Every finding on record at Oak Haven Rehabilitation and Healthcare Center

Based on observation, interview and record review, The facility failed to ensure a cognitively impaired resident (#61) who was identified as being at high risk for elopement, wandering and exhibited exit seeking behaviors did not exit the building without supervision; and failed to ensure the resident's (#61) environment remained as free of accident hazards as possible for 1 (#61) of 5 sampled residents reviewed for elopement risk. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the building unsupervised. Resident #61 was found by S6CNA standing on the side of a busy two-lane highway that runs in front of the facility, with a posted speed limit of 55 miles per hour. Facility administration were made aware of a door wanderguard system malfunction since 02/13/2026 and did not implement appropriate interventions to prevent elopement. This deficient practice continued at a potential for more than minimal harm for the 5 residents in the facility who were identified to require supervision, were assessed as being at risk for elopement, and wore a wanderguard bracelet. S1Admin was notified of the immediate jeopardy on 04/15/2026 at 3:58 p.m. The Immediate Jeopardy was removed on 04/16/2026 at 5:47 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews, and observations that the Plan of Removal have been initiated and/or implemented. Findings:On 04/15/2026, review of the facility's policy titled Elopements and Wandering Residents with a revision date of 09/01/2024 read in part. This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.Definitions: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so.Policy Explanation and Compliance Guidelines:1. The facility is equipped with door locks/alarms to help avoid elopements. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement and unsafe wandering, including identification and assessment of risk.4. Monitoring and managing residents at risk for elopement and unsafe wandering include:c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.d. Adequate supervision will be provided to help prevent accidents or elopements. On 04/15/2026 review of the facility's undated policy titled Resident Alarms read in part.It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines:1. The use of alarms does not eliminate the need for adequate supervision of the resident. Types of alarms include:e. Wander/elopement alarms-includes the devices such as bracelets, pins/buttons worn on the residents clothing, or building/unit exit sensors worn/ attached to the resident that alert staff when the resident nears or exits an area or building.6. Monitoring and modification:a. Supervision shall be provided to the resident in accordance with the resident's plan of care. Review of Resident #61's medical record revealed an admission date of 09/17/2025, with diagnoses that included, in part. Dementia in other Diseases, Mild, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; Mild Neurocognitive Disorder due to Known Physiological Condition with Behavioral Disturbance; Cognitive Communication Deficit; Major Depressive Disorder; Anxiety Disorder; and Type Two Diabetes Mellitus with Hyperglycemia. Review of a Quarterly MDS with an ARD of 03/18/2026, revealed Resident #61 had a BIMS score of 3, indicating severe cognitive impairment. Resident #61 was ambulatory without the use of assistive devices and required supervision or touching assistance from staff during transfers and ambulation. Resident #61 utilized a wanderguard/elopement alarm on a daily basis. Review of Resident #61's Care Plan initiated on 10/20/2025 read in part.Resident #61 was an elopement risk/wanderer related to attempts to leave the facility unattended. Interventions in place prior to the elopement included: wander alert bracelet placed on resident's right ankle, staff verification/skin inspection at band location, and confirmation of signal operation. On 04/14/2026 at 1:15 p.m., interview with S5CNA revealed Resident #61 was known to exhibit exit-seeking behaviors, including verbalizing a desire to go home and attempting to leave the facility. S5CNA reported that Resident #61 had recently been found outside of the facility by S6CNA. On 04/14/2026 at 1:25 p.m., an interview with Resident #61's Responsible Party revealed Resident #61 frequently verbalized a desire to return home, had attempted to leave the facility on multiple occasions, and wears a wanderguard. The Responsible Party stated he was notified of a recent incident, though unable to recall the exact date, in which Resident #61 was found outside in the parking lot and was subsequently escorted back into the facility. On 04/14/2026 at 2:07 p.m., interview with S6CNA revealed on 03/26/2026, at approximately 7:30 p.m., she observed Resident #61 standing next to the road, outside of the facility, without staff supervision. S6CNA reported she notified S8CNA, and both staff members attempted to redirect the resident back into the facility. S6CNA stated Resident #61 was agitated and not easily redirected. S6CNA further reported that S8CNA entered the facility to obtain additional assistance from S9CNA. On 04/14/2026 at 2:13 p.m., interview with S3CNA revealed on 03/26/2026, between 7:00 p.m. and 7:30 p.m., Resident #61 was observed standing near exit door A. S3CNA stated at the time, she believed Resident #61 was a family member and did not recognize him as a resident. S3CNA reported she asked Resident #61 if he needed to exit the facility, to which he responded yes. S3CNA then entered the door code and allowed Resident #61 to exit the facility. S3CNA confirmed she did not accompany Resident #61 outside, as she believed he was a visitor. S3CNA reported that she was unaware Resident #61 wore a wanderguard and that no alarm sounded when Resident #61 exited the building. On 04/14/2026 at 2:25 p.m., interview with S8CNA revealed on 03/26/2026, between 7:00 p.m. and 7:30 p.m., S6CNA notified her that Resident #61 was standing next to the highway, outside of the facility. S8CNA stated that upon observing Resident #61, he was standing next to the road with his thumb raised, appearing to attempt to obtain a ride. S8CNA reported that Resident #61 appeared agitated and initially resisted returning to the facility. S8CNA stated that she and S6CNA obtained assistance from S9CNA to safely return Resident #61 to the facility. On 04/14/2026 at 2:59 p.m., interview with S2DON confirmed that on the evening of 03/26/2026 Resident #61 had been let out of the facility by a staff member. S2DON reported that S7LPN notified her that Resident #61 had exited the facility and walked toward the roadway. On 4/14/2026 at 4:40 p.m., interview with S9CNA revealed he was notified by S8CNA that Resident #61 was walking along the road, outside of the facility, appeared agitated, and was not allowing S6CNA or S8CNA to escort him back into the facility. S9CNA stated that upon arrival outside, Resident #61 was observed standing next to the roadway. S9CNA stated that staff were able to safely redirect Resident #61 back into the facility. S9CNA stated that when Resident #61 re-entered the building through exit door B, the alarm did not activate, indicating the wanderguard system was not functioning properly. On 4/14/2026 at 5:19 p.m., observations were conducted of the facility's wanderguard system. Observation revealed multiple exits, including Exit Door A, Exit Door B, and Exit Door C, failed to alarm and did not remain locked when residents wearing wanderguard devices were in close proximity to the doors and staff entered the door code. On 04/14/2026 at 6:05 p.m., interview with S7LPN revealed she was working the evening shift on 03/26/2026, when Resident #61 was found outside of the facility. S7LPN stated that she last observed Resident #61 at approximately 7:29 p.m. in the day room, at which time S7LPN checked Resident #61's blood glucose. S7LPN reported she was notified by S8CNA that Resident #61 had been found in the parking lot, but was unsure of the exact time. S7LPN stated that she was informed S3CNA entered the door code and allowed Resident #61 to exit the building. S7LPN confirmed that Resident #61 is identified as an elopement risk and wears a wanderguard bracelet. S7LPN reported that she contacted S2DON at approximately 7:55 p.m. on 03/26/2026, to inform her that Resident #61 had been found outside in the parking lot. On 04/15/2026 at 9:08 a.m., interview with Resident #61 revealed he was able to recall the evening he exited the facility. Resident #61 reported that it was beginning to get dark outside. Resident #61 stated he exited the facility and began walking along the roadside. Resident #61 confirmed he was outside alone and that no staff members were present with him. Resident #61 reported as he continued walking down the road, three staff members, identified as two females and one male, approached him. Resident #61 acknowledged that he became agitated and resisted staff, stating he wanted to go to town. At the time of interview, Resident #61 was noted to be wearing a wanderguard bracelet. On 4/15/2026 at 9:55 a.m., interview with S11LPN/CNASup stated she was informed by S3CNA that she entered the door code and allowed Resident #61 to exit the facility, believing Resident #61 was a visitor. S11LPN/CNAsup reported S3CNA worked on Resident #61's hall three days prior to the incident and should have been able to identify Resident #61. S11LPN/CNAsup reported CNAs are expected to familiarize themselves with the residents and their care needs on assigned halls prior to working the shift. On 04/16/2026 at 3:33 p.m., Interview with S1Admin and S4RNC revealed that properly functioning entrance/exit doors should remain locked and trigger an alarm when a wanderguard device is in close proximity, even when a staff member enters the door code. S1Admin confirmed the facility's security system was evaluated on 02/13/2026, by an outside contractor, at which time deficiencies were identified that required replacement of the wanderguard system. S1Admin confirmed that no additional supervision measures were put in place to prevent elopements after being made aware of a needed system replacement, as staff relied on the doors remaining locked. The Facility's plan of removal included:1. Review of the elopement and wandering policy reviewed by administrator, DON, and RNC with no identified changes needed on 04/14/2026.2. All residents identified as being an elopement risk had a care plan review completed by DON and MDS nurse to ensure wandering and elopement risk are identified and interventions and supervision needs are in place on 4/14/26.3. All current residents will have updated elopement risk assessments completed.4. The MDS nurse reviewed section E of the MDS for all residents on 4/14/26. Care plans were reviewed and updated to ensure they reflect audit findings. No concerns were identified.5. The DON and MDS nurse re-evaluated residents at risk for wandering/elopement using an elopement risk assessment tool on 4/14/26. No changes in status noted.6. Effective 4/15/26, a staff member was specifically placed at each wanderguard equipped exit door that was identified as not properly functioning with an alarm system and this direct supervision will remain in place until the door alarm system is fully repaired and verified as operational. These staff members are responsible for verifying all persons exiting the facility and intervening immediately if a resident attempts to leave unsupervised. A door watch observation log will be maintained and visual aids will be provided to door monitors on residents identified for elopement risk.7. Wanderguards and door systems were tested and verified by Maintenance Supervisor on 4/14/26 and it was identified that the door locking mechanism was functioning properly, however the audible wanderguard alarm chime was intermittently not functioning properly. The wander guard system will be discontinued to promote individualized resident centered care. Policies related to wanderguard systems revised to reflect system changes of the facility, effective 4/16/26. 8. Elopement Risk Identification Binders, which includes visual identification, will be utilized for identify residents who are at risk to elope. Only staff who are successfully trained on elopement will have the door codes.9. In-service education initiated for all staff on 4/14/26 by DON regarding wandering, elopement, elopement drill protocol, identifying residents at risk for elopement and resident safety. New hires will be included in this training during orientation process. Any staff on leave will receive in-service education and understanding verified by DON or Administrator prior to start of next shift. Posttest required to be completed with 100% pass rate to ensure retention of information. Elopement prevention and identifying residents at risk for elopement is included in all staff new hire orientation and training.10. Effective 4/16/26, the DON or designee will audit new admissions, quarterly assessments and significant change assessments for elopement risk and ensure appropriate interventions are in place.11. Effective 4/16/26, the DON or designee will audit completed MDS's to ensure the care plan reflects needs/concerns identified in the CAA's.12. Effective 4/15/26, an Elopement Quality Assurance Performance Improvement plan was implemented by DON to review and interpret all audit findings. All findings will be discussed at the weekly QAPI meeting for a minimum of three months or until the pattern of compliance is maintained.13. Effective 4/15/26, a posttest focused on monitoring staff comprehension about elopement prevention and identifying residents at risks for elopement will be utilized to ensure staff comprehension and compliance. This will be done on 3 random staff 3 times a week. 14. Regional Nurse Consultant will monitor Administrator and DON weekly x3 month to ensure an effective system of adequate supervision and monitoring of residents at risk for elopement is maintained by all staff to prevent future elopements. 15. Effective 4/16/26, Maintenance will check the door locking mechanism daily x 3 weeks then continue weekly.16. RN supervisor or charge nurse will assess all new admissions for elopement risks after business hours.The facility asserts the Likelihood for serious harm to any recipient no longer exists 4/16/26.

Based on observation and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#61) of 5 sampled residents reviewed for elopement. The facility failed to ensure staff were knowledgeable and able to identify residents at risk for elopement. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the building unsupervised. Resident #61 was found by S6CNA standing on the side of a busy two-lane highway that runs in front of the facility, with a posted speed limit of 55 miles per hour. Facility administration were made aware of a door wanderguard system malfunction since 02/13/2026 and did not implement appropriate interventions to prevent elopement. This deficient practice continued at a potential for more than minimal harm for the 5 residents in the facility who were identified to require supervision, were assessed as being at risk for elopement, and wore a wanderguard bracelet. S1Admin was notified of the immediate jeopardy on 04/15/2026 at 5:16 p.m. The Immediate Jeopardy was removed on 04/16/2026 at 5:47 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented. Findings:On 04/14/2026, review of an undated facility policy titled Training Requirements read in part.It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Policy Explanation and Compliance Guidelines:4. All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program.6. Training content includes, at a minimum:g. Dementia management and care of the cognitively impaired Review of a Quarterly MDS with an ARD of 03/18/2026, revealed Resident #61 had a BIMS score of 3, indicating severe cognitive impairment. Resident #61 was ambulatory without the use of assistive devices and required supervision or touching assistance from staff during transfers and ambulation. Resident #61 utilized a wanderguard/elopement alarm on a daily basis. Review of Resident #61's Care Plan initiated on 10/20/2025 read in part.Resident #61 was an elopement risk/wanderer related to attempts to leave the facility unattended. Interventions in place prior to the elopement included: wander alert bracelet placed on resident's right ankle, staff verification/skin inspection at band location, and confirmation of signal operation. On 04/14/2026 at 2:07 p.m., an interview with S6CNA revealed that on 03/26/2026, at approximately 7:30 p.m., while taking trash to the dumpster, S6CNA observed Resident #61 standing next to the roadway outside of the facility without staff supervision. S6CNA stated she did not recognize Resident #61 as a resident but didn't feel right about it, and subsequently notified S8CNA. S6CNA reported she and S8CNA attempted to redirect the resident back into the facility; however, Resident #61 was agitated and not easily redirected. S6CNA further reported that S8CNA re-entered the facility to obtain additional assistance from S9CNA. S6CNA stated she was unsure how to determine if a resident was at high risk for elopement. On 04/14/2026 at 2:13 p.m., interview with S3CNA revealed Resident #61 was observed standing near Exit Door A. S3CNA stated that at the time, she believed Resident #61 was a family member and did not recognize him as a resident. S3CNA confirmed she had previously observed Resident #61 in the facility sitting in common areas; however, S3CNA believed Resident #61 was a visitor rather than a resident. S3CNA reported she asked Resident #61 if he needed to exit the facility, to which he responded yes. S3CNA then entered the door code and allowed Resident #61 to exit the facility. S3CNA stated the alarm did not sound when Resident #61 exited the building. S3CNA reported that she was unaware Resident #61 wore a wanderguard bracelet and stated she was unsure how to determine if a resident was at high risk for elopement. On 4/14/2026 at 2:59 p.m., interview with S2DON revealed that staff receive education on elopement upon hire as well as during monthly in-services. S2DON stated staff should be aware of the red binder located at the front desk, which contains identifying information and photographs of residents who were high risk for elopement but were not. On 4/14/2026 at 4:40 p.m., interview with S9CNA revealed he was notified by S8CNA that Resident #61 was walking along the road, outside of the facility, appeared agitated, and was not allowing S6CNA or S8CNA to escort him back into the facility. S9CNA stated that upon arrival outside, Resident #61 was observed standing next to the roadway. S9CNA stated that staff were able to safely redirect Resident #61 back into the facility. S9CNA stated he was unsure how to determine if a resident was at high risk for elopement. On 04/14/2026 at 6:05 p.m., interview with S7LPN revealed she was working the evening shift on 03/26/2026, when Resident #61 was found outside of the facility. S7LPN stated that she was informed S3CNA entered the door code and allowed Resident #61 to exit the building, believing Resident #61 was a visitor. S7LPN confirmed that Resident #61 was identified as an elopement risk and wore a wanderguard bracelet. S7LPN stated she was unsure how to identify residents on other halls that were determined to be high risk for elopement. On 4/15/2026 at 9:55 a.m., interview with S11LPN/CNAsup revealed S3CNA told her that she entered the door code and allowed Resident #61 to exit the facility, believing Resident #61 was a visitor. S11LPN/CNAsup reported S3CNA had worked on Resident #61's hall three days prior to the incident and should have been familiar with the resident. On 04/15/2026 at 1:25 p.m., interview with S14CNA revealed she had been employed at the facility for six months. S12 CNA stated she was unsure how to identify residents in the facility that were at high risk for elopement. 04/15/2026 at 2:23 p.m., S1Admin acknowledged that staff members were unable to identify residents throughout the facility who were at high risk for elopement, but should have been. S1Admin confirmed that additional staff training was needed and acknowledged their training had not been effective. The Facility's plan of removal included:1. On 3/26/26, affected resident was returned to the facility and assessed by nurse to ensure no harm was noted as well as checking placement and functionality of wander guard.2. Administrator, DON and RNC reviewed elopement and wandering resident's policy with no identified changes needed on 4/14/263. All residents identified as being an elopement risk had care plan review completed by DON and MDS nurse to ensure wandering and elopement risk are identified and interventions and supervision needs are in place on 4/14/26.4. All current residents will have updated elopement risk assessments completed on 4/16/26.5. The MDS nurse reviewed section E of the MDS for all residents on 4/14/26. Care plans were reviewed and updated to ensure they reflect audit findings. No concerns were identified.6. The DON and MDS nurse re-evaluated residents at risk for wandering/elopement using an elopement risk assessment tool on 4/14/26. No changes in status noted.7. Effective 4/15/26, staff member was specifically placed at each wander guard equipped exit door that was identified as not properly functioning with an alarm system and this direct supervision will remain in place until the door alarm system is fully repaired and verified as operational. These staff members are responsible for verifying all persons exiting the facility and intervening immediately if a resident attempts to leave unsupervised. Effective 4/15/26, a door watch observation log and visual aides of residents at risk to elope will be provided to door monitors8. Wanderguards and door systems were tested and verified by Maintenance Supervisor on 4/14/26 and it was identified that the door locking mechanism was functioning properly, however the audible wander guard alarm chime was intermittently not functioning properly. Final root cause analysis identified that the facility has maintained a functioning secured door system in place at all times. The wander guard system will be discontinued to promote individualized resident centered care. Policies related to wanderguard systems revised to reflect system changes of the facility, effective 4/16/26. Elopement Risk Identification Binders, which includes visual identification, will be utilized for identify residents who are at risk to elope. Only staff who are successfully trained on elopement will have the door codes.9. Regional Nurse Consultant in-serviced Administrator and Director of Nursing on 4/15/26 regarding administering the facility in a manner that enables it to use its resources effectively including having an effective system in place to ensure residents at high risk for elopements are adequately supervised, ensuring staff are trained to identify all residents who are at risk for elopement, and responding appropriately to identification of malfunctioning equipment.10. All staff in-service education initiated on 4/14/26 by DON regarding wandering, elopement, elopement drill protocol, identifying residents at risk for elopement and resident safety. Any staff on leave will receive in-service education and understanding verified through post testing by DON or Administrator prior to start of next shift. Door staff competence has been completed. 11. Elopement Prevention and identifying residents is included in new hire orientation and training for all staff.12. Effective 4/16/26, the DON or designee will audit new admissions, quarterly assessments and significant change assessments for elopement risk and ensure appropriate interventions are in place.13. Effective 4/16/26, the DON or designee will audit completed MDS's to ensure the care plan reflects needs/concerns identified in the CAA's.14. Effective 4/15/26 an Elopement Quality Assurance Performance Improvement plan was implemented by DON to review and interpret all audit findings. All findings will be discussed at the weekly QAPI meeting for a minimum of three months or until the pattern of compliance is maintained.15. Effective 4/15/26, a post test focused on monitoring staff comprehension about elopement prevention and identifying residents at risks for elopement will be utilized to ensure staff comprehension and compliance. This will be done on 3 random staff 3 times a week. 16. Regional Nurse Consultant will monitor Administrator and DON weekly x3 month to ensure an effective system of adequate supervision and monitoring of residents at risk for elopement is maintained by all staff to prevent future elopements. 17. Effective 4/16/26, Maintenance will check the door locking mechanism daily x 3 weeks then continue weekly.18. All ongoing monitoring will be completed weekly x3 months unless otherwise specified.19. RN supervisor or charge nurse will assess all new admissions for elopement risks after business hours.The facility asserts the Likelihood for serious harm to any recipient no longer exists 4/16/26.

Based on observation, record review, and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (Resident #61) of 5 sampled residents reviewed for elopement. The facility failed to:1. Ensure a cognitively impaired resident (#61) who was identified as being at high risk for elopement, wandering and exhibited exit seeking behaviors did not exit the building without supervision;2. Ensure staff were knowledgeable and able to identify residents at risk for elopement;3. Implement appropriate interventions and/or increase supervision after identifying the wanderguard security system was not functioning properly; and4. Ensure the resident's environment remained as free of accident hazards as possible. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the building unsupervised. Resident #61 was found by S6CNA standing on the side of a busy two-lane highway that runs in front of the facility, with a posted speed limit of 55 miles per hour. Facility administration were made aware of a door wanderguard system malfunction since 02/13/2026 and did not implement appropriate interventions to prevent elopement. This deficient practice continued at a potential for more than minimal harm for the 5 residents in the facility who were identified to require supervision, were assessed as being at risk for elopement, and wore a wanderguard bracelet. S1Admin was notified of the Immediate Jeopardy situation on 04/15/2026 at 3:58 p.m. The Immediate Jeopardy was removed on 04/16/2026 at 5:47 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented. Findings:Cross refer to F689 and F726 On 04/15/2026, review of the facility's policy titled Elopements and Wandering Residents with a revision date of 09/01/2024 read in part. This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.Definitions: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or necessary supervision to do so.Policy Explanation and Compliance Guidelines:1. The facility is equipped with door locks/alarms to help avoid elopements. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement and unsafe wandering, including identification and assessment of risk.4. Monitoring and managing residents at risk for elopement and unsafe wandering include:c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.d. Adequate supervision will be provided to help prevent accidents or elopements. On 04/15/2026 review of the facility's undated policy titled Resident Alarms read in part.It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines:1. The use of alarms does not eliminate the need for adequate supervision of the resident. Types of alarms include:e. Wander/elopement alarms-includes the devices such as bracelets, pins/buttons worn on the residents clothing, or building/unit exit sensors worn/ attached to the resident that alert staff when the resident nears or exits an area or building.6. Monitoring and modification:a. Supervision shall be provided to the resident in accordance with the resident's plan of care.b. When alarms are utilized, additional monitoring shall be provided, included but not limited to:i. Verifying alarms are used in accordance with residents care plan.ii. Verifying alarms are working properly. On 04/14/2026 at 2:13 p.m., interview with S3CNA revealed Resident #61 was observed standing near Exit Door A. S3CNA stated that at the time, she believed Resident #61 was a family member and did not recognize him as a resident. S3CNA confirmed she had previously observed Resident #61 in the facility sitting in common areas; however, S3CNA believed Resident #61 was a visitor rather than a resident. S3CNA reported she asked Resident #61 if he needed to exit the facility, to which he responded yes. S3CNA then entered the door code and allowed Resident #61 to exit the facility. S3CNA stated the alarm did not sound when Resident #61 exited the building. S3CNA reported that she was unaware Resident #61 wore a wanderguard bracelet and stated she was unsure how to determine if a resident was at high risk for elopement. On 4/14/2026 at 4:40 p.m., interview with S9CNA revealed he was notified by S8CNA that Resident #61 was walking along the road, outside of the facility, appeared agitated, and was not allowing S6CNA or S8CNA to escort him back into the facility. S9CNA stated that upon arrival outside, Resident #61 was observed standing next to the roadway. S9CNA stated that staff were able to safely redirect Resident #61 back into the facility. S9CNA stated that when Resident #61 re-entered the building through exit door B, the alarm did not activate, indicating the wanderguard system was not functioning properly. On 4/14/2026 at 5:19 p.m., observation revealed multiple exits, including Exit Door A, Exit Door B, and Exit Door C, failed to alarm and did not remain locked when residents wearing wanderguard devices were in close proximity to the doors and staff entered the door code. On 04/15/2026 at 2:57 p.m., interview with S12Maintenance revealed that in February 2026, he identified a problem with the facility's front door security system and reported his findings to S1Admin. S12Maintenance stated that on 02/13/2026, an outside contractor evaluated the wanderguard system and was unable to repair the issues at that time. S12Maintenance reported the contractor recommended full replacement of the system. S12Maintanance reported that although the issues were initially identified with the front doors, due to frequency interference, the malfunction had the potential to affect multiple doors throughout the facility. S12Maintenance confirmed that a quote for system replacement was obtained and provided to S1Admin. On 04/16/2026 at 3:33 p.m., Interview with S1Admin and S4RNC revealed that properly functioning entrance/exit doors should remain locked and trigger an alarm when a wanderguard device is in close proximity, even when a staff member enters the door code. S1Admin confirmed the facility's security system was evaluated on 02/13/2026, by an outside contractor, at which time deficiencies were identified that required replacement of the wanderguard system. S1Admin confirmed that no in-service training or re-education had been conducted with staff regarding the malfunctioning wanderguard system or on identification and supervision of residents at high risk for elopement at that time. S1Admin confirmed that no additional supervision measures were put in place to prevent elopements, as staff relied on the doors remaining locked. The Facility's plan of removal included:1. On 3/26/26, affected resident was returned to the facility and assessed by nurse to ensure no harm was noted as well as checking placement and functionality of wander guard.2. Administrator, DON and RNC reviewed elopement and wandering resident's policy with no identified changes needed on 4/14/26.3. All residents identified as being an elopement risk had care plan review completed by DON and MDS nurse to ensure wandering and elopement risk are identified and interventions and supervision needs are in place on 4/14/26.4. The MDS nurse reviewed section E of the MDS for all residents on 4/14/26. Care plans were reviewed and updated to ensure they reflect audit findings. No concerns were identified.5. The DON and MDS nurse re-evaluated residents at risk for wandering/elopement using an elopement risk assessment tool on 4/14/26. No changes in status noted.6. Effective 4/15/26, a staff member was specifically placed at each wander guard equipped exit door that was identified as not properly functioning with an alarm system and this direct supervision will remain in place until the door alarm system is fully repaired and verified as operational. These staff members are responsible for verifying all persons exiting the facility and intervening immediately if a resident attempts to leave unsupervised. A door watch observation log will be maintained and visual aids will be provided to door monitors on residents identified for elopement risk.7. Wanderguards and door systems were tested and verified by Maintenance Supervisor on 4/14/26 and it was identified that the door locking mechanism was functioning properly, however the audible wander guard alarm chime was intermittently not functioning properly. Final root cause analysis identified that the facility has maintained a functioning secured door system in place at all times.8. The wanderguard system will be discontinued to promote individualized resident centered care. Policies related to wanderguard systems revised to reflect system changes of the facility, effective 4/16/26. 9. Elopement Risk Identification Binders, which includes visual identification, will be utilized for identify residents who are at risk to elope. Only staff who are successfully trained on elopement will have the door codes.10. Regional Nurse Consultant in-serviced Administrator and Director of Nursing on 4/15/26 regarding administering the facility in a manner that enables it to use its resources effectively including having an effective system in place to ensure residents at high risk for elopements are adequately supervised, ensuring staff are trained to identify all residents who are at risk for elopement, and responding appropriately to identification of malfunctioning equipment. 11. All staff in-service education initiated on 4/14/26 by DON regarding wandering, elopement, elopement drill protocol, identifying residents at risk for elopement and resident safety. Any staff on leave will receive in-service education and understanding verified through post testing by DON or Administrator prior to start of next shift.12. Door staff competence has been completed. 13. Elopement Prevention and identifying residents is included in new hire orientation and training for all staff.

Based on observation and interview, the facility failed to post nurse staffing information on a daily basis that included in part the total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 93.Findings:Observation on 04/13/2026 at 7:30 a.m. revealed a Staffing Reporting Form dated 04/10/2026 on display at the front desk. There was no updated Actual Hours Worked for the date at the top of the form, nor another form dated today's date.Observation on 04/14/2026 at 9:45 a.m. revealed a Staffing Reporting Form dated 04/14/2026. There was no posted form with actual hours worked from the previous day (04/13/2026). There was also no binder available at the front desk with the previous forms available.Interview on 04/15/2026 at 11:10 a.m. with S1Admin and S2DON confirmed that they were unaware that Actual Hours Worked on the Staffing Reporting Form were required to be updated and posted or kept where the public could access the forms.Interview on 04/15/2026 at 11:30 a.m. with S15 AdminAsst confirmed that she was unaware that the updated Staffing Forms were required to be posted. Therefore, the previous days' forms had not been posted.

Based on observations and interviews, the facility failed to ensure pureed foods were prepared using methods that preserved its nutritional value. The facility failed to follow a recipe regarding portion size and ingredients while preparing pureed food, thereby compromising the nutritional adequacy of the meal for all 12 residents on a puree diet. Total facility census was 93. Findings:Review of facility policy titled Puree Food Preparation revised 2025, revealed in part. It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. 6. Resident receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per policy and procedure. Observation of S12 Dietary [NAME] on 04/13/2026 at 5:38 a.m. revealed the following:1. There was no recipe being followed to prepare pureed ham. S12 Dietary Cook, stated I judge the amount of ham to use.2. S12 Dietary [NAME] used a glass to pour chicken broth on the pureed ham. S12 Dietary Cook, stated I was told to just pour the chicken broth in until the ham starts to thicken up, then hold a spatula in it to see if it was the right consistency.3. S12 Dietary [NAME] poured two boxes of egg mixture in a pan, and put it in the oven. When asked if she had to measure how much egg mixture to use, S12 Dietary [NAME] stated, I have been doing this long enough to know, I don't need to measure. Interview at the time of observation with S12 Dietary [NAME] confirmed she did not follow an approved recipe to prepare pureed ham or eggs, but should have. Observation of S13 Dietary Manager on 04/13/2026 at 6:25 a.m. revealed the following:1. There was no recipe being followed to prepare pureed bread and no measuring utensils were utilized during this observation. 2. S13 Dietary Manager removed an unmeasured amount of bread from the package and placed it in the blender. S13 Dietary Manager added an unmeasured amount of sugar from a bowl and put it into the blender with the bread, then poured an unmeasured amount of milk from a jug and put into the blender with the bread and sugar; S13 Dietary Manager also added vanilla to the bread in the blender, by pouring it in the cap. Interview at the time of observation with S13 Dietary Manager confirmed she did not follow an approved recipe to prepare pureed bread, but should have. Interview on 04/13/26 at 9:12 a.m. with S1 Administrator confirmed S12 Dietary [NAME] and S13 Dietary Manager should have followed an approved recipe to prepare pureed foods.

Based on observation and interview the facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. Total facility census was 93. Findings:Observation on 04/13/2026 at 5:10 a.m. accompanied by S13 Dietary Manager revealed:1. A box of biscuits open to air in the freezer.2. A box of steak fingers open to air in the freezer. Interview at the time of observation with S13 Dietary Manager confirmed the above listed items were open to air, and should not have been.

Based on observations, interviews, and record review, the facility failed to ensure that dietary support personnel were competent to safely and effectively perform the functions of the food and nutrition service. This deficient practice had the potential to affect the 89 residents who were prepared and served meals from the kitchen.During the initial tour of the kitchen on 12/01/2025 at 09:00 a.m., revealed no documentation reflecting dishwasher temperatures and sanitation checks were being performed routinely in the kitchen.In an interview on 12/01/2025 at 10:45 a.m., S6Dietary revealed he had been employed at the facility for about 3 months and is a dietary aide in the kitchen. S6Dietary revealed he was not trained on how to properly wash and sanitize dishes. S6Dietary revealed he did not know how to set up a 3-compartment sink. S6Dietary confirmed he had never checked the dishwasher temperature or sanitizer level when using the dishwasher; therefore, he had never recorded dishwasher temperatures or sanitizer levels.In an interview on 12/01/2025 at 10:50 a.m., S5Dietary revealed she had been employed at the facility for 1 year and had worked as a CNA until approximately two weeks ago, when she started her new role as a cook in the kitchen. S5Dietary revealed she was not trained on how to properly wash and sanitize dishes, including setting up a 3-compartment sink, checking sanitizer in a 3-compartment sink, or checking sanitizer levels in the dishwasher. S5Dietary confirmed she does not check or record sanitizer levels when handwashing or using the dishwasher, but should.On 12/01/2025 at 11:00 a.m., Observation of S4Cook preparing pureed Broccoli revealed S4Cook did not follow any recipe or measurements during the process.In an interview on 12/01/2025 at 12:30 p.m., S4Cook revealed she had been employed at the facility for three to four months and had been cooking at the facility for about two months. S4Cook revealed she was not trained to follow a recipe when preparing pureed food. S4Cook revealed that she was trained to check the temperature of food before serving, but was not educated on the appropriate temperatures for each food.In an interview on 12/02/2025 at 09:45 a.m. S5Dietary revealed she does not follow recipes when pureeing food. S5Dietary revealed she was not trained to follow recipes when preparing puree. S5Dietary revealed that she was not trained to check the temperature of food after cooking or before serving. S5Dietary revealed that she was informed by S3DM yesterday morning, 12/01/2025, upon starting her shift that she needed to check the food temperatures. S3Dietary revealed, prior to yesterday, 12/01/2025, she had never checked the temperatures of the food she prepared before serving food to the residents in the facility.Review of S4Cook, S5Dietary, S6Dietary, personnel files revealed no documentation of training specific to tasks performed by dietary staff to ensure they can safely and effectively carry out the functions of the food and nutrition service.In an interview on 12/01/2025 at 09:30 a.m. S3DM confirmed that food temperatures are not being monitored and recorded per policy, and that they should be. S3DM confirmed that she has a dietary manager should be checking food temperature logs, dishwashing logs, and freezer/cooler logs to ensure they are being completed daily, and she has not been.In an interview on 12/03/2025 at 12:40 p.m., S7Cook revealed she had been employed at facility for two weeks and is a cook in the kitchen. S7Cook further revealed she does not follow a recipe when she prepares pureed food. In an interview on 12/01/2025 at 1:45 p.m., S1Administrator revealed there has been a high turnover rate in the kitchen, and the majority of the dietary staff are new. S1Administrator further revealed that the dietary manager is responsible for training.In an interview on 12/03/2025 at 4:08 p.m., the above findings were discussed with S1Administrator. S1Administrator acknowledged that a lack of training was identified among dietary personnel.

Based on observations and interviews, the facility failed to ensure that pureed food was prepared using methods that preserved its nutritional value. The facility failed to follow a recipe regarding portion size and ingredients while preparing pureed food, thereby compromising the nutritional adequacy of the meal for all 7 residents on a puree diet.Review of facility policy titled Puree Food Preparation revised 09/01/2024, revealed in part. It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. 6. Resident receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per policy and procedure. 7. Puree Food Preparation Guidelines per serving: Vegetables (leaf, stem, or flower): Add 2 tablespoons mashed potato flakes.Review of facility approved recipe: Lemon Broccoli (#36865-P.[NAME] Broccoli Lemon 1/2 Cup) Week 1 revealed in part. 1 serving size was 1/2 cup of broccoli. Recipe yielded 3 1/2 cups of Lemon Broccoli for 7 residents. Instructions: Measure the number of servings using the prepared recipe portion. Drain well to minimize the use of thickener to obtain the appropriate consistency. Place in a blender or food processor. Add liquid, if needed (ex, reserved liquid, broth, milk, gravy, or sauce), to assist with pureeing. Puree with a blender or food processor until smooth. If needed, gradually add thickener. EX. Mashed potato flakes, cream of rice, or commercial thickener.During the return visit to the kitchen on 12/01/2025 at 10:20 a.m., S3 DM stated that the facility had 7 residents on a puree diet.On 12/01/2025 at 11:00 a.m., observation of S4Cook preparing lemon Broccoli puree. Observation revealed the following: S4Cook broke up four pieces of sliced bread in the food processor, then added two scoops of broccoli from an unmeasured metal spoon and placed it in the food processor. S4Cook adds an unmeasured amount of liquid labeled apple juice from a juice pitcher into the food processor and mixes the ingredients. Once mixed, S4Cook attempts to stand her spoon in the food mixture. S4Cook adds two more slices of bread to the puree and mixes. S4Cook adds two unmeasured scoops of broccoli and three slices of bread to the food processor and mixes. S4Cook adds two more unmeasured scoops of broccoli to the processor, along with an unmeasured amount of apple juice, and mixes. S4Cook then added 4 more pieces of sliced bread and mixed. Broccoli puree was then placed on the steam table.In an interview on 12/01/2025 at 12:30 p.m., S4Cook revealed she has been employed at the facility for about 4 months and has been a cook there for about 2 months. S4Cook revealed she was not trained to follow a recipe when preparing pureed food. S4Cook confirmed that she does not follow any recipe when preparing pureed food. In an interview on 12/01/2025 at 12:47 p.m., S3DM stated that dietary staff do not follow recipes when pureeing food and added, It's just common sense. S3DM confirmed that dietary staff do not follow recipes when preparing pureed food, and should.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 89 residents who received meals from the kitchen. The facility failed to ensure:1. Dish washing machine temperature and sanitizer status are monitored and logged daily.2. Coolers and freezer temperatures are monitored and logged daily.3. Food temperatures are recorded daily to ensure food is at the proper temperature before trays are assembled.4. Dietary staff wore hair restraints while preparing food.Review of facility policy titled Dietary Personal Hygiene, revised 09/1/2024, revealed in part. It is the policy of this facility to utilize the following guidelines for employee personal hygiene to prevent contamination of food by food service employees. 4. All dietary staff must wear hair restraints (e.g. hairnet, hat, and or beard restraint) to prevent hair from contacting food.Review of facility policy titled Record of Food Temperatures, revised 09/01/2024, revealed in part. It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature (s) before trays were assembled. 6. Measure and record the temperatures for each food product and milk at all meals. Record the temperature on the daily temperature log.Review of facility policy titled Monitoring of Cooler/Freezer Temperature, revised 09/01/2024, revealed in part. It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. Temperatures will be checked and logged at least twice per by designated personnel.Review of facility policy titled Dishwasher Temperature revised 09/10/2024, revealed in part. It is the policy of this facility to ensure dishes and utensils are clean under sanitary conditions through adequate dishwasher temperatures. 5. Chemical Solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufactures guidelines. Results of concentration shall be recorded. 6. Water temperature shall be measured and recorded prior to each meal/and or after dishwasher has been emptied or refilled for cleaning purposes.1.During the initial tour of the kitchen on 12/01/2025 at 09:00 a.m., a lack of documented logs for the kitchen dishwashing machine and temperature status was identified. In an interview conducted at this time, S3DM confirmed dish washing temperature checks and sanitizer checks are not logged daily in the kitchen, and should be.2.On 12/01/2025 at 09:28 a.m. review of Dietary Daily Temperature log binder for November 2025 with S3DM revealed there was no documentation that cooler or freezer temperature checks were performed as follows:11/21/2025- midafternoon temperatures or dinner temperatures11/22/2025 - dinner temperatures11/23/2025 - opening temperatures, midafternoon temperatures, or dinner temperatures11/24/2025 - opening temperatures, midafternoon temperatures, or dinner temperatures11/25/2025 - opening temperatures, midafternoon temperatures, or dinner temperatures11/26/2025 - opening temperatures, midafternoon temperatures, or dinner temperatures11/27/2025- opening temperatures, midafternoon temperatures, or dinner temperatures11/28/2025- opening temperatures, midafternoon temperatures, or dinner temperatures11/29/2025 - opening temperatures, midafternoon temperatures, or dinner temperatures11/30/2025- opening temperatures, midafternoon temperatures, or dinner temperaturesIn an interview on 12/01/2025 at 09:29 a.m. S3DM confirmed that freezer and cooler temperatures are not being monitored and recorded daily, and should be.3.On 12/01/2025 at 09:30 a.m., review of the Dietary Daily Temperature log for November 2025 with S3DM revealed there was no documentation that food temperature checks were performed as follows:11/10/2025 - dinner11/21/2025- lunch or dinner11/22/2025- lunch or dinner11/23/2025- lunch or dinner11/24/2025- lunch or dinner11/25/2025 - lunch or dinner11/26/2025- lunch or dinner11/27/2025 - Breakfast, lunch, or dinner11/28/2025 - breakfast, lunch, or dinner11/29/2025 - breakfast, lunch, or dinner11/30/2025- breakfast, lunch, or dinnerIn an interview on 12/01/2025 at 09:30 a.m. S3DM confirmed that food temperatures are not being monitored and recorded per policy, and that they should be. 4.An observation on 12/01/2025 at 10:45 a.m. revealed S6Dietary in the kitchen preparing sandwiches. S6Dietary observed with facial hair approximately 1.5 centimeters (cm) long without a proper facial hair covering in place.An observation on 12/01/2025 at 12:23 p.m., revealed S6Dietary handling food without a proper facial hair covering in place.In an interview on 12/01/2025 at 12:23 p.m., S6Dietary revealed he does not wear a facial hair covering when handling, serving, or preparing food. S6Dietary confirmed he was not wearing a facial hair covering, but should have been.In an interview on 12/01/2025 at 12:47 p.m., S3DM confirmed S6Dietary was not wearing a facial hair covering while handling food, and should have been.

Based on observation, interview, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure Resident #4's physician's orders for a dietary supplement was carried out.Review of facility policy titled, Nutritional and Dietary Supplements, revised 09/01/2024, revealed in part. It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and the resident's highest practicable level of well-being. The facility will provide nutritional and dietary supplements to each resident, consistent with the residents' assessed needs.Review of Resident #4's medical record revealed an admission date of 05/31/2022, with diagnoses that included, in part. Unspecified Dementia, Severe, with Agitation, Bipolar Disorder, Major Depressive Disorder, Generalized Muscle Weakness, and Dysphagia.Review of Resident #4's quarterly MDS with ARD of 11/26/2025 revealed in part . Resident #4 had a BIMS of 4, indicating severe cognitive impairment. Review of Resident #4's documented weights from 09/24/2025 to 11/26/2025 revealed the following:11/26/2025 16:00 131.0 lbs (pounds) 11/19/2025 13:41 132.0 Lbs 11/12/2025 11:54 132.6 Lbs 11/6/2025 16:14 132.0 Lbs 10/29/2025 11:44 134.0 Lbs 9/24/2025 14:33 143.0 LbsReview of Resident #4's 12/2025 physician orders revealed in part. 10/31/2025: Ice cream daily with lunch one time a day for weight loss.Review of Resident #4's Care plan with initiation date of 05/31/2022 revealed Resident #4 had a nutritional problem related to mechanical altered diet, depression, GERD, dementia, and bipolar disorder with interventions that included but not limited to. 10/29/2025 Weight Loss Intervention: Add ice cream 4oz daily, 11/12/2025 Continue house supplement/ice cream, Provide and serve my supplements as ordered, and provide, serve my diet as ordered. Monitor intake and record every meal. Resident #4 had an ADL self-care performance deficit related to dementia with interventions that included, in part. EATING: I am totally dependent on (1) staff for eating.In an observation on 12/03/2025 at 12:52 p.m., Resident #4's completed meal try revealed no indications that the resident was served ice cream with her lunch. Observation of Resident #4's dietary card revealed no reflection that Resident #4 is ordered 4oz (ounces) of ice cream at lunch daily. In an interview on 12/03/2025 at 1:00 p.m., S9CNA revealed she assisted/fed Resident #4 lunch that day. S9CNA confirmed the resident was not served ice cream with her lunch and did not receive ice cream at any time during lunch that day.In an interview on 12/03/2025 at 1:02 p.m., S8CNA revealed that she has been employed at the facility for 8 years, is familiar with Resident #4, and often assists Resident #4 with her lunch. S8CNA revealed that the Resident is served ice cream on occasion when the kitchen serves a dessert that does not align with the Resident #4's diet. S8CNA confirmed that Resident #4 is not served ice cream daily with lunch.In an interview on 12/03/2025 at 1:30 p.m., S2DON stated that if a Resident is to receive special dietary foods from the kitchen, it should be reflected on the resident's dietary card. Review of Resident #4's 12/03/2025 lunch dietary card with S2DON at this time. S2DON confirmed that Resident #4's order for 4 ounces of ice cream daily is not reflected on her dietary card and should be. S2DON acknowledged Resident #4 did not receive the nutritional intervention of ice cream daily with lunch, as ordered, and should have.

Based on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings. Findings: Review of the facility's record of the Resident Council meeting held on 02/26/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals. Review of the facility's record of the Resident Council meeting held on 03/26/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals. Review of the facility's record of the Resident Council meeting held on 04/30/2025 revealed, in part .Old Business/Unresolved issues included CNAs talking loudly down the hallways and on telephones, and CNAs not offering residents a choice of meals. During the facility's Resident Council meeting on 05/05/2025 at 1:30 p.m., residents complained that staff continued to talk loudly down the hallways and on their phones, and that they were still not being offered a choice of meals. The residents stated these issues had been discussed at multiple Resident Council meetings, but had not been resolved by the facility. Interview on 05/05/2025 at 1:50 p.m., S17 Activities Director confirmed residents had complained of CNAs talking loudly down the hallways and on telephones, and CNAs not offering the residents a choice of meals during the 02/26/2025, 03/26/2025, and 04/30/2025 Resident Council meetings. S17 Activities Director confirmed residents' complaints remained unresolved. Interview on 05/06/2025 at 12:05 p.m., S1 Administrator confirmed she was aware of the residents' complaints of CNAs talking loudly down the hallways and on telephones, and CNAs not offering the residents a choice of meals. S1 Administrator stated these complaints had been documented as unresolved at the Resident Council meetings held on 02/26/2025, 03/26/2025, and 04/30/2025. S1 Administrator confirmed she had not performed any monitoring related to these issues. S1 Administrator confirmed these complaints had not been resolved, but should have been. S1 Administrator confirmed all resident complaints should be resolved promptly, but had not been.

Based on observation and interview, the facility failed to ensure controlled medications were stored in separately locked compartments in 1 (Medication Room A) of 2 (Medication Room A and Medication Room B) medication rooms observed. Findings: Observation on 05/06/2025 at 09:45 a.m. of Medication Room A revealed one bottle of Lorazepam oral concentrate (controlled medication) in medication refrigerator placed next to medication lockbox. Interview on 05/06/2025 at 09:46 a.m. with S5 LPN (Licensed Practical Nurse) confirmed the above findings. S5 LPN confirmed the bottle of Lorazepam oral concentrate should have been in the medication refrigerator lockbox and was not because the key to the lockbox would not unlock the lockbox. S5 LPN stated she did not notify anyone of her inability to open medication lockbox. On 05/06/2025 at 09:46 a.m. S2 DON arrived to Medication Room A during above interview with S5 LPN. S2 DON confirmed Lorazepam and any other controlled medications that require refrigeration should be locked securely in medication refrigerator in lockbox.

Based on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (#4) of 1 Residents reviewed for advance directives. The facility failed to ensure all medical records regarding advance directives consistently reflected Resident #4's wishes to be a DNI (Do not intubate). The total sample size was 29. Findings: Review of Resident #4's EHR (Electronic Health Record) revealed an admitted [DATE] with a re-entry date of [DATE] with diagnosis which included: Acute on Chronic Diastolic (Congestive) Heart Failure, Chronic Respiratory Failure, Type 2 Diabetes Mellitus without Complications, Morbid Obesity, Non-rheumatic Aortic Valve Stenosis, Atherosclerosis Heart Disease, Hypertension, Depressive Disorder, Chronic Kidney disease. Further review of Resident #4's EHR's bed board revealed a code status of Full Code. Review of Resident #4's Significant Change MDS with ARD of [DATE] revealed Resident #4 was interviewable with a BIMS of 14, which indicated intact cognition. Resident #4 was dependent on staff for toileting, showering/bathing, dressing upper and lower body, and personal hygiene. Resident #4 received Hospice Services. Review of Resident #4's current ,d+[DATE] physician's orders revealed an order dated [DATE] which read code status of Full Code. Review of the LaPOST (Louisiana Physician Order for Scope of Treatment) revealed Resident #4's code status was listed as CPR (cardiopulmonary resuscitation)/attempt resuscitation with limited additional interventions which included: Do not use intubations, advance airway interventions, or mechanical ventilation. LaPOST was signed by Resident #4's daughter on [DATE]. Review of Resident #4's progress note dated [DATE] at 04:18 p.m. revealed a Hospice nurse visited resident and brought LaPOST. The progress note revealed Resident #4 is officially a DNI. Review of Resident #4's Admission Record Demographic Sheet revealed . Advanced Directive/ Living Will section completed as none on record. In an interview on [DATE] at 09:52 a.m., S6 LPN stated when transferring a resident to the hospital she would include the resident's advance directive in report to the receiving facility. S6 LPN revealed she determined resident's advance directive by reviewing the EHR bed board or physician orders. In an interview on [DATE] at 02:15 p.m., S7 LPN stated when transferring a resident to the hospital she would include the resident's advance directive in report to the receiving facility. S7 LPN revealed she determined resident's advance directive by reviewing the EHR bed board or the physician orders. Interview on [DATE] at 02:40 p.m. with S2 DON revealed each resident should have an order indicating code status within their medical records. S2 DON revealed documents transferred to the hospital would include . transfer form, physician orders, and admission record demographic sheet. S2 DON confirmed that Resident #4's physician orders and EHR's bed board revealed full code only and did not specify Resident #4's request for specific limited interventions, as listed on her LaPOST. S2 DON acknowledged when nurses are giving report to the receiving facility based on the bed board and orders, Resident #4's request for limited interventions would not be communicated.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #68) of 29 sampled residents. Findings: Review of Resident #68's electronic medical record revealed an admitted [DATE], with diagnoses that included, in part .Parkinson's Disease with Dyskinesia. Review of Resident #68's quarterly MDS with an Assessment Reference Date (ARD) of 02/10/2025 revealed, in part .a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Resident #68 had adequate hearing and did not use hearing aids. Observation and interview with Resident #68 on 05/05/2025 at 9:42 a.m. revealed she had difficulty hearing. Resident #68 stated she did not have hearing aids, but wanted them. Resident #68 stated she was provided with headphones during bingo, which improved her hearing and made it possible for her to participate. Observation and interview with Resident #68 on 05/05/2025 at 1:30 p.m. during Resident Council meeting revealed she had difficulty hearing, which interfered with her ability to participate in the group discussion. Resident #68 stated she had difficulty hearing when there was any background noise, or when more than one person was speaking. Interview with S15 Charge Nurse and S18 MDS conducted on 05/07/2025 at 9:15 a.m. S15 Charge Nurse stated residents were provided with headphones during bingo if the background noise in the dining area made it difficult for them to hear. S15 Charge Nurse stated the dining room was very noisy due to the noise from the kitchen, the number of people in the area, the facility entrance being in close proximity, and the music played in the area. S15 Charge Nurse and S18 MDS confirmed residents who had difficulty hearing due to the background noise during bingo, would also have difficulty hearing during meals and any time they were in the dining area. S18 MDS stated he was not aware Resident #68 had difficulty hearing, or that she used headphones during bingo. S18 MDS confirmed Resident #68's quarterly MDS with an ARD of 02/10/2025 indicated she had adequate hearing. Interview with S23 Social Services Director on 05/07/2025 at 12:23 p.m. confirmed Resident #68 had hearing difficulty. Interview with S17 Activities Director on 05/07/2025 at 12:41 p.m. confirmed Resident #68 had difficulty hearing during bingo, during Resident Council meetings, and any time there were background noises.

Based on record review and interview, the facility failed to ensure the person-centered care plan was implemented for 2 (#13, #76) out of 29 sampled residents. Findings: Resident #13 On 05/07/2025, a review of facility policy titled Medication Monitoring dated 09/01/2024, revealed in part . This facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. . Licensed nurses, with periodic oversight by nurse managers, shall: .Adhere to facility polices and current standards of practice for administration and monitoring of medications . Interventions shall be identified on the residents comprehensive care plan for the systematic monitoring of high risk medications to facilitate early identification of adverse consequences. Review of the electronic health record for Resident #13 revealed an admitted [DATE] with diagnoses that included: Type 2 Diabetes, Major Depressive Disorder, Paroxysmal Atrial Fibrillation, Heart Failure, Hypertension, Mild Neurocognitive Disorder due to known physiological condition with behavioral disturbance, and Bipolar Disorder with psychotic features. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/2025, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. Review of care plan initiated 05/01/2024 revealed Resident #13 was on anticoagulant therapy. Interventions included administer anticoagulant medications as ordered by physician, monitor for side effects and effectiveness each shift, monitor/document/report PRN (as needed) if resident exhibits any adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of physician orders for month of 04/2025, revealed an order dated 01/15/2025, for Eliquis (anticoagulant) 5 milligram (MG), one tablet by mouth two times a day related to Paroxysmal Atrial Fibrillation (irregular heart rhythm). Review of electronic health record on 05/06/2025 at 10:50 a.m. revealed no evidence of anticoagulant monitoring for side effects and effectiveness each shift. Interview on 05/06/2025 at 02:40 p.m. with S8 RN revealed S8 RN was aware Resident #13 is currently prescribed an anticoagulant. S8 RN confirmed any resident receiving an anticoagulant should be monitored. S8 RN stated if a resident is receiving monitoring for any form of medication, the task would be triggered to be documented in the electronic medication administration record (EMAR). Review of Resident #13's EMAR with S8 RN, revealed no evidence of anticoagulant monitoring. During interview on 05/06/2025 at 02:50 p.m., S2 DON confirmed Resident #13 was receiving an anticoagulant medication. Electronic health record and EMAR reviewed with S2 DON. S2 DON confirmed Resident #13 was care planned for anticoagulant monitoring for side effects and effectiveness each shift. S2 DON confirmed Resident #13 anticoagulant therapy was not being monitored each shift and should have been. 51596 Resident #76 Review of Resident #76's electronic medical record revealed an admitted [DATE], with diagnoses that included, in part . Alzheimer's, Dementia with Behavioral Disturbance, Anxiety Disorder, and Major Depressive Disorder with Severe Psychotic Symptoms. Review of Resident #76's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/2025 revealed, in part .a Brief Interview for Mental Status (BIMS) score was not provided due to the resident being rarely or never understood. Resident #76 had 2 or more falls without injury and 1 fall with minor injury. Review of Resident #76's current care plan revealed, in part .I am at risk for falls related to confusion and being unaware of safety needs, initiated on 03/13/2024. Interventions included, in part .fall mat to left side of bed initiated on 10/22/2024, and fall mat to right side of bed initiated on 10/28/2024. Observation of Resident #76 on 05/05/2025 at 9:45 a.m. revealed a fall mat placed on the floor to the right side of the bed. The fall mat was against the wall, and 12 inches away from the bedside. No fall mat observed on the left side of the bed. Observation of Resident #76 on 05/06/2025 at 9:35 a.m. revealed a fall mat placed on the floor to the right side of the bed. The fall mat was against the wall, and 12 inches away from the bedside. A small trash can was placed on top of the fall mat. No fall mat observed on the left side of the bed. Observation of Resident #76 on 05/07/2025 at 9:50 a.m. revealed a fall mat placed on the floor to the right side of the bed. The fall mat was against the wall, and 12 inches away from the bedside. A small trash can, a chair, and a three-drawer chest were placed on top of the fall mat. No fall mat observed on the left side of the bed. Interview of S13 LPN on 05/07/2025 at 9:50 a.m. revealed the trash can, chair, and three-drawer chest should not have been placed on Resident #76's fall mat. S13 LPN confirmed Resident #76's fall mat was incorrectly placed on the right side of the resident's bed. S13 LPN confirmed Resident #76 did not have a fall mat on the left side of her bed.

Based on record review, observation, and interview, the facility failed to provide care and services that met professional standards of quality for 1 (#41) of 2 (#41 and #60) residents observed during medication pass. The facility nurse failed to properly position Resident #41 for administration of a breathing treatment. Findings: Resident #41 On 05/06/2025, review of facility policy titled, Medication Administration, with reviewed/revised date of 09/01/2024, revealed in part . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Policy Explanation and Compliance Guidelines . Position resident to accommodate administration of medication .Administer medication as ordered in accordance with manufacturer specifications . Review of Resident #41's electronic medical record revealed an admitted [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), congenital stenosis and stricture of esophagus, Hypertension, and Gastroesophageal Reflux Disease without esophagitis. Review of Resident #41's care plan initiated 02/01/2022, revealed resident had Chronic Obstructive Pulmonary Disease (COPD) with chronic cough related to smoking. Interventions included administer medications as ordered and monitor document side effects and effectiveness, receive aerosol or bronchodilators as ordered and monitor document side effects and effectiveness, monitor for any signs or symptoms of acute respiratory insufficiency, monitor/document/report PRN (as needed) for any signs and symptoms of respiratory infection, and respiratory therapy program nurse to evaluate and treat as indicated. Review of Resident #41's physician orders for month of 04/2025, revealed the following: 11/29/2024: Elevate HOB (head of bed) secondary to resident being short of breath when lying flat. 04/23/2025: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally three times a day for SOB (shortness of breath) for 14 days. Medication pass observation was conducted on 05/06/2025 at 08:00 a.m. with S5 Licensed Practical Nurse (LPN). Observation on 05/06/2025 at 08:18 a.m. revealed S5 LPN administered Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution via nebulizer facemask to Resident #41. Resident #41 was lying in bed, with head of the bed elevated at approximately 10 to 15 degrees during administration of Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution. On 05/06/2025 at 08:26 a.m., review of manufacturer instructional insert from Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution box with S5 LPN, revealed in part . Sit in comfortable, upright position; place the mouth piece in your mouth or put on the face mask; and turn on compressor . S5 LPN confirmed Resident #41 was not in the correct position for proper administration of Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution. S5 LPN confirmed Resident #41 should have been placed in an upright position during the administration of Ipratropium Bromide 0.5 milligram (mg)/Albuterol Sulfate 3mg inhalation solution.

Based on observation, interviews, and record review, the facility failed to provide the necessary care and services to ensure a resident maintained the ability to carry out activities of daily living. The facility failed to provide a communication aid for 1 (Resident #26) of 2 (Resident #26 and Resident #68) residents sampled for communication and sensory concerns. Findings: Review of Resident #26's electronic medical record revealed an admitted [DATE] with diagnoses including, in part .Aphasia following Unspecified Cerebrovascular Disease, Mixed Receptive-Expressive Language Disorder, and Dementia. Review of Resident #26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/19/2025 revealed, in part .a Brief Interview for Mental Status (BIMS) score was not provided due to resident being rarely or never understood. Resident #26 had unclear speech. Review of Resident #26's current Care Plan revealed, in part . I have a communication problem related to aphasia, initiated on 07/05/2019. Interventions included, in part .use alternative communication tools as needed. Observation of Resident #26 on 05/05/2025 at 12:00 p.m. revealed impaired communication. Resident #26 was lying on her bed. She repeatedly stated P .P! while lifting her arm and indicating toward the wall behind her head. No communication aid was noted in the resident's room. Interview with S16 CNA Supervisor on 05/05/2025 at 12:04 p.m. revealed Resident #26 used a communication board to communicate with staff. She stated the communication board should have been on the resident's bedside table. Interview with S16 CNA Supervisor and S12 CNA on 05/05/2025 at 12:05 p.m. revealed Resident #26 did not have a communication board in her room, but should have. Interview with S13 LPN on 05/05/2025 at 12:13 p.m. revealed Resident #26 was able to communicate with staff using a communication board. S13 LPN confirmed Resident #26 should have had a communication board, but did not. Interview with S15 Charge Nurse on 05/07/2025 at 9:24 a.m. revealed Resident #26 used a communication board to communicate with staff. S15 Charge Nurse confirmed Resident #26 did not have a communication board on 05/05/2025, but should have.

Based on observation, interview, and record review, the facility failed to ensure a resident received proper treatment and assistive devices to maintain and/or improve hearing ability for 1 (Resident #68) of 2 (Resident #26 and Resident #68) residents reviewed for communication and sensory. Findings: Review of Resident #68's electronic medical record revealed an admitted [DATE] with diagnoses including, in part, Parkinson's Disease with Dyskinesia. Review of Resident #68's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/10/2025 revealed, in part, a Brief Interview for Mental Status (BIMS) score BIMS Score of 13, indicating intact cognition. Resident #68 had adequate hearing and did not use a hearing aid. Observation and interview of Resident #68 on 05/05/2025 at 9:42 a.m. revealed she had difficulty hearing. Resident #68 stated she did not have hearing aids, but wanted them. Observation and interview of Resident #68 on 05/05/2025 at 1:30 p.m. revealed she had difficulty hearing during the Resident Council meeting. Resident #68 stated she had difficulty hearing when there was background noise, or when more than one person was speaking. Interview with S23 Social Services Director on 05/07/2025 at 12:23 p.m. revealed she was responsible for scheduling residents with hearing difficulty for an audiology evaluation. She stated the facility assisted residents with obtaining hearing aids, if needed. S23 Social Services Director revealed Resident #68 did have difficulty hearing, had not had an audiology evaluation, and did not have hearing aids. S23 Social Services Director confirmed Resident #68 should have been scheduled for an audiologist evaluation and screened for hearing aids, but had not. Interview with S17 Activities Director on 05/07/2025 at 12:41 p.m. confirmed Resident #68 had difficulty hearing during bingo and Resident Council meetings.

Based on record review and interview the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion by failing to provide restorative therapy for 1 (#80) of 3 (#16, #54, and #80) residents reviewed for limited range of motion. Findings: Review of Resident #80's medical record revealed she was admitted to the facility on [DATE]. Resident #80 had diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebrovascular Accident affecting Left Dominant side. Review of Resident #80's Quarterly MDS with ARD of 02/10/2025 revealed Resident #80 had a BIMS of 15, which indicated cognition was intact. Resident #80 had upper and lower extremity impairment on one side. Resident #80 required substantial/maximal assistance from staff for: Eating, Oral Hygiene, Toileting, Showering/Bathing, Dressing, and Personal Hygiene. Review of Resident #80's CPOC (Comprehensive Person Centered Plan of Care) with a target completion date of 05/11/2025 revealed in part . Limited physical mobility related to Stroke, Weakness, and Hemiplegia. Interventions included; I will have gentle range of motion as tolerated with daily care with an initiation date of 09/14/2024. Record Review of Resident #80's tasks report with a 14 day lookback period revealed she was to receive gentle passive range of motion with each personal care task and as needed. Review of the report revealed staff did not perform this task as care planned for Resident #80 with the exception of dates 05/05/2025 and 05/06/2025. Interview on 05/05/2025 at 11:53 a.m. with Resident #80 and her husband stated she did not receive physical therapy services. Resident #80 revealed staff did not perform range of motion exercises with her. Resident #80 stated she would like for staff to perform range of motion exercises with her to prevent further decline. Resident #80 stated when she asked staff to help her perform some exercises they respond That's not my job. Interview on 05/06/2025 at 3:48 p.m. with Resident #80 and her husband revealed nursing and CNA staff did not perform range of motion exercises with her at any point in time during her admission. Interview on 05/06/2025 at 3:53 p.m. with S10 CNA whom was assigned to care for Resident #80 revealed she did not perform range of motion exercises with resident. Interview on 05/06/2025 at 4:00 p.m. with S9 Director of Rehab Services confirmed Resident #80 had not received physical therapy services since 11/2024. S9 Director of Rehab Services stated he would speak with S1 Administrator about getting Resident #80 evaluated, so that she could possibly get some hours for therapy services. S9 Director of Rehab Services revealed Resident #80 would benefit from having nursing staff perform range of motion exercises daily to prevent further decline. Interview on 05/06/2025 at 4:11 p.m. with S2 DON confirmed Resident #80 was care planned since 09/2024 to received range of motion exercises daily and as needed by staff. S2 DON confirmed this intervention had not been set up as a task, so there was no documentation of that intervention being implemented in accordance with Resident #80's CPOC. S2 DON acknowledged Resident #80 should have had range of motion exercises completed to prevent further decline, but had not.

Based on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 94. Findings: Review of a facility policy on [DATE] at 12:08 p.m. titled, Sanitation Inspection with a revised date of [DATE] revealed the following in part .It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. Review of a facility policy on [DATE] at 12:08 p.m. titled, Food Safety Requirements with a revised date of [DATE] revealed the following in part .Food will also be stored in accordance with professional standards for food service safety. Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. 3. iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping food covered or in tight containers. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g. hairnet hat, and/or beard restraint) to prevent hair from contacting food. Hairnets should be worn when cooking, preparing, or assembling food. Observation on [DATE] at 8:37 a.m. of the facility kitchen accompanied by S3 Dietary Manager revealed the following: Main Refrigerator: 1. One undated, opened plastic container of beef broth with an expiration date of [DATE]. Main Freezer: 2. One undated, opened frozen bag of broccoli spears. Dry Pantry Storage: 3. Six 5lb. (pound) bags of Ramsen non-fat dry milk with an expiration date of [DATE]. Walk-In Refrigerator: 4. One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of breakfast sausage patties (over 20 individual loose patties). 5. One opened cardboard box that contained: opened, unsealed, and undated plastic wrap of sliced bacon strips (over 20 individual loose bacon strips). S3 Dietary Manager confirmed all of the above findings during the kitchen walk-through observation. S3 Dietary Manager confirmed the above listed items were expired, opened, unsealed, and/or undated and should have been disposed of properly. Observation of meal preparation on [DATE] at 10:20 a.m. of S11 [NAME] revealed he had a long curly beard without hair/beard restraints. Observed S11 Cook's beard uncovered throughout meal preparation. S11 [NAME] stated he was unaware to wear a hair/beard restraint while in the kitchen. In an interview on [DATE] at 4:25 p.m., S1 Administrator confirmed the kitchen should not have any expired, unsealed, and/or undated food items available for usage and these food items should have been disposed of properly. S1 Administrator confirmed S11 [NAME] is aware to wear a hair/beard restraint while in the kitchen and should have worn a hair/beard restraint while preparing meals.

Based on observation, interview and record review, the facility failed to provide adequate supervision, and use extensive, 2 person physical assistance for turning, repositioning and bed mobility for 1 (#1) of 2 (#1 and #2) residents reviewed for falls. This failed practice resulted in an actual harm situation on 11/07/2024 at 9:35 a.m., when Resident #1, who was severely impaired cognitively; had diagnoses that included Hemiplegia, and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side; Unspecified Dementia; and required substantial/ maximal assistance for shower/ bathing and rolling left and right; rolled out of bed while receiving a bed bath by S4 CNA. Resident #1 fell on to the floor, and sustained a Closed Right Hip Fracture. Findings: Review of the facility's policy and procedure with revision date of March 2018, and titled Activities of Daily Living (ADLs), Supporting read in part . Policy Interpretation and Implementation 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the ARD and the following MDS definitions in part . d. Extensive Assistance - While resident performed part of activity over the last 7 days, staff provided weight-bearing support. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate. Review of Resident #1's medical record revealed an admitted [DATE], with diagnoses that included in part . Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, and Unspecified Dementia. Review of Resident #1's Quarterly MDS with an ARD 10/30/2024, revealed a BIMS score of 00 (severely impaired cognitively). The MDS revealed in part . Resident #1 was coded for functional limitations in ROM with impairment on one side for upper and lower extremities. Resident #1 required substantial/ maximal assistance for shower/ bathing, toileting, dressing, and rolling left and right. Review of Resident #1's Care Plan with a target date of 12/02/2024, revealed the following: 1. High risk for falls r/t limited mobility, r/t previous CVA affecting right side; right side hemiplegia. I scoot myself around in bed at times, with a goal to be free of falls. Interventions included in part . I am a fall risk. Follow facility fall protocol - Initiated 07/03/2019. 09/15/2024 - Fall without injury. Ensure resident is in middle of bed upon rounds. 11/07/2024 - Fall with major injury. Leave resident's door open for frequent rounding and increased visualization. 2. ADL self-care performance deficit r/t CVA with right sided hemiplegia and dementia, with a goal to maintain current level of ADL function. Initiated on 07/03/2019. Interventions included in part . Assist me with dressing, bed mobility, personal hygiene, toileting, eating and transfers - revision on 06/14/2024; Assist me with bathing as needed; and honor my choice for type of bath I prefer - revision on 01/09/2024. Observation on 12/02/2024 at 11:00 a.m., and 12/03/2024 at 10:00 a.m., revealed Resident #1 lying in bed with call light within reach. Resident #1 was not interviewable. Resident #1's bed was in low position, with mattress with bolsters on each side of Resident #1, and a fall mat was observed on the window side of the bed. Signage was noted over the HOB that revealed a fall leaf, a picture of a bed with the number 2 (2 person assist), a red heart (DNR), a blue triangle (color of the lift pad), fall mat, a red circle (use lift for transfers), a coffee cup (to prevent scalding when drinking), nectar thick liquids, no ice, no straws, turn schedule, pillow under right arm, and elevate right wrist. Interview with S6 CNA Supervisor on 12/04/2024 at 9:35 a.m. revealed that a binder was located at each nurses' station for the HOB signage with pictures and meanings of each picture. S4 CNA was in-serviced on the overhead bed signage and its meanings when she was hired and throughout orientation, and S4 CNA was aware that the book was located at the nurses' station. S6 CNA Supervisor stated that the HOB signage on 11/07/2024, revealed Resident #1 was required to have 2 person extensive assistance with ADLs, bed mobility and transfers, and should have had 2 persons assisting with her bathing and turning while in bed. Interview on 12/04/2024 at 10:15 a.m. with S7 FNP revealed that prior to fall with injury of hip fracture, Resident #1 was bed bound. S7 NP stated the nurse called her and she came shortly, assessed Resident #1 and initially c/o her right arm and waiting for mobile x-ray. S7 FNP revealed Resident #1 continued to complain with facial grimacing, and sent her out to the hospital for further evaluation and x-rays. Telephone interview on 12/04/2024 at 12:30 p.m. with S4 CNA, revealed Resident #1 was on her list of residents to receive a bed bath that day; however, she stated she didn't remember looking at the over-head bed signage before providing Resident #1's care to see what assistance with care was needed. She stated she knew she could check the kiosk, but didn't look at the kiosk either, prior to caring for Resident #1, and should have. Interview on 12/04/2024 at 2:30 p.m. with S2 ADON, revealed the information that was included on each resident's HOB signage and in the Kiosk, was generated directly from the current MDS assessment, and that Resident #1's intervention for 2 person extensive assistance for bed mobility, turning and repositioning in bed was initiated on 01/08/2024. Interview on 12/05/2024 at 1:55 p.m. with S4 CNA, revealed she provided care to Resident #1 3-4 months ago, prior to the incident. During that time the resident was bathed by bath aides. S4 CNA stated she worked with Resident #1 on 11/07/2024, and Resident #1 was scheduled to have her bed bath right after breakfast. S4 CNA stated she was giving Resident #1 a bed bath on 11/07/2024 by herself, and rolled Resident #1 onto her left side, on the opposite side of the bed she (S4 CNA) was on. S4 CNA stated she had her arm on Resident #1 when she (Resident #1) started scooting closer to the edge of her bed, and rolled out of the bed, and onto the floor. S4 CNA stated she called for help and pressed the call light for assistance, and the nurse and 2 CNAs came into room to assist. S4 CNA stated she had been trained on the over bed signage and use of the kiosk for resident care, but didn't remember looking at Resident #1's HOB signage prior to providing her bed bath. Interview on 12/05/2024 at 2:50 p.m. with S3 LPN revealed that she cared for Resident #1 on 11/07/2024, and was summoned to her room after she fell out of her bed. She stated Resident #1 was found lying on the floor on her side. S3 LPN reported according to Resident #1's overhead bed signage and ADL Documentation on 11/07/2024, Resident #1 was required to have 2 person extensive assistance with ADLs, bed mobility and transfers, and should have had 2 persons assisting with her bathing and turning while in bed. Review of Resident #1's Radiology results dated 11/07/2024 at 3:01 p.m. read in part .History/ Reason for X-Ray: Fall, Right shoulder, elbow pain; fall, Right hip pain. Procedure: Pelvis AP 1 view/ Right Hip AP and Lateral. Impression: Right Trans-Cervical Femoral Neck Fracture. Review of Nursing Progress Notes dated 11/07/2024 at 9;35 a.m., revealed in part .S3 LPN stated she was summoned to Resident #1's room and noted the resident lying flat on her back. Resident #1 assisted up times 3 person assist. Neuro-checks in progress. S7 FNP notifed with new orders for x-ray of bilateral upper arms, and bilateral hip and legs. Interview on 12/05/2024 at 3:50 p.m. with S1 DON, and review of the ADL documentation located in the Kiosk, revealed Resident #1 required extensive assistance with 2 person assistance. The ADL documentation revealed in part . 3,3, which indicated Resident #1 required extensive assistance with 2 person assistance for bed mobility and transfers. S1 DON revealed the X-rays showed Resident #1 had a fracture to her Right Femur. S1 DON confirmed S4 CNA should not have attempted to provide ADLs and turn Resident #1 in her bed by herself.

Based on interview and record review facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders, and the resident's advance directives for 1 (Resident #76) of 2 (Resident #76 and Resident #77) closed records reviewed out of a total sample of 23. The facility failed to: 1. Ensure S4 LPN acted in accordance with Resident #76's Advanced Directives and Physician Orders, and initiated CPR when the resident was found unresponsive and without a pulse; and 2. Ensure EMS and the physician were notified when Resident #76 was found unresponsive, without a pulse. This deficient practice resulted in an Immediate Jeopardy for Resident #76 that began on [DATE] at approximately 6:00 a.m., when S6 CNA found Resident #76 in bed, unresponsive, and not looking right. S6 CNA notified S4 LPN, who failed to initiate CPR when she found Resident #76 unresponsive and without a pulse. Resident #76's Advanced Directives revealed that extraordinary measures should be taken in case of an extreme emergency, and Physician's Orders revealed a Full Code Status. The facility did not notify EMS and Resident #76's physician. Resident #76 was pronounced deceased on [DATE] at 6:30 a.m. by the Coroner. The administrator was notified of the Immediate Jeopardy situation on [DATE] at 2:18 p.m. The Immediate Jeopardy was removed on [DATE] at 2:08 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for all 41 residents identified as a Full Code who resided in the facility. Findings: Review of the facility's undated policy titled: Resident Right - Advanced Directive Tracking Program, read in part . Intent: It is the policy of the facility to honor the advance directives of all residents. Procedure: 18. In the event that a resident experiences cardiopulmonary arrest the nurse on duty shall immediately determine the resident's status as a code or no-code. 19. If the person is a full code, the nurse or designee shall begin Cardiopulmonary resuscitation and direct someone to call 911. Review of Resident #76's EHR revealed an admitted [DATE], with the following diagnoses: Acute and Chronic Respiratory Failure with Hypoxia; Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation; Acute and Chronic Systolic (Congestive) Heart Failure; and Critical Illness Myopathy. Review of Resident #76's Advanced Directive dated [DATE] revealed that extraordinary measures should be taken in case of an extreme emergency. Review of Resident #76's physician orders dated [DATE], read in part . Full Code Status. Review of Resident #76's Care Plan read in part .I am a full code. No interventions noted. Review of Resident #76's Nurse's Notes dated [DATE] 10:22 a.m., and written by S4 LPN read in part .Resident #76 non-responsive. S4 LPN went to resident room to reassess resident, noted resident nonresponsive, no pulse, no respirations. S5 LPN notified family of resident unresponsiveness via phone call. RP son notified staff that he was ok and aware of present outcome/death, would notify his siblings and would contact funeral home and call us back. Notified Sheriff's Dept. and called Coroner. Time of death noted at 6:30 a.m. Resident's son called and notified that he contacted funeral home. Coroner released body to funeral home at 8:15 a.m. Interview on [DATE] at 8:12 a.m. with S4 LPN revealed S6 CNA came to her and told her Resident #76 did not look right, her color was different. S4 LPN stated she went to get her stethoscope, and asked S6 CNA to get S5 LPN to come meet her. S4 LPN stated that she told S5 LPN that Resident #76 may have passed, and S5 LPN told her she was a full code. S4 LPN stated that she started the assessment, and S5 LPN ran to call the resident's son. S4 LPN stated that she was still assessing Resident #76 when S5 LPN returned and told her Resident #76's son said to let her go. S4 LPN stated she had not started CPR because she was still assessing. S4 LPN confirmed she should have begun CPR immediately after determining the resident did not have a pulse. She stated she notified the coroner, but did not alert EMS or notify the MD. Interview on [DATE] at 8:20 a.m. with S5 LPN, revealed S6 CNA told her that S4 LPN needed her because Resident #76 may have passed. S5 LPN stated that she told S4 LPN that Resident #76 was a full code, and that she was going to contact the resident's son. S5 LPN stated Resident #76's son asked not to perform CPR on the resident. S5 LPN stated when she walked into Resident #76's room (unable to remember time), S4 LPN was preparing to start CPR, and S5 LPN told her Resident #76's son stated not to do CPR. Interview on [DATE] at 8:25 a.m. with S6 CNA revealed that she normally got Resident #76 out of bed every morning around 6:00 a.m. at the beginning of her shift. S6 CNA stated that when she went to get the resident out of bed, the resident's color was not right, and she was unresponsive. S6 CNA stated she did not start CPR, but notified S4 LPN. S6 CNA stated S4 LPN sent her to get another nurse. Telephone interview on [DATE] at 9:08 a.m. with Resident #76's son, revealed the nurse called him around 6:30 a.m. and told him Good morning, we were passing breakfast trays this morning and mama passed. Resident #76's son stated those were her exact words. Resident #76's son stated the nurse did not ask him about performing CPR. Resident #76's son stated that his mother was a full code and that he expected that the facility had performed CPR and called the ambulance. Interview on [DATE] at 9:30 a.m. with S1 Administrator revealed all nursing staff had up-to-date CPR certifications. S1 Administrator stated that CNAs are not CPR certified, and they should notify the nurse if a resident was found nonresponsive. S1 Administrator stated the LPN should have immediately started CPR on Resident #76 because she was a full code. Interview on [DATE] at 12:18 p.m. with S2 DON and S4 LPN revealed that S4 LPN stated that she should have initiated CPR on Resident #76, but chose not to do so after S5 LPN told her what the resident's son said. S4 LPN stated she should not have made the decision not to do CPR based on a call made to the family, and she should have followed MD Orders instead. S2 DON confirmed S4 LPN should have followed MD orders, and performed CPR on Resident #76 immediately after finding her unresponsive, and without a pulse.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (#57) of 4 (#31, #38, #57, #92) residents sampled for accidents in a total sample of 20. This deficient practice resulted in an Actual Harm for Resident #57 on [DATE] at 4:15 a.m. when the resident was taken by wheelchair to the dining room, left alone and unattended, and fell to the floor. The resident who was at risk for falls, had been confused, hollering out and repeatedly trying to get out of the bed throughout the night shift. The resident was transferred to a local hospital and diagnosed with [REDACTED]. Findings: Review of the Order Summary Report dated [DATE] revealed resident #57's [DIAGNOSES REDACTED]. Observation of the resident on [DATE] at 10:05 a.m. revealed she was lying in a low bed with a cervical collar on, the Hospice Nurse was in the room. The resident opened her eyes, pulled at the cervical collar and did not speak during the observation. The Hospice nurse stated the resident was admitted to Hospice after sustaining hip and cervical fractures after a fall in December, 2019, because she was not a surgical candidate. Review of the resident's Comprehensive Care Plan revealed the following problems were included: 1. Problem - assistance required with ADLs due to Alzheimer's and impaired balance, and the approaches included that any changes, any potential for self-care deficit, and declines in function would be monitored/documented/reported by the CNA, LPN and RN. 2. Problem - impaired thought processes related to Alzheimer's and the approaches included provide cues, reorient and supervise as needed. Monitor/document/report prn any changes in cognitive function, specifically changes in decision making ability, recall and general awareness. 3. Problem - wish to stay in facility long term and the approaches included staff will provide resident with 24 hour supervision and care as needed. Review of the resident's Quarterly MDS dated [DATE] (ARD) revealed the resident's Cognitive BI[CONDITION] score was 3 (severe cognitive impairment). The resident required extensive assistance of 2 for bed mobility, transfer and dressing, and extensive assistance of 1 for locomotion on and off the unit. Further review revealed her balance was not steady for moving from seated to standing position and that for surface to surface transfer she was only able to stabilize herself with staff assistance. Further review revealed the resident did not have functional limitations in ROM in her upper or lower extremities, and that the resident used a wheelchair for assistance with mobility. Review of the resident's Fall Risk Factors Scale dated [DATE] and [DATE] revealed the resident had an impaired gait, had fallen before, and overestimated or forgot her limitations (mental status). The resident was assessed to have a Fall Risk Score of [AGE] (High Risk = 45 and higher). Review of the FNP Progress Note dated [DATE] revealed the resident had increased confusion in evenings but was cooperative. Review of a Progress Notes dated and timed [DATE] - 4:30 a.m. by LPN (S14) revealed resident #57 tried to get out of bed most of the night. At 4:15 a.m. the CNAs got her up into the wheelchair, brought her to the dining room, then returned to their halls to make rounds. The nurse wrote that she heard the resident yell Help Me and that she found the resident had fallen out of the wheelchair onto the floor. Further review revealed the resident was assessed and transferred by ambulance to the hospital at 5:20 a.m. Review of the January and February 2020 physician's orders [REDACTED]. Review of the MD History of Present Illness from the hospital record dated [DATE] revealed the resident with history of Dementia was transferred to the hospital from the nursing home after falling out of her wheelchair on [DATE]. The resident was noted to have a C1 arch fracture and a left intertrochanteric [MEDICAL CONDITION]. Review of the Orthopedic MD Consultation Report from the hospital record dated [DATE] revealed the plan for the resident was non-operative treatment of [REDACTED]. Review of the CT Scan Report from the hospital record dated [DATE] of the C-Spine revealed the resident had Anterior and Bilateral C1 Arch Fracture without malposition of the C,[DATE] level. Review of the MD History of Present Illness from the hospital record dated [DATE] revealed the resident fell out of the wheelchair at the NH due to worsening dementia. The Diagnosis, Assessment and Plan included C1 Cervical Fracture, Left [MEDICAL CONDITION], and instructions to wear the cervical collar at all times, limiting bending, and twisting. Review of the Hospital Discharge Summary dated [DATE] revealed the resident was returning to the NH with plans for comfort and Hospice Care. Interview on [DATE] at 10:20 a.m. with S19 CNA revealed the resident no longer tried to get out of bed, and now stayed in bed. Interview on [DATE] at 5:55 a.m. with S14 LPN revealed she worked the night shift full time on the resident's hall, and was the LPN on duty when the resident fell on [DATE]. She stated the resident was very confused, hollered out a lot, kept trying to get out of bed and was looking for her deceased husband. She stated S15 CNA placed a chair in the hallway by the resident's room and sat there for part of that night to watch the resident and the hall. She stated the resident continued to try to get up throughout the night and at 4:00 a.m. staff had to make their rounds so they decided to get her up to her wheelchair and bring her to the front dining room where staff could help observe her. She stated it was not unusual for the resident to have behaviors and try to get up during the night shift, but it was worse that night. She stated typically residents started getting up after 6:00 a.m., after the arrival of the day shift. She confirmed there was no one in the dining room to observe the resident at that time, and that within 5 to 10 minutes after staff left the resident in the dining room she heard the resident holler. Interview on [DATE] at 9:15 a.m. with S20 LPN (C Hall) revealed resident # 57 had Dementia and had a history of [REDACTED]. She stated before the fall in [DATE] she stood with the assistance of one and could step and pivot to sit in the wheelchair. Interview on [DATE] at 12:35 p.m. with S17 Neighborhood Coordinator, CNA for the resident's hall (C Hall) revealed the resident's Dementia had gotten worse over the past year and she had been staying in bed more and more. Interview on [DATE] at 1:35 p.m. with S1 DON confirmed the resident had experienced a fall with major injuries on the night shift of [DATE], and that the resident had Dementia and confusion and was at high risk for falls. Further interview with S1 DON revealed she had interviewed staff concerning the resident's [DATE] fall, and was told that the resident wanted to get up out of bed. She stated she thought the most appropriate thing to do was to do what the resident asked, and after they did that, she thought they had met her needs. Interview on [DATE] at 3:41 p.m. with S15 CNA revealed the resident had increased behaviors on [DATE] during the 10:00 p.m. to 6:00 a.m. shift. She stated the resident had a history of [REDACTED]. She stated the resident had nights when she tried to get up out of bed but it was much worse that night. She stated the resident talked about her deceased husband and kept telling them he was coming to get her that night. S15 CNA stated she kept letting the nurse know and had talked to the nurse at least 6 times that night about the resident's confusion, and repeated attempts to get out of bed. She stated close to 4:00 a.m., the nurse told her she could get the resident up to a wheelchair and could take her to the dining room. She and S16 CNA got the resident up in her wheelchair and took her to the dining room. Both she and S16 CNA left the resident in the dining room to go back to their halls; shortly after leaving the resident, the nurse called her because the resident had fallen.

Based on observation, record review and interview the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents, for 1 ( #84) of 2( #84 and #101) stage 2 residents review for accidents out of a total of 21 stage residents. According to the Resident Census and Conditions of Resident form provided by the facility revealed a total census of 80. The failed practice resulted in an actual harm situation when resident #84 fell out of bed on 3/11/17. Resident #84 was identified by the facility as being a resident that required extensive assistance with bed mobility for self performance, and two person assistance with support provided. The CNA who was bathing the resident turned the resident without assistance resulting in the resident rolling out of the bed onto the floor. The resident was sent to the hospital and x-rays showed that there was a Spiral Fracture involving the proximal shaft of the Humerus, Spiral Oblique Fracture of the proximal Humerus, Seventh Rib Fracture, Spiral Fracture distal shaft of the Humerus, and a soft tissue injury to the left elbow. Findings: Observation of resident #84's left arm on 3/13/17 at 12:00 p.m. revealed it was wrapped with Kerlix gauze and placed in a sling. Interview with the resident at that time revealed his left ribs were hurting, and the resident described his pain as a 10 on a pain scale of 1-10. The resident stated he had previously had a stroke that resulted in left sided weakness. The resident stated a CNA was bathing him in his bed on 3/11/17 at 4:00 a.m. She turned him over onto his right side and his left leg went off the bed, and then his body fell off the bed. The resident stated the bed was in the up position due to being bathe by the CNA. The resident stated he fell against his over bed table that was against the wall. Review of resident #84's Face Sheet revealed an admitted [DATE] with [DIAGNOSES REDACTED]. Review of the resident's annual MDS with an ARD of 1/11/17 revealed the resident's BIMS score was coded as 15 (cognitively intact). Further review of the MDS revealed the resident required extensive physical assistance with bed mobility, and two plus person assistance with support provided. Review of the resident's Comprehensive Plan of Care with a problem onset date of 3/13/17, and a goal date of 6/12/17 revealed a problem of Closed Rib Fracture, and Closed Left Humeral Fracture. Approaches included: to refer the resident to orthopedic as ordered/needed; administer pain medication as ordered; notify MD as needed; maintain splint as ordered; maintain sling as ordered; and X-ray as ordered. Further review of the approaches revealed Fall on 3/11/17, with an approach to include 2 person assist for bed mobility. Review of the Departmental notes revealed the following: On 3/11/17 at 7:04 a.m., S4 LPN documented a late entry for 3/11/17 at 4:10 a.m. The note read that a CNA reported resident fell on the floor. CNA was giving a bed bath and the resident was assisting with grabbing the side rail for assist with bed mobility. Resident fell to the floor. Further documentation revealed LPN entered the room and the resident was lying on his left side with his left arm under him. The resident stated he slid to the floor holding on to the side rail with his right hand. A body assessment revealed a skin tear to the left arm 7 cm in length and a small amount of blood. The area was cleansed and Telfa applied. The resident c/o left arm pain, [DIAGNOSES REDACTED] to his left side due to S/P CVA. The resident stated he did not hit his head. The resident was able to move his right side extremities well. Neuro checks started. On 3/11/17 at 8:26 p.m., S5 LPN documented that the resident returned from the hospital, alert, oriented X 3, speaking as normal self, not distraught or anxious at this time. C/O severe pain in left side primarily upper arm and shoulder and also left ribs. Further review of the notes revealed the resident had a Spiral Fracture to his left Distal Humerus shaft. A Spiral Fracture to his left proximal Humerus shaft. Fracture to the left 7th rib and a dislocated left hip. Review of the hospital x- ray reports dated 3/11/17 revealed the following: 1. Chest 1 view performed on 3/11/17 at 9:52 a.m. Impression: left humeral fracture. 2. Elbow complete Min #V left performed on 3/11/17. Impression: Soft tissue injury. 3. Humerus Mon 2 V left performed on 3/11/17. Impression: Spiral Oblique Fracture of the proximal Humerus seventh rib fracture. 4. Three view left rib. Findings: The bony structures are osteoporotic. Spiral Fracture involving the proximal shaft of the Humerus is again noted. No definite rib fractures are identified. 5. Three view left shoulder. Impression: Spiral Fracture distal shaft of the Humerus Interview on 3/13/17 at 12:00 p.m. with the resident's wife revealed on Saturday, 3/11/17 at 4:30 a.m. she received a telephone call from S4 LPN. The resident's wife stated S4 LPN told her S8 CNA was giving the resident a bed bath. She stated S4 CNA went to turn the resident on his right side and he fell on the floor. The resident's wife stated the resident was sent to the hospital and diagnosed with [REDACTED]. The resident's wife stated the resident was a 2 person assist with bathing and she did not know why S4 CNA was bathing the resident at 4:30 a.m. in the morning. The resident's wife stated the resident also received some skin tears to his left upper arm. Interview on 3/14/17 at 7:45 a.m. with S9 CNA Supervisor revealed the resident needed only one CNA to bath him and turn him from side to side because he could hold on to the rail and help assist. Since his fall out of bed on 3/11/17, the resident is a 2 person assist with ADL and bed mobility. Observation on 3/14/17 at 7:50 a.m. revealed S10 CNA and S11 CNA repositioned and pulled the resident up in bed. The CNAs were observed to use the resident's draw sheet/pads and reposition the resident up to the head of the bed. Interview at that time with S10 CNA and S11 CNA revealed it took 2 CNAs to reposition the resident in bed. Interview on 3/14/17 at 7:55 a.m. with resident #84 revealed before his fall he was gotten up in his wheelchair every other day, would go outside and sit with family, and would go to the Bingo activity sometimes. The resident stated he had not gotten out of bed since his fall because he was in too much pain. Interview on 3/14/17 at 10:15 a.m. with S9 CNA Supervisor revealed the resident's care plan was changed on 3/13/17, after his fall on 3/11/17, to reveal the resident required 2 person assistance for bed mobility. S9 CNA Supervisor stated on 3/13/17 she in-serviced the CNAs on bathing residents while in bed, because she wanted to educate the CNAs on turning residents toward them instead of away from them. Interview on 3/14/17 at 10:35 a.m. with S1 Administrator revealed the nurse had immediately put in place that 2 persons were to assist the resident with bed mobility, repositioning, and bathing after his fall on 3/11/17. Interview on 3/14/17 at 11:20 a.m. with S2 Acting DON revealed she worked Saturday 3/11/17 from 6:00 a.m. to 10:30 a.m. She stated she discussed the resident's fall with S5 LPN who worked 6:00 a.m. to 2:00 p.m., and 2:00 p.m. to 10:00 p.m. on 3/11/17. S2 Acting DON stated she talked with the resident's wife and the wife was upset that the resident was bathe by one person. S2 Acting DON stated S5 LPN and she discussed that they would have 2 persons to assist the resident when he returned to the facility from the hospital. She stated one CNA bathed the resident, assisted with ADLs and turned the resident from front to back. Since the resident's fall on 3/11/17, 2 CNAs now bathed the resident and assist with turning. Interview on 3/14/17 at 12:45 p.m. with S4 LPN revealed she worked 10:00 p.m. to 6:00 a.m. on 3/10 17 to 3/11/17. She stated she had the 100 and 300 halls. She stated S8 CNA came to get her from the 300 hall and reported that resident #84 had fallen out of the bed. S4 LPN stated when she entered the resident's room, she saw the resident on the floor on his left side with his hip resting on the bottom of the over-bed table. S4 LPN stated she assessed the resident's skin and he had a skin tear on his left arm. She stated she cleaned the area and put a dressing on it. S4 LPN also stated she put a pillow under the resident's head and under his left arm because he was complaining that his arm hurt. S4 LPN further stated she telephoned the physician and the resident's wife. She stated when the ambulance arrived, they assessed the resident and she helped them lift the resident off the floor and onto the stretcher. S4 LPN revealed she in-serviced the CNA that when resident #84 returned, he would be a 2 person assist with all ADLs. S4 LPN stated the resident could assist with turning over, so he did not need 2 CNAs to bath and turn him to wash his back. She stated when S8 CNA got ready to bathe the resident's back, she would pull the draw pad and the resident would grab the side rail and help assist with turning. S4 LPN stated the resident was a one person assist with bathing and 2 person assist with bed mobility. She also stated the CNAs had to turn the resident to wash his back; however, she did not know why 2 persons did not assist with turning the resident during his baths. Interview on 3/14/17 at 1:45 p.m. with S8 CNA revealed she had been working with the resident over a year. S8 CNA stated any staff that bathed the resident, always bathed him by themselves. S8 CNA stated she used the same routine bathing the resident. She stated when it was time to wash the resident's back, she pulled on the resident's draw pad as he used the side rail to assist in turning himself away from her. S8 CNA stated she folded the pad under the resident and he pushed his hip up so the pad would go as far as it could under him. S8 CNA stated when the resident put his left leg over his right leg and lifted up on his hip, he fell completely off the bed. She stated after the resident's fall, S4 LPN in-serviced her and the other CNAs to always use 2 persons when bathing the resident. S8 CNA stated she always thought the resident needed 2 person assistance with bed mobility, but they never had enough CNAs on the hall to have 2 persons assist. S8 CNA stated there were 2 CNAs working on the hall on 3/11/17 and one CNA on the other 3 halls. S8 CNA also stated the other CNA (S15) that was working on the hall she was on, was one-on-one with a resident and she could not leave that resident to assist her. S8 CNA also stated if she had gotten a CNA off another hall, then that hall would have been without a CNA. S8 CNA revealed she was told in the past to use 2 person assist with the resident if she could, but one person would do. S8 CNA stated she never in the past asked someone to help turn the resident to his side while she washed his back. S8 CNA also stated staff had discussed working short before in the Monday meeting, and the Administrator stated she would try to get enough staff help. S8 CNA also stated S4 LPN had told her in the past to let her know (S4 LPN) if she needed help and she would try to find someone. S8 CNA stated that was the first time the resident had fallen out of bed since she had been bathing him. Interview on 3/15/17 at 10:10 a.m. with S7 RN/MDS revealed he helped with the resident's Annual Assessment on 1/11/17. He stated the resident was coded for bed mobility as being extensive assist with 2 person physical assist. S7 RN/MDS stated when he reviewed the resident's functional status there were some days the resident needed 2 people and then there were some days one person could turn the resident because he assisted with turns on some days. S7 RN/MDS confirmed he did not care plan the resident according to his MDS functional status for bed mobility, and that the resident should had been care planned for 2 person assistance for bed mobility.