & bathing. Bilateral bolsters to remain in place during bed baths, in-service on bed baths and bed mobility. " During an interview on 5/17/12 at 9:39 a.m. with S8, LPN, CCC, (Clinical Care Coordinator), she stated that she did the MDS and Care Plan for Resident #3. The resident ' s MDS assessments for 3/25/12 and 4/1/12, and the resident ' s care plan were reviewed with S8LPN, CCC. She confirmed that the care plan addressed that the resident was to have bilateral bolsters while in bed. She confirmed that the resident was on the falling star program which included having " pink sheet " on the resident ' s bulletin board that gives the CNAs the information that is needed to care for the resident. During observation and review of Resident #3 ' s pink sheet with S8, LPN, CCC, she confirmed that the resident had 2 pink sheets on her bulletin board; one prior to the incident and one after the incident. S8, LPN, CCC dated the top of each sheet at the time of the interview/observation to reflect the dates that the 2 pink sheets were updated by her. The first sheet had an update date of 1/14/12 which included (with other measures) to Turn/Reposition every 2 hours as needed right to left keep off back, high risk for falls, maintain use of bolsters when in bed. She confirmed that the second pink sheet was updated on 5/14/12 after the incident to include: leave C-Collar in place except for bathing, 2 person assistance with bed mobility transfers, and bathing, and bilateral bolsters to remain in place during bath. Both sheets were on the resident ' s bulletin board on 5/17/12. She stated that the interventions listed on the 2 pink sheets should also be on the resident ' s care plan. An interview was conducted with S1, CNA on 5-18-12 at 12:00 p.m. She stated that on 5-13-12, the day that Resident #3 fell and sustained injury, she had entered the resident ' s room and observed that the resident was full of feces. The CNA stated that Resident #3 had bolsters in place on her bed. She further stated that she had worked at the facility for approximately one month and did not know the history of the resident or why the bolsters were on the resident ' s bed. S1, CNA then stated that she had not been trained on how to apply or remove the bolsters and that it was the first time she had ever worked with bolsters. S1, CNA stated that as she prepared to clean the resident, she removed the bolsters from the bed and turned the resident on her side and toward herself. She further stated that as she turned her, the resident ' s upper body began falling from the top of the bed and that she wasn ' t able to stop the resident from falling to the floor. S1, CNA confirmed that she was the only staff member present in Resident #3 ' s room at the time of the incident. She also stated that Resident #3 required only one staff member to provide her care. S1, CNA then stated that she was trained on the use of bolsters after the incident occurred. During an interview with S2, DON on 5/18/12 at 2:25 p.m., she stated she did not know there was a problem with the CNAs doing care by themselves or that bolsters were being removed during care. During an interview with S4, Administrator on 5/18/12 at 2:30 p.m., he stated that he did not know that there was a problem with the CNAs working alone when a resident is assessed for 2 + person assistance. He also stated that he did not know that the bolsters were being removed when they were supposed to stay in place.

Based on record review and staff interview the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents by failing to: 1. Ensure adequate nursing assessment, supervision, directive, and training for the use of bolsters while in bed; 2. Ensure that nurses' aides are able to demonstrate competency in skills for the use of bolsters in bed; 3. Adequately inform staff as to the use of bolsters while in bed; and 4. Adequately inform nursing staff as to the number of persons needed for assistance with bed mobility for 1 (#3) of 5 sampled resident ( #1.2.3.4.5 ) out of a total of 18 residents currently using bolsters. (Resident # ' s 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21) Resident #3 was care planned on 12/27/11 for at risk for falls with an approach of Bilateral bolsters while in bed. Resident #3 was in immediate jeopardy on 5/13/12 at 10:30 a.m. when S1, CNA, (Certified Nursing Assistant), without appropriate training, knowledge of the resident ' s care needs, or adequate nursing supervision, removed the bilateral bolsters from the resident ' s bed, performed a bed bath which included bed mobility with 1 person physical assistance instead of 2 person physical assistance as identified on the resident ' s MDS (Minimum Data Set) assessments. The resident fell out of bed onto the floor when turned to her side during the bed bath. Resident #3 sustained lacerations to her forehead and a C2 (Cervical) fracture as a result of the fall from the bed during the bed bath. Resident #3 was transferred to the hospital on [DATE] at 10:58 a.m., following the incident which occurred on 5/13/12 at 10:30 a.m. with a [DIAGNOSES REDACTED].. The Immediate Jeopardy for Resident #3 ended at the time of transfer to the hospital on [DATE] at 10:58 a.m. This deficient practice had the potential to affect 18 other residents in the nursing facility currently using bolsters on their beds. The immediate jeopardy continued for all 18 other residents (Resident # ' s 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21) identified by the facility as using bolsters while in bed. Resident # 3 was in immediate jeopardy when she returned to the facility on [DATE] at 9:30 p.m., and the facility had not trained the CNA staff on the proper use of bolsters. The immediate jeopardy ended for resident # 3 when she was sent to the hospital on [DATE] at 10:16 a.m. for an unrelated medical condition. The immediate jeopardy situation continued for the 18 other resident currently identified by the facility as using bolsters in bed. Immediate Jeopardy was called on 5/17/12 at 3:55 p.m. due to the facility failing to accurately train staff regarding the use of bolsters at all times while resident is in bed. The Immediate Jeopardy for Resident # 3 was removed when Resident # 3 returned to the hospital on [DATE] at 10:16 a.m. However, the Immediate Jeopardy continued for the 18 other residents identified by the nursing facility currently using bolsters in bed at the time of the call due to the nursing facility having failed to accurately train staff regarding the use of bolsters and the identified times that bolsters are to be in place. The Immediate Jeopardy was removed 5/18/12 at 10:30 a.m. S4, Administrator presented a plan of removal for the other 18 residents to address all residents in the facility with bolsters. This plan of removal for the other 18 residents dated 5/17/12 included additional in-service held regarding the proper use of bed bolsters; that bed bolsters are to be used at all times while the resident is in the bed per physician's order [REDACTED]. While the immediate jeopardy was removed on 5/18/12, the facility remained out of compliance at Level 3 for Resident #3, and Level 2 for the other 18 residents currently using bolsters. Findings: Resident #3 ' s current [DIAGNOSES REDACTED].Gastrostomy, Depend-Supplement Oxygen, Esophageal Reflux, other Psoriasis. Resident #3 ' s record revealed that she had a history (12/20/11 H&P-History & Physical) of Cerebrovascular accident, dysphagia, and hemiparesis. This H&P also indicated that Resident #3 was severely demented. Review of two of Resident #3 ' s MDS assessments with reference dates of 3/25/12 and 4/1/2012, both reflected that Resident #3 was assessed by the nursing facility as: 1. Bed Mobility - 3/3 for bed mobility which included how the resident ...turns side to side, and positions body while in bed ...; meaning she required extensive assistance/2+ person physical assistance.(Resident involved in activity, staff provide weight-bearing support, with two + person physical assistance). 2. Bathing was identified on the 3/25/12 MDS assessment as 3/2; describing how the resident takes a ...sponge bath .... Meaning extensive assistance - resident involved in activity, staff provide weight-bearing support/1person physical assistance. Review of Resident #3 ' s plan of care reflected that the facility care planned the resident at risk for falls as of 12/27/11 with updates to goals and approaches up to 6/29/12. The approaches for 6/29/12 included High risk for falls, resident on falling star program, star placed on pink sheet on bulletin board; the plan included Bilateral bolsters while in bed. Place resident on fall-prevention program. Give resident verbal reminders not to ambulate or transfer without assistance. These approaches did not reflect the extensive/2+physical assistance with bed mobility that Resident #3 required as the facility had identified on the resident ' s MDS assessments. Review of the nurse ' s notes for Resident #3 dated 5/13/12 reflected documentation by S7,LPN of an incident in which Resident #3 fell out of the bed during a bed bath on 5/13/12 at 10:30 am. S7, LPN documented in this note that she was outside the resident ' s door when S1, CNA yelled for her to come in the room. S7, LPN wrote that she rushed in the room to find Resident #3 lying on her left side with the left side of her " forehead planted on the floor , in a large puddle of blood ... ...two lacerations over her left eyebrow, resident was conscious. " Review of the facility incident and accident report reflected that on 5/13/12 at 10:30 a.m., Resident #3 fell from the bed onto the floor when S1, CNA turned the resident towards her during a bed bath. The report reflected that S1, CNA explained to S7, LPN that she was administering a bed bath to Resident #3, she turned Resident #3 towards her, at the side she was standing, Resident #3 rolled to the end of the mattress, and she noted that Resident #3 was falling. S1, CNA reported that she tried to stop the fall, but Resident #3 fell to the floor. The report reflected that Resident #3 had 2 lacerations above her left eye with blood pouring out of each one. The report reflected that Resident #3 left the facility per ambulance on 5/13/12 at 10:58 a.m. Review of hospital records revealed that the resident presented to 2 hospitals on 5/13/12. The first hospital conducted a CT (Computerized Tomography) Scan on 5/13/12 at 12:09 p.m. The impression noted on the CT scan reflected: " 1. THERE IS A C2 FRACTURE WITH MILD DISPLACEMENT, AS DESCRIBED. NO FRACTURE ELSEWHERE. 2. RELATIVELY MILD DEGENERATIVE CHANGES OF THE CERVICAL SPINE. 3. OSTEOPENIA/OSTEOPOROSIS AND ATHEROSCLEROTIC DISEASE. " Hospital records reflect that Resident #3 was examined at the second hospital on [DATE] at 1700 hours. The physician noted that he/she was called by physician from hospital #1 to see Resident #3 for a neck fracture. The physician noted that the resident had a Stable C2 ant. (Anterior) Column fx (fracture) with a recommendation for a Philadelphia Collar x 6 weeks - can be removed for hygiene, and follow up with this physician in 6 weeks. Review of the nurse ' s notes reflected that Resident #3 returned to the nursing facility on 5/13/12 at 9:30 p.m. Additional approaches were added to the plan of care, after the incident, on 5/13/12 and 5/14/12. The 5/13/12 approach included a statement, " 5/13/12 @ 10:30 a.m ..... Res (Resident) fell from bed onto floor, Noted lying on (L) side, 2 lacerations to (L) eye, bathing res (resident) and when she turned res (resident) she rolled to end of mattress. Cervical fx-C2. " The added approach dated 5/13/12 included - send to ER (emergency room ), neuro (neurological) checks every1hour. The additional approaches added on 5/14/12 included " 2 person assistance (with) bed mobility, transfers, & bathing. Bilateral bolsters to remain in place during bed baths, in-service on bed baths and bed mobility. " During an interview on 5/17/12 at 9:39 a.m. with S8, LPN, CCC, (Clinical Care Coordinator), she stated that she did the MDS and Care Plan for Resident #3. The resident ' s MDS assessments for 3/25/12 and 4/1/12, and the resident ' s care plan were reviewed with S8LPN, CCC. She confirmed that Resident #3 ' s care plan approaches prior to the date of the incident, did not reflect the type of assistance or the number of people needed for assistance with bed mobility identified on the MDS as 3/3- Extensive/2+ physical assistance. She confirmed that the care plan addressed that the resident was to have bilateral bolsters while in bed. She confirmed that the resident was on the falling star program which included having " pink sheet " on the resident ' s bulletin board that gives the CNAs the information that is needed to care for the resident. She stated that if 2+ physical assistance is not noted on the pink sheet, then the CNA knows to provide only 1 person physical assistance. During observation and review of Resident #3 ' s pink sheet with S8, LPN, CCC, she confirmed that the resident had 2 pink sheets on her bulletin board; one prior to the incident and one after the incident. S8, LPN, CCC dated the top of each sheet at the time of the interview/observation to reflect the dates that the 2 pink sheets were updated by her. The first sheet had an update date of 1/14/12 which included (with other measures) to Turn/Reposition every 2 hours as needed right to left keep off back, high risk for falls, maintain use of bolsters when in bed ...S8, LPN, CCC confirmed that the pink sheets did not include extensive/2+person physical assistance with bed mobility as identified on the 3/25/12 MDS or 4/1/12 MDS assessments. She confirmed that the second pink sheet was updated on 5/14/12 after the incident to include: leave C-Collar in place except for bathing, 2 person assistance with bed mobility transfers, and bathing, and bilateral bolsters to remain in place during bath. Both sheets were on the resident ' s bulletin board on 5/17/12. She stated that the interventions listed on the 2 pink sheets should also be on the resident ' s care plan. During an interview with S3LPN on 5/16/12 at 2:50 p.m., she stated that she is in charge of the oversight of CNA training. She was asked how she monitors new CNAs to ensure their competency in nursing skills prior to allowing them to work independently with residents. She stated that she does not have documentation of CNA demonstration of competency in skills. She states that upon hire and post hire, the CNAs go through a " Silver Chair " video training, and the new hire will work in orientation with another CNA. However, she could not provide documented evidence that the facility ensured an assessment of new CNAs demonstration of competency. On 5/16/12 at 3:25 pm during another interview with S3 LPN, CCC, she verified that she did not have written documented evidence of CNA demonstration of competency in skills post hire or at any other time during employment of any CNA currently on staff. When asked how she ensures CNA competency before a CNA is allowed to work independently, she stated that they (facility) will put another CNA working with the new employee to train. She stated that she gets verbal reports from the trainer, and that at times she makes observations of a new employee ' s work performance. However, she could not provide documented evidence of the facility ' s method of verification of CNA demonstration of competency, or documentation of the facility ' s evaluation of CNA staff demonstration of performance/competency upon hire or at any other time of employment. Review of 5 employee records , including S1 CNA, S13 CNA, S14 CNA, S15 CNA, S16 CNA) who was caring for Resident #3 at the time of the incident, did not reveal evidence of demonstration of competency skills prior to working independently upon completion of orientation or at any other time during their employment with the nursing facility. An interview was conducted with S2, DON (Director of Nurses) on 5-16-12 at 2:47 p.m. When questioned about how the facility ensures the competency of the CNAs (Certified Nursing Assistants) and special monitoring/evaluative tools to document demonstration of competency of skills, she stated that she was not aware of documented evidence of CNA demonstration of competency of skills. When further questioned about how the facility monitors for CNA competency, she stated that S3, LPN monitors the CNAs and new hires for training. She further stated that S3, LPN was a charge nurse, CNA supervisor, and the monitor of CNA training. An interview was conducted with S4, Administrator on 5-16-12 at 3:45 p.m. He stated that the facility did not have documented evidence of return demonstration of skill competency for the CNAs. He verified that the facility could not provide a policy for CNA competence or evidence of CNA performance competency reviews completed by the facility. Review of the CNA ADL Assistance and Support records for the months of March, April, and May of 2012, revealed varied documentation by the CNAs each day and each shift. The documentation varied as to the extent and the number of people providing assistance for bed mobility to Resident #3. The variations ranged from 3/2 - extensive assistance/1person physical assist to 4/2 - total dependence/1+person assist, to 4/3 - total dependence/2+ physical assist, to 8 = ADL activity itself did not occur during entire period. There was no documentation of what level of service the CNAs performed for bathing during the months of March, April, and May 2012. Further review of the ADL Assistance and Support records revealed that at the time of the incident which occurred with Resident #3 on 5/13/12 at 10:30 a.m., the CNA documented 3/2 (extensive/1 person physical assist) for bed mobility and there was no documentation of the assistance provided for bathing on 5/13/12 day shift. During an interview with S2, DON on 5/17/12 at 1:30 p.m., she was asked to explain the documentation of the CNA staff on the ADL Assistance and Support records for the months of March, April, and May as it differed from the facility ' s MDS assessments of 3/25/12 and 4/1/12 for bed mobility. She stated that the CNAs ' documentation was different each day or shift depending on the resident ' s need at the time. S2, DON was asked how or who makes this daily determination of ADL need. Surveyor received no response. S2, DON stated that the documentation that the CNAs report is what is used to make the determination on the MDS as to the resident ' s assistance level/need. She confirmed that the CNAs document what service is actually performed. S2, DON was asked if the CNAs are supposed to report a change in a resident ' s ADL need (improvement/decline), and if changes are reported, is there another assessment by nursing to determine the resident ' s type and amount of assistance needed. S2, DON did not have a response other than to repeat that the CNAs document what they did and not what the MDS assessment reflected because the MDS assessment only reflected a certain look back period of time. She stated that a resident may need more assistance one day and not another. Surveyor was not given an explanation as to how or under what circumstances or professional standard the CNA staff is trained, competent, knowledgeable, or allowed to make daily ADL determinations. Surveyor was never given an explanation as to how the CNA staff knows how much assistance and the type of assistance that the Resident ' s assessment and care plan reflected. An interview was conducted with S1, CNA on 5-18-12 at 12:00 p.m. She stated that on 5-13-12, the day that Resident #3 fell and sustained injury, she had entered the resident ' s room and observed that the resident was full of feces. The CNA stated that Resident #3 had bolsters in place on her bed. She further stated that she had worked at the facility for approximately one month and did not know the history of the resident or why the bolsters were on the resident ' s bed. S1, CNA then stated that she had not been trained on how to apply or remove the bolsters and that it was the first time she had ever worked with bolsters. S1, CNA stated that as she prepared to clean the resident, she removed the bolsters from the bed and turned the resident on her side and toward herself. She further stated that as she turned her, the resident ' s upper body began falling from the top of the bed and that she wasn ' t able to stop the resident from falling to the floor. S1, CNA confirmed that she was the only staff member present in Resident #3 ' s room at the time of the incident. She also stated that Resident #3 required only one staff member to provide her care. S1, CNA then stated that she was trained on the use of bolsters after the incident occurred. Review of the in-service dated 5/14/12 revealed an attachment of the topics discussed. A bullet section titled " Safety Equipment, " reflected .....make sure all bolster, cushions etc. remain in place until care is completed. The in-service did not address the many ways to use bolsters, different times of use, the different sizes of bolsters, and the proper application of bolsters (unilaterally or bilaterally), as described on the facility ' s list of residents using bolsters. During an interview with S2, DON on 5/18/12 at 2:25 p.m., she stated she did not know there was a problem with the CNAs doing care by themselves or that bolsters were being removed during care. During an interview with S4, Administrator on 5/18/12 at 2:30 p.m., he stated that he did not know that there was a problem with the CNAs working alone when a resident is assessed for 2 + person assistance. He also stated that he did not know that the bolsters were being removed when they were supposed to stay in place.

Based on record review and staff interview, the facility failed to ensure that it administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to: 1. Ensure staff education, training, and return demonstration on: 1. the use of bolsters while in bed; 2. the different ways and times to use bolsters; 3. the different sizes of or placements of bolsters used; or 4. the proper application of bolsters (unilaterally or bilaterally), as described on the facility ' s list of residents with orders for bolsters (Resident #3) for 1 (#3) of 5 sampled resident s ( #1.2.3.4.5 ) out of a total of 18 other residents currently using bolsters. (Resident #'s 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21). 2. Have a system of supervision in place to determine CNA clinical competence on the use of bolsters while in bed. 3. Have a system in place to ensure an accurate resident care plan was developed and implemented using the resident's comprehensive assessment (#3). 4. Have a system in place to ensure all staff members including CNA staff were aware of resident's care plan interventions for bed mobility and fall prevention. Resident #3 was care planned on 12/27/11 for at risk for falls with an approach of Bilateral bolsters while in bed. Resident #3 was in immediate jeopardy on 5/13/12 at 10:30 a.m. when S1, CNA, (Certified Nursing Assistant), without appropriate training, knowledge of the resident ' s care needs, or adequate nursing supervision, removed the bilateral bolsters from the resident ' s bed, performed a bed bath which included bed mobility with 1 person physical assistance instead of 2 person physical assistance as identified on the resident ' s MDS (Minimum Data Set) assessments. The resident fell out of bed onto the floor when turned to her side during the bed bath. Resident #3 sustained lacerations to her forehead and a C2 (Cervical) fracture as a result of the fall from the bed during the bed bath. Resident #3 was transferred to the hospital on [DATE] at 10:58 a.m., following the incident which occurred on 5/13/12 at 10:30 a.m. with a [DIAGNOSES REDACTED].. The Immediate Jeopardy for Resident #3 ended at the time of transfer to the hospital on [DATE] at 10:58 a.m. This deficient practice had the potential to affect 18 other residents in the nursing facility currently using bolsters on their beds. The immediate jeopardy continued for all 18 other residents (Resident # ' s 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21) identified by the facility as using bolsters while in bed. Resident # 3 was in immediate jeopardy when she returned to the facility on [DATE] at 9:30 p.m., and the facility had not trained the CNA staff on the proper use of bolsters. The immediate jeopardy ended for resident # 3 when she was sent to the hospital on [DATE] at 10:16 a.m. for an unrelated medical condition. The immediate jeopardy situation continued for the 18 other resident currently identified by the facility as using bolsters in bed. Immediate Jeopardy was called on 5/17/12 at 3:55 p.m. due to the facility failing to accurately train staff regarding the use of bolsters at all times while resident is in bed. The Immediate Jeopardy for Resident # 3 was removed when Resident # 3 returned to the hospital on [DATE] at 10:16 a.m. However, the Immediate Jeopardy continued for the 18 other residents identified by the nursing facility currently using bolsters in bed at the time of the call due to the nursing facility having failed to accurately train staff regarding the use of bolsters and the identified times that bolsters are to be in place. The Immediate Jeopardy was removed 5/18/12 at 10:30 a.m. S4, Administrator presented a plan of removal for the other 18 residents to address all residents in the facility with bolsters. This plan of removal for the other 18 residents dated 5/17/12 included additional in-service held regarding the proper use of bed bolsters; that bed bolsters are to be used at all times while the resident is in the bed per physician's order [REDACTED]. While the immediate jeopardy was removed on 5/18/12, the facility remained out of compliance at a Level 3 for Resident #3 and a Level 2 for the other residents currently using bolsters. Findings: Resident #3 ' s current [DIAGNOSES REDACTED].Gastrostomy, Depend-Supplement Oxygen, [MEDICAL CONDITION] Reflux, other Psoriasis. Resident #3 ' s record revealed that she had a history (12/20/11 H&P-History & Physical) of [MEDICAL CONDITION], dysphagia, and [MEDICAL CONDITION]. This H&P also indicated that Resident #3 was severely demented. Review of two of Resident #3 ' s MDS assessments with reference dates of 3/25/12 and 4/1/2012, both reflected that Resident #3 was assessed by the nursing facility as: 1. Bed Mobility - 3/3 for bed mobility which included how the resident ...turns side to side, and positions body while in bed ...; meaning she required extensive assistance/2+ person physical assistance.(Resident involved in activity, staff provide weight-bearing support, with two + person physical assistance). 2. Bathing was identified on the 3/25/12 MDS assessment as 3/2; describing how the resident takes a ...sponge bath .... Meaning extensive assistance - resident involved in activity, staff provide weight-bearing support/1person physical assistance. Review of Resident #3 ' s plan of care reflected that the facility care planned the resident at risk for falls as of 12/27/11 with updates to goals and approaches up to 6/29/12. The approaches for 6/29/12 included High risk for falls, resident on falling star program, star placed on pink sheet on bulletin board; the plan included Bilateral bolsters while in bed. Place resident on fall-prevention program. Give resident verbal reminders not to ambulate or transfer without assistance. These approaches did not reflect the extensive/2+physical assistance with bed mobility that Resident #3 required as the facility had identified on the resident ' s MDS assessments. Review of the nurse ' s notes for Resident #3 dated 5/13/12 reflected documentation by S7,LPN of an incident in which Resident #3 fell out of the bed during a bed bath on 5/13/12 at 10:30 am. S7, LPN documented in this note that she was outside the resident ' s door when S1, CNA yelled for her to come in the room. S7, LPN wrote that she rushed in the room to find Resident #3 lying on her left side with the left side of her " forehead planted on the floor , in a large puddle of blood ... ...two lacerations over her left eyebrow, resident was conscious. " Review of the facility incident and accident report reflected that on 5/13/12 at 10:30 a.m., Resident #3 fell from the bed onto the floor when S1, CNA turned the resident towards her during a bed bath. The report reflected that S1, CNA explained to S7, LPN that she was administering a bed bath to Resident #3, she turned Resident #3 towards her, at the side she was standing, Resident #3 rolled to the end of the mattress, and she noted that Resident #3 was falling. S1, CNA reported that she tried to stop the fall, but Resident #3 fell to the floor. The report reflected that Resident #3 had 2 lacerations above her left eye with blood pouring out of each one. The report reflected that Resident #3 left the facility per ambulance on 5/13/12 at 10:58 a.m. Review of hospital records revealed that the resident presented to 2 hospitals on 5/13/12. The first hospital conducted a CT (Computerized Tomography) Scan on 5/13/12 at 12:09 p.m. The impression noted on the CT scan reflected: " 1. THERE IS A C2 FRACTURE WITH MILD DISPLACEMENT, AS DESCRIBED. NO FRACTURE ELSEWHERE. 2. RELATIVELY MILD [MEDICAL CONDITION] CHANGES OF THE CERVICAL SPINE. 3. OSTEOPENIA/[MEDICAL CONDITION] AND [MEDICAL CONDITION] DISEASE. " Hospital records reflect that Resident #3 was examined at the second hospital on [DATE] at 1700 hours. The physician noted that he/she was called by physician from hospital #1 to see Resident #3 for a neck fracture. The physician noted that the resident had a Stable C2 ant. (Anterior) Column fx (fracture) with a recommendation for a Philadelphia Collar x 6 weeks - can be removed for hygiene, and follow up with this physician in 6 weeks. Review of the nurse ' s notes reflected that Resident #3 returned to the nursing facility on 5/13/12 at 9:30 p.m. Additional approaches were added to the plan of care, after the incident, on 5/13/12 and 5/14/12. The 5/13/12 approach included a statement, " 5/13/12 @ 10:30 a.m ..... Res (Resident) fell from bed onto floor, Noted lying on (L) side, 2 lacerations to (L) eye, bathing res (resident) and when she turned res (resident) she rolled to end of mattress. Cervical fx-C2. " The added approach dated 5/13/12 included - send to ER (emergency room ), neuro (neurological) checks every1hour. The additional approaches added on 5/14/12 included " 2 person assistance (with) bed mobility, transfers, & bathing. Bilateral bolsters to remain in place during bed baths, in-service on bed baths and bed mobility. " During an interview on 5/17/12 at 9:39 a.m. with S8, LPN, CCC, (Clinical Care Coordinator), she stated that she did the MDS and Care Plan for Resident #3. The resident ' s MDS assessments for 3/25/12 and 4/1/12, and the resident ' s care plan were reviewed with S8LPN, CCC. She confirmed that Resident #3 ' s care plan approaches prior to the date of the incident, did not reflect the type of assistance or the number of people needed for assistance with bed mobility identified on the MDS as 3/3- Extensive/2+ physical assistance. She confirmed that the care plan addressed that the resident was to have bilateral bolsters while in bed. She confirmed that the resident was on the falling star program which included having " pink sheet " on the resident ' s bulletin board that gives the CNAs the information that is needed to care for the resident. She stated that if 2+ physical assistance is not noted on the pink sheet, then the CNA knows to provide only 1 person physical assistance. During observation and review of Resident #3 ' s pink sheet with S8, LPN, CCC, she confirmed that the resident had 2 pink sheets on her bulletin board; one prior to the incident and one after the incident. S8, LPN, CCC dated the top of each sheet at the time of the interview/observation to reflect the dates that the 2 pink sheets were updated by her. The first sheet had an update date of 1/14/12 which included (with other measures) to Turn/Reposition every 2 hours as needed right to left keep off back, high risk for falls, maintain use of bolsters when in bed ...S8, LPN, CCC confirmed that the pink sheets did not include extensive/2+person physical assistance with bed mobility as identified on the 3/25/12 MDS or 4/1/12 MDS assessments. She confirmed that the second pink sheet was updated on 5/14/12 after the incident to include: leave C-Collar in place except for bathing, 2 person assistance with bed mobility transfers, and bathing, and bilateral bolsters to remain in place during bath. Both sheets were on the resident ' s bulletin board on 5/17/12. She stated that the interventions listed on the 2 pink sheets should also be on the resident ' s care plan. During an interview with S3LPN on 5/16/12 at 2:50 p.m., she stated that she is in charge of the oversight of CNA training. She was asked how she monitors new CNAs to ensure their competency in nursing skills prior to allowing them to work independently with residents. She stated that she does not have documentation of CNA demonstration of competency in skills. She states that upon hire and post hire, the CNAs go through a " Silver Chair " video training, and the new hire will work in orientation with another CNA. However, she could not provide documented evidence that the facility ensured an assessment of new CNAs demonstration of competency. On 5/16/12 at 3:25 pm during another interview with S3 LPN, CCC, she verified that she did not have written documented evidence of CNA demonstration of competency in skills post hire or at any other time during employment of any CNA currently on staff. When asked how she ensures CNA competency before a CNA is allowed to work independently, she stated that they (facility) will put another CNA working with the new employee to train. She stated that she gets verbal reports from the trainer, and that at times she makes observations of a new employee ' s work performance. However, she could not provide documented evidence of the facility ' s method of verification of CNA demonstration of competency, or documentation of the facility ' s evaluation of CNA staff demonstration of performance/competency upon hire or at any other time of employment. Review of 5 employee records (S1 CNA, S13 CNA, S14 CNA, S15 CNA, S16 CNA) , including S1, CNA who was caring for Resident #3 at the time of the incident, did not reveal evidence of demonstration of competency skills prior to working independently upon completion of orientation or at any other time during their employment with the nursing facility. An interview was conducted with S2, DON (Director of Nurses) on 5-16-12 at 2:47 p.m. When questioned about how the facility ensures the competency of the CNAs (Certified Nursing Assistants) and special monitoring/evaluative tools to document demonstration of competency of skills, she stated that she was not aware of documented evidence of CNA demonstration of competency of skills. When further questioned about how the facility monitors for CNA competency, she stated that S3, LPN monitors the CNAs and new hires for training. She further stated that S3, LPN was a charge nurse, CNA supervisor, and the monitor of CNA training. An interview was conducted with S4, Administrator on 5-16-12 at 3:45 p.m. He stated that the facility did not have documented evidence of return demonstration of skill competency for the CNAs. He verified that the facility could not provide a policy for CNA competence or evidence of CNA performance competency reviews completed by the facility. Review of the CNA ADL Assistance and Support records for the months of March, April, and May of 2012, revealed varied documentation by the CNAs each day and each shift. The documentation varied as to the extent and the number of people providing assistance for bed mobility to Resident #3. The variations ranged from 3/2 - extensive assistance/1person physical assist to 4/2 - total dependence/1+person assist, to 4/3 - total dependence/2+ physical assist, to 8 = ADL activity itself did not occur during entire period. There was no documentation of what level of service the CNAs performed for bathing during the months of March, April, and May 2012. Further review of the ADL Assistance and Support records revealed that at the time of the incident which occurred with Resident #3 on 5/13/12 at 10:30 a.m., the CNA documented 3/2 (extensive/1 person physical assist) for bed mobility and there was no documentation of the assistance provided for bathing on 5/13/12 day shift. During an interview with S2, DON on 5/17/12 at 1:30 p.m., she was asked to explain the documentation of the CNA staff on the ADL Assistance and Support records for the months of March, April, and May as it differed from the facility ' s MDS assessments of 3/25/12 and 4/1/12 for bed mobility. She stated that the CNAs ' documentation was different each day or shift depending on the resident ' s need at the time. S2, DON was asked how or who makes this daily determination of ADL need. Surveyor received no response. S2, DON stated that the documentation that the CNAs report is what is used to make the determination on the MDS as to the resident ' s assistance level/need. She confirmed that the CNAs document what service is actually performed. S2, DON was asked if the CNAs are supposed to report a change in a resident ' s ADL need (improvement/decline), and if changes are reported, is there another assessment by nursing to determine the resident ' s type and amount of assistance needed. S2, DON did not have a response other than to repeat that the CNAs document what they did and not what the MDS assessment reflected because the MDS assessment only reflected a certain look back period of time. She stated that a resident may need more assistance one day and not another. Surveyor was not given an explanation as to how or under what circumstances or professional standard the CNA staff is trained, competent, knowledgeable, or allowed to make daily ADL determinations. Surveyor was never given an explanation as to how the CNA staff knows how much assistance and the type of assistance that the Resident ' s assessment and care plan reflected. An interview was conducted with S1, CNA on 5-18-12 at 12:00 p.m. She stated that on 5-13-12, the day that Resident #3 fell and sustained injury, she had entered the resident ' s room and observed that the resident was full of feces. The CNA stated that Resident #3 had bolsters in place on her bed. She further stated that she had worked at the facility for approximately one month and did not know the history of the resident or why the bolsters were on the resident ' s bed. S1, CNA then stated that she had not been trained on how to apply or remove the bolsters and that it was the first time she had ever worked with bolsters. S1, CNA stated that as she prepared to clean the resident, she removed the bolsters from the bed and turned the resident on her side and toward herself. She further stated that as she turned her, the resident ' s upper body began falling from the top of the bed and that she wasn ' t able to stop the resident from falling to the floor. S1, CNA confirmed that she was the only staff member present in Resident #3 ' s room at the time of the incident. She also stated that Resident #3 required only one staff member to provide her care. S1, CNA then stated that she was trained on the use of bolsters after the incident occurred. Review of the in-service dated 5/14/12 revealed an attachment of the topics discussed. A bullet section titled " Safety Equipment, " reflected .....make sure all bolster, cushions etc. remain in place until care is completed. The in-service did not address the many ways to use bolsters, different times of use, the different sizes of bolsters, and the proper application of bolsters (unilaterally or bilaterally), as described on the facility ' s list of residents using bolsters. During an interview with S2, DON on 5/18/12 at 2:25 p.m., she stated she did not know there was a problem with the CNAs doing care by themselves or that bolsters were being removed during care. During an interview with S4, Administrator on 5/18/12 at 2:30 p.m., he stated that he did not know that there was a problem with the CNAs working alone when a resident is assessed for 2 + person assistance. He also stated that he did not know that the bolsters were being removed when they were supposed to stay in place.

Based on observation, interview, and record review, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents ' needs, as identified through resident assessments, and described in the care plan by failing to provide training, supervision and monitoring to the nurse aides employed at the facility which included return demonstration of a skill learned for 5 of 5 employee records reviewed. Resident #3 was care planned on 12/27/11 for at risk for falls with an approach of Bilateral bolsters while in bed. Resident #3 was in immediate jeopardy on 5/13/12 at 10:30 a.m. when S1, CNA, (Certified Nursing Assistant), without appropriate training, knowledge of the resident ' s care needs, or adequate nursing supervision, removed the bilateral bolsters from the resident ' s bed, performed a bed bath which included bed mobility with 1 person physical assistance instead of 2 person physical assistance as identified on the resident ' s MDS (Minimum Data Set) assessments. The resident fell out of bed onto the floor when turned to her side during the bed bath. Resident #3 sustained lacerations to her forehead and a C2 (Cervical) fracture as a result of the fall from the bed during the bed bath. Resident #3 was transferred to the hospital on [DATE] at 10:58 a.m., following the incident which occurred on 5/13/12 at 10:30 a.m. with a [DIAGNOSES REDACTED].. The Immediate Jeopardy for Resident #3 ended at the time of transfer to the hospital on [DATE] at 10:58 a.m. This deficient practice had the potential to affect 18 other residents in the nursing facility currently using bolsters on their beds. The immediate jeopardy continued for all 18 other residents (Resident # ' s 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21) identified by the facility as using bolsters while in bed. Resident # 3 was in immediate jeopardy when she returned to the facility on [DATE] at 9:30 p.m., and the facility had not trained the CNA staff on the proper use of bolsters. The immediate jeopardy ended for resident # 3 when she was sent to the hospital on [DATE] at 10:16 a.m. for an unrelated medical condition. The immediate jeopardy situation continued for the 18 other resident currently identified by the facility as using bolsters in bed. Immediate Jeopardy was called on 5/17/12 at 3:55 p.m. due to the facility failing to accurately train staff regarding the use of bolsters at all times while resident is in bed. The Immediate Jeopardy for Resident # 3 was removed when Resident # 3 returned to the hospital on [DATE] at 10:16 a.m. However, the Immediate Jeopardy continued for the 18 other residents identified by the nursing facility currently using bolsters in bed at the time of the call due to the nursing facility having failed to accurately train staff regarding the use of bolsters and the identified times that bolsters are to be in place. The Immediate Jeopardy was removed 5/18/12 at 10:30 a.m. S4, Administrator presented a plan of removal for the other 18 residents to address all residents in the facility with bolsters. This plan of removal for the other 18 residents dated 5/17/12 included additional in-service held regarding the proper use of bed bolsters; that bed bolsters are to be used at all times while the resident is in the bed per physician's order [REDACTED]. While the immediate jeopardy was removed on 5/18/12, the facility remained out of compliance at Level 3 for Resident #3, and Level 2 for the other 18 residents currently using bolsters. Findings: Resident #3 ' s current [DIAGNOSES REDACTED].Gastrostomy, Depend-Supplement Oxygen, [MEDICAL CONDITION] Reflux, other Psoriasis. Resident #3 ' s record revealed that she had a history (12/20/11 H&P-History & Physical) of [MEDICAL CONDITION], dysphagia, and [MEDICAL CONDITION]. This H&P also indicated that Resident #3 was severely demented. Review of two of Resident #3 ' s MDS assessments with reference dates of 3/25/12 and 4/1/2012, both reflected that Resident #3 was assessed by the nursing facility as: 1. Bed Mobility - 3/3 for bed mobility which included how the resident ...turns side to side, and positions body while in bed ...; meaning she required extensive assistance/2+ person physical assistance.(Resident involved in activity, staff provide weight-bearing support, with two + person physical assistance). 2. Bathing was identified on the 3/25/12 MDS assessment as 3/2; describing how the resident takes a ...sponge bath .... Meaning extensive assistance - resident involved in activity, staff provide weight-bearing support/1person physical assistance. Review of Resident #3 ' s plan of care reflected that the facility care planned the resident at risk for falls as of 12/27/11 with updates to goals and approaches up to 6/29/12. The approaches for 6/29/12 included the use of bilateral bolsters while in bed. Review of the nurse ' s notes for Resident #3 dated 5/13/12 reflected documentation by S7,LPN of an incident in which Resident #3 fell out of the bed during a bed bath on 5/13/12 at 10:30 am. S7, LPN documented in this note that she was outside the resident ' s door when S1, CNA yelled for her to come in the room. S7, LPN wrote that she rushed in the room to find Resident #3 lying on her left side with the left side of her " forehead planted on the floor , in a large puddle of blood ... ...two lacerations over her left eyebrow, resident was conscious. " Review of the facility incident and accident report reflected that on 5/13/12 at 10:30 a.m., Resident #3 fell from the bed onto the floor when S1, CNA turned the resident towards her during a bed bath. The report reflected that S1, CNA explained to S7, LPN that she was administering a bed bath to Resident #3, she turned Resident #3 towards her, at the side she was standing, Resident #3 rolled to the end of the mattress, and she noted that Resident #3 was falling. S1, CNA reported that she tried to stop the fall, but Resident #3 fell to the floor. The report reflected that Resident #3 had 2 lacerations above her left eye with blood pouring out of each one. The report reflected that Resident #3 left the facility per ambulance on 5/13/12 at 10:58 a.m. Review of hospital records revealed that the resident presented to 2 hospitals on 5/13/12. The first hospital conducted a CT (Computerized Tomography) Scan on 5/13/12 at 12:09 p.m. The impression noted on the CT scan reflected: " 1. THERE IS A C2 FRACTURE WITH MILD DISPLACEMENT, AS DESCRIBED. NO FRACTURE ELSEWHERE. 2. RELATIVELY MILD [MEDICAL CONDITION] CHANGES OF THE CERVICAL SPINE. 3. OSTEOPENIA/[MEDICAL CONDITION] AND [MEDICAL CONDITION] DISEASE. " During an interview on 5/17/12 at 9:39 a.m. with S8, LPN, CCC, (Clinical Care Coordinator), she stated that she did the MDS and Care Plan for Resident #3. She confirmed that the care plan addressed that the resident was to have bilateral bolsters while in bed. She confirmed that the resident was on the falling star program which included having " pink sheet " on the resident ' s bulletin board that gives the CNAs the information that is needed to care for the resident. During observation and review of Resident #3 ' s pink sheet with S8, LPN, CCC, she confirmed that the pink sheet reflected, Turn/Reposition every 2 hours as needed right to left keep off back, high risk for falls, maintain use of bolsters when in bed. During another interview with S3LPN on 5/16/12 at 2:50 p.m., she stated that she is in charge of the oversight of CNA training. She was asked how she monitors new CNAs to ensure their competency in nursing skills prior to allowing them to work independently with residents. She stated that she does not have documentation of CNA demonstration of competency in skills. She states that upon hire and post hire, the CNAs go through a " Silver Chair " video training, and the new hire will work in orientation with another CNA. However, she could not provide documented evidence that the facility ensured an assessment of new CNAs demonstration of competency. On 5/16/12 at 3:25 pm during another interview with S3 LPN, CCC, she verified that she did not have written documented evidence of CNA demonstration of competency in skills post hire or at any other time during employment of any CNA currently on staff. When asked how she ensures CNA competency before a CNA is allowed to work independently, she stated that they (facility) will put another CNA working with the new employee to train. She stated that she gets verbal reports from the trainer, and that at times she makes observations of a new employee ' s work performance. However, she could not provide documented evidence of the facility ' s method of verification of CNA demonstration of competency, or documentation of the facility ' s evaluation of CNA staff demonstration of performance/competency upon hire or at any other time of employment. Review of 5 employee records (S1 CNA, S13 CNA, S14 CNA, S15,CNA, S16 CNA), including S1, CNA who was caring for Resident #3 at the time of the incident, did not reveal evidence of demonstration of competency skills prior to working independently upon completion of orientation or at any other time during their employment with the nursing facility. An interview was conducted with S2, DON (Director of Nurses) on 5-16-12 at 2:47 p.m. When questioned about how the facility ensures the competency of the CNAs (Certified Nursing Assistants) and special monitoring/evaluative tools to document demonstration of competency of skills, she stated that she was not aware of documented evidence of CNA demonstration of competency of skills. When further questioned about how the facility monitors for CNA competency, she stated that S3, LPN monitors the CNAs and new hires for training. She further stated that S3, LPN was a charge nurse, CNA supervisor, and the monitor of CNA training. An interview was conducted with S4, Administrator on 5-16-12 at 3:45 p.m. He stated that the facility did not have documented evidence of return demonstration of skill competency for the CNAs. He verified that the facility could not provide a policy for CNA competence or evidence of CNA performance competency reviews completed by the facility. Review of the facility ' s nurse aide in-service training and orientation program revealed that the nurse aides were given in-service training on a variety of subjects with their signatures present on the paperwork. It was further noted that none of the paperwork contained any type of return demonstration information. Also, review of the nurse aide orientation program revealed no reference of the aides having had to participate in any type of return demonstration An interview was conducted with S1, CNA on 5-18-12 at 12:00 p.m. She stated that on 5-13-12, the day that Resident #3 fell and sustained injury, she had entered the resident ' s room and observed that the resident was full of feces. The CNA stated that Resident #3 had bolsters in place on her bed. She further stated that she had worked at the facility for approximately one month and did not know the history of the resident or why the bolsters were on the resident ' s bed. S1, CNA then stated that she had not been trained on how to apply or remove the bolsters and that it was the first time she had ever worked with bolsters. S1, CNA stated that as she prepared to clean the resident, she removed the bolsters from the bed and turned the resident on her side and toward herself. She further stated that as she turned her, the resident ' s upper body began falling from the top of the bed and that she wasn ' t able to stop the resident from falling to the floor. S1, CNA confirmed that she was the only staff member present in Resident #3 ' s room at the time of the incident. She also stated that Resident #3 required only one staff member to provide her care. S1, CNA then stated that she was trained on the use of bolsters after the incident occurred.

Based on record review and staff interview the facility failed to ensure that services were provided by qualified persons in accordance with each resident 's written plan of care by failing to follow the plan of care to for the use of bolsters while in bed for 1 (#3) of 3 sampled residents care planned for bolsters (#1, #2, #3) out of a total of 18 residents currently using bolsters (Resident # 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21). Resident #3 was care planned on 12/27/11 for at risk for falls with an approach of Bilateral bolsters while in bed. Resident #3 was in immediate jeopardy on 5/13/12 at 10:30 a.m. when S1, CNA, (Certified Nursing Assistant), without appropriate training, knowledge of the resident ' s care needs, or adequate nursing supervision, removed the bilateral bolsters from the resident ' s bed, performed a bed bath which included bed mobility with 1 person physical assistance instead of 2 person physical assistance as identified on the resident ' s MDS (Minimum Data Set) assessments. The resident fell out of bed onto the floor when turned to her side during the bed bath. Resident #3 sustained lacerations to her forehead and a C2 (Cervical) fracture as a result of the fall from the bed during the bed bath. Resident #3 was transferred to the hospital on [DATE] at 10:58 a.m., following the incident which occurred on 5/13/12 at 10:30 a.m. with a [DIAGNOSES REDACTED].. The Immediate Jeopardy for Resident #3 ended at the time of transfer to the hospital on [DATE] at 10:58 a.m. This deficient practice had the potential to affect 18 other residents in the nursing facility currently using bolsters on their beds. The immediate jeopardy continued for all 18 other residents (Resident # ' s 1, 2, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21) identified by the facility as using bolsters while in bed. Resident # 3 was in immediate jeopardy when she returned to the facility on [DATE] at 9:30 p.m., and the facility had not trained the CNA staff on the proper use of bolsters. The immediate jeopardy ended for resident # 3 when she was sent to the hospital on [DATE] at 10:16 a.m. for an unrelated medical condition. The immediate jeopardy situation continued for the 18 other resident currently identified by the facility as using bolsters in bed. Immediate Jeopardy was called on 5/17/12 at 3:55 p.m. due to the facility failing to accurately train staff regarding the use of bolsters at all times while resident is in bed. The Immediate Jeopardy for Resident # 3 was removed when Resident # 3 returned to the hospital on [DATE] at 10:16 a.m. However, the Immediate Jeopardy continued for the 18 other residents identified by the nursing facility currently using bolsters in bed at the time of the call due to the nursing facility having failed to accurately train staff regarding the use of bolsters and the identified times that bolsters are to be in place. The Immediate Jeopardy was removed 5/18/12 at 10:30 a.m. S4, Administrator presented a plan of removal for the other 18 residents to address all residents in the facility with bolsters. This plan of removal for the other 18 residents dated 5/17/12 included additional in-service held regarding the proper use of bed bolsters; that bed bolsters are to be used at all times while the resident is in the bed per physician's order [REDACTED]. While the immediate jeopardy was removed on 5/18/12, the facility remained out of compliance at Level 3 for Resident #3, and Level 2 for the other 18 residents currently using bolsters. Findings: Resident #3 ' s current [DIAGNOSES REDACTED].Gastrostomy, Depend-Supplement Oxygen, [MEDICAL CONDITION] Reflux, other Psoriasis. Resident #3 ' s record revealed that she had a history (12/20/11 H&P-History & Physical) of [MEDICAL CONDITION], dysphagia, and [MEDICAL CONDITION]. This H&P also indicated that Resident #3 was severely demented. Review of two of Resident #3 ' s MDS assessments with reference dates of 3/25/12 and 4/1/2012, both reflected that Resident #3 was assessed by the nursing facility as: 1. Bed Mobility - 3/3 for bed mobility which included how the resident ...turns side to side, and positions body while in bed ...; meaning she required extensive assistance/2+ person physical assistance.(Resident involved in activity, staff provide weight-bearing support, with two + person physical assistance). 2. Bathing was identified on the 3/25/12 MDS assessment as 3/2; describing how the resident takes a ...sponge bath .... Meaning extensive assistance - resident involved in activity, staff provide weight-bearing support/1person physical assistance. Review of Resident #3 ' s plan of care reflected that the facility care planned the resident at risk for falls as of 12/27/11 with updates to goals and approaches up to 6/29/12. The approaches for 6/29/12 on the care plan included Bilateral bolsters while in bed; Place resident on fall-prevention program High risk for falls, resident on falling star program, star placed on pink sheet on bulletin board; Give resident verbal reminders not to ambulate or transfer without assistance. Review of the nurse ' s notes for Resident #3 dated 5/13/12 reflected documentation by S7,LPN of an incident in which Resident #3 fell out of the bed during a bed bath on 5/13/12 at 10:30 am. S7, LPN documented in the note that she was outside the resident ' s door when S1, CNA yelled for her to come in the room. S7, LPN wrote that she rushed in the room to find Resident #3 lying on her left side with the left side of her " forehead planted on the floor , in a large puddle of blood ... ...two lacerations over her left eyebrow, resident was conscious. " Review of the facility incident and accident report reflected that on 5/13/12 at 10:30 a.m., Resident #3 fell from the bed onto the floor when S1, CNA turned the resident towards her during a bed bath. The report reflected that S1, CNA explained to S7, LPN that she was administering a bed bath to Resident #3, she turned Resident #3 towards her, at the side she was standing, Resident #3 rolled to the end of the mattress, and she noted that Resident #3 was falling. S1, CNA reported that she tried to stop the fall, but Resident #3 fell to the floor. The report reflected that Resident #3 had 2 lacerations above her left eye with blood pouring out of each one. The report reflected that Resident #3 left the facility per ambulance on 5/13/12 at 10:58 a.m. Review of hospital records revealed that the resident presented to 2 hospitals on 5/13/12. The first hospital conducted a CT (Computerized Tomography) Scan on 5/13/12 at 12:09 p.m. The impression noted on the CT scan reflected: " 1. THERE IS A C2 FRACTURE WITH MILD DISPLACEMENT, AS DESCRIBED. NO FRACTURE ELSEWHERE. 2. RELATIVELY MILD [MEDICAL CONDITION] CHANGES OF THE CERVICAL SPINE. 3. OSTEOPENIA/[MEDICAL CONDITION] AND [MEDICAL CONDITION] DISEASE. " Hospital records reflect that Resident #3 was examined at the second hospital on [DATE] at 1700 hours. The physician noted that he/she was called by physician from hospital #1 to see Resident #3 for a neck fracture. The physician noted that the resident had a Stable C2 ant. (Anterior) Column fx (fracture) with a recommendation for a Philadelphia Collar x 6 weeks - can be removed for hygiene, and follow up with this physician in 6 weeks. Review of the nurse ' s notes reflected that Resident #3 returned to the nursing facility on 5/13/12 at 9:30 p.m. Additional approaches were added to the plan of care, after the incident, on 5/13/12 and 5/14/12. The 5/13/12 approach included a statement, " 5/13/12 @ 10:30 a.m ..... Res (Resident) fell from bed onto floor, Noted lying on (L) side, 2 lacerations to (L) eye, bathing res (resident) and when she turned res (resident) she rolled to end of mattress. Cervical fx-C2. " The added approach dated 5/13/12 included - send to ER (emergency room ), neuro (neurological) checks every1hour. The additional approaches added on 5/14/12 included " 2 person assistance (with) bed mobility, transfers, & bathing. Bilateral bolsters to remain in place during bed baths, in-service on bed baths and bed mobility. " During an interview on 5/17/12 at 9:39 a.m. with S8, LPN, CCC, (Clinical Care Coordinator), she stated that she did the MDS and Care Plan for Resident #3. The resident ' s MDS assessments for 3/25/12 and 4/1/12, and the resident ' s care plan were reviewed with S8LPN, CCC. She confirmed that the care plan addressed that the resident was to have bilateral bolsters while in bed. She confirmed that the resident was on the falling star program which included having " pink sheet " on the resident ' s bulletin board that gives the CNAs the information that is needed to care for the resident. During observation and review of Resident #3 ' s pink sheet with S8, LPN, CCC, she confirmed that the resident had 2 pink sheets on her bulletin board; one prior to the incident and one after the incident. S8, LPN, CCC dated the top of each sheet at the time of the interview/observation to reflect the dates that the 2 pink sheets were updated by her. The first sheet had an update date of 1/14/12 which included (with other measures) to Turn/Reposition every 2 hours as needed right to left keep off back, high risk for falls, maintain use of bolsters when in bed. She confirmed that the second pink sheet was updated on 5/14/12 after the incident to include: leave C-Collar in place except for bathing, 2 person assistance with bed mobility transfers, and bathing, and bilateral bolsters to remain in place during bath. Both sheets were on the resident ' s bulletin board on 5/17/12. She stated that the interventions listed on the 2 pink sheets should also be on the resident ' s care plan. An interview was conducted with S1, CNA on 5-18-12 at 12:00 p.m. She stated that on 5-13-12, the day that Resident #3 fell and sustained injury, she had entered the resident ' s room and observed that the resident was full of feces. The CNA stated that Resident #3 had bolsters in place on her bed. She further stated that she had worked at the facility for approximately one month and did not know the history of the resident or why the bolsters were on the resident ' s bed. S1, CNA then stated that she had not been trained on how to apply or remove the bolsters and that it was the first time she had ever worked with bolsters. S1, CNA stated that as she prepared to clean the resident, she removed the bolsters from the bed and turned the resident on her side and toward herself. She further stated that as she turned her, the resident ' s upper body began falling from the top of the bed and that she wasn ' t able to stop the resident from falling to the floor. S1, CNA confirmed that she was the only staff member present in Resident #3 ' s room at the time of the incident. She also stated that Resident #3 required only one staff member to provide her care. S1, CNA then stated that she was trained on the use of bolsters after the incident occurred. During an interview with S2, DON on 5/18/12 at 2:25 p.m., she stated she did not know there was a problem with the CNAs doing care by themselves or that bolsters were being removed during care. During an interview with S4, Administrator on 5/18/12 at 2:30 p.m., he stated that he did not know that there was a problem with the CNAs working alone when a resident is assessed for 2 + person assistance. He also stated that he did not know that the bolsters were being removed when they were supposed to stay in place.