Every finding on record at Pontchartrain Health Care Center

Based on record review, observation, and interviews, the facility failed to ensure it provided medications, as ordered by the prescriber, to meet the needs of 1 (#4) of 6 residents reviewed for medications. Findings: Review of the facility's policy titled Pharmacy Services Overview, with a revision date of 04/2019, revealed the following, in part:Policy StatementThe facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications.Policy Interpretation and Implementation4. Residents have sufficient supply of their prescribed medications and receive medications in a timely manner. Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #4's Significant Change MDS with an ARD of 05/19/2026 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #4's Current Physician Orders revealed the following, in part:Start date 07/08/2026. Mouthwash. Give 10 ml by mouth every 6 hours for mouth ulcers. Swish and spit for 7 Days. Magic mouthwash contents: viscous lidocaine 2%, diphenhydramine (2.5 mg/mL), and an antacid (Maalox). Status: On Hold. Reason for hold: pharmacy. Review of Resident #4's MAR dated July 2026 revealed the Magic Mouthwash had been on hold since 07/11/2026 at 7:00 p.m. On 07/14/2026 at 8:30 a.m., an interview was conducted with Resident #4. She stated mouthwash was ordered for her last week because she currently had sores in her mouth. She stated she had not received the mouthwash in days. She stated nursing staff told her they were waiting on pharmacy to send it. On 07/15/2026 at 11:42 a.m., an interview was conducted with S14LPN. She stated she was aware Resident #4 had mouthwash ordered, but the mouthwash was on hold because pharmacy had not sent it yet. She stated the mouthwash was not on her medication cart, Med Cart 2. She stated she had not called pharmacy to follow up on the medication. On 07/15/2026 at 12:15 p.m., an interview was conducted with a pharmacist from the pharmacy used by the facility. She stated Resident #4 had an order for Magic Mouthwash which was a combination of lidocaine, Benadryl, and Maalox. She stated the pharmacy received notification the facility needed a refill on Saturday 07/11/2026. She stated the pharmacy was out of lidocaine at that time and had to order it. She stated the lidocaine came in on Monday, 07/13/2026. She stated she reviewed pharmacy documentation and Resident #4's Magic Mouthwash was delivered to the facility Monday night. On 07/15/2026 at 12:32 p.m., an interview was conducted with S2DON. She reviewed Resident #4's MAR and verified the Magic Mouthwash had been on hold since Saturday 07/11/2026. At that time, an observation of Med Cart 2 was made with S2DON. S2DON opened Med Cart 2 and Resident #4's Magic Mouthwash was observed to be in the medication cart. Resident #4's Magic Mouthwash had a dispense date of 07/13/2026 which was verified by S2DON. S2DON confirmed the facility had Resident #4's mouthwash since 07/13/2026, and she should have been receiving it per physician orders.

Based on observation and interviews, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure 1 (Medication Cart #1) of 3 Medication Carts observed were kept locked when not under direct observation of authorized staff. Review of the facility's policy titled, Medication Labeling and Storage with a revised date of February 2026 revealed the following, in part:Medication Storage:4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biological are locked when not in use and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.On 07/14/2026 at 11:16 a.m., an observation was made of Med Cart #1 unlocked and unattended near resident rooms. On 07/14/2026 at 11:19 a.m., an interview was conducted with S6LPN. S6LPN stated she was responsible for Med Cart #1. S6LPN confirmed Med Cart #1 was left unattended, unlocked and not within her sight. S6LPN confirmed she should have locked the medication cart prior to leaving it unattended. On 07/14/2026 at 4:21 p.m., an interview was conducted with S2DON. S2DON confirmed all medication carts containing medications should be locked when unattended.

Based on observation and interviews the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure staff with facial hair wore a beard restraint.This deficient practice had the potential to affect any of the 98 residents who received nourishment from the facility's kitchen.On 07/13/2026 at 08:10 a.m. an observation of the facility's kitchen food preparation area was conducted with S4DM. An observation of two male employees both with beards and mustaches not wearing beard restraint while serving morning meal. On 07/14/2026 at 8:18 a.m., an interview was conducted with S4DM. S4DM confirmed S5DS and S6DS were not wearing a beard restraint over their facial hair and should have.On 07/14/25 at 8:18 a.m., an interview was conducted with S1ADM. S1ADM confirmed beard restraints should have been worn by anyone with a facial hair in the food preparation area.

Based on record review, observations, and interviews, the facility failed to provide fluids sufficient to maintain adequate hydration. The facility failed to provide a water pitcher or any fluid for hydration within reach for 1 (#3) of 2 residents reviewed for UTI's. Findings: Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE], with diagnoses which included Dementia and UTI's. Review of Resident #3's Quarterly MDS with an ARD of 06/22/2026 revealed a BIMS of 3, which indicated she was severely cognitively impaired. Further review revealed Resident #3 had no impairment to her upper extremities and was independent for eating. Review of Resident #3's current Care Plan revealed the following, in part:Focus: History of UTI: 03/06/2026; 06/15/2026Interventions: Encourage and assist with fluid intake daily. On 07/13/2026 at 11:30 a.m., an interview was conducted with Resident #3's family member. She stated Resident #3 had a history of UTI's. She stated she visited Resident #3 three times a week. She stated when she visited Resident #3, the resident rarely had water or other fluids at her bedside. She stated if Resident #3 had water at the bedside, it was not within her reach. She stated Resident #3 was able to, and would, drink water independently if it was within her reach. She stated when she visited, she placed Resident #3's water on her bedside table in front of her, and she was able to grab it and drink it when she wanted to. On 07/14/2026 at 8:05 a.m., an observation was made of Resident #3. She was lying in bed with her eyes opened. A cup of water was observed sitting on the left corner of her dresser, which was out of her reach and line of sight. No other fluids were at the bedside. On 07/14/2026 from 10:38 a.m.-2:32 p.m., a continuous observation was made of Resident #3's ice water cup. Her water was observed sitting on the left corner of her dresser, out of her reach and out of her line of sight during this timeframe. No other fluids were kept at the bedside during this timeframe. On 07/14/2026 at 3:35 p.m., an observation was made of Resident #3. She was lying in bed with her eyes opened. A cup of water was observed sitting on the left corner of her dresser, which was out of her reach and out of her line of sight. No other fluids were at the bedside. On 07/15/2026 at 10:16 a.m., an observation was made of Resident #3. She was lying in bed with her eyes opened. Her bedside table was at the bottom of her bed, with no fluids on it. A cup of water was observed on her dresser, behind her head and out of her line of sight. On 07/15/2026 at 11:27 a.m., an interview was conducted with S13CNA. She stated Resident #3 could drink independently. She confirmed Resident #3's cup of water was behind her head, on her dresser, and no other hydration at her bedside. She stated Resident #3's family would put the water on her bedside table in front of her when they visited, but when the family left, staff would put the water back on the dresser. She stated staff kept Resident #3's water on her dresser because if they put it close to her, she would spill it in her bed. On 07/15/2026 at 11:35 a.m., an interview was conducted with Resident #3's family member, who was at Resident #3's bedside. The family member stated when she came in this morning, Resident #3's water was behind her head, on her dresser. The family member stated Resident #3 could not reach the water when it was on her dresser. The family member stated she moved Resident #3's bedside table close to her and placed the water on it. At this time, Resident #3's bedside table was observed over her torso and ice water was observed on the table. Resident #3 was observed to drink 4 ounces of the water independently. On 07/15/2026 at 11:45 a.m., an interview was conducted with S14LPN. She stated Resident #3 could drink independently. She stated if Resident #3 had water or other fluids at her bedside within reach, she would be able to grab it on her own to drink it. She confirmed residents should have hydration within their reach throughout the day. On 07/15/2026 at 12:31 p.m., an interview was conducted with S2DON. She was notified of the above observations. She stated Resident #3 was able to drink independently and should have had hydration within her reach throughout the day.

Based on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding by failing to:1. Ensure free water bags were changed in appropriate timeframe for 1 (#2) of 2 residents reviewed for tube feedings; and2. Ensure free water flushes were administered per physician's orders for 1 (#59) of 2 residents reviewed for tube feedings. Findings: 1. Review of the Clinical Record for Resident #2 revealed she was admitted to the facility on [DATE] with diagnoses, which included Dysphagia Following Cerebral Infarction. Further review revealed a diagnosis of Encounter for Attention to Gastrostomy on 02/11/2026. Review of the current Physician Orders for Resident #2 revealed, in part, the following: Enteral Feed Order every day and night shift for tube feeding.Glucerna 1.5 at 55 ml/hr x22 hours water flush via pump at 40 mL/hr to meet protein and fluid needs. An observation was made on 07/14/2026 at 8:51 a.m., of Resident #2's tube feeding solution spiked and hanging in Resident #2's room currently infusing. Further observations revealed the free water bag was observed to have 400 mls of water in it and was dated 07/12/2026. Observed bag of free water label read: Do not use for greater than 24 hours. An observation was made on 07/14/2026 at 8:54 a.m., of Resident #2's tube feeding with S12LPN. She confirmed Resident #2's free water bag was dated 07/12/2026 and that the bag read Do not use for greater than 24 hours. She stated the free water bag and the tube feed container should be changed every 24 hours. An interview was conducted on 07/15/2026 at 11:50 a.m. with S2DON. She stated both the free water bag and the tube feeding bag should be changed every 24 hours. She was made aware of the above observation and confirmed the free water bag should have been changed on 07/13/2026. 2.Review of Resident #59's clinical record revealed he was admitted to the facility on [DATE] with diagnoses which included Gastrostomy Status.Review of Resident #59's current physician orders revealed in part, the following:Flush PEG tube with 100mL of water every 4 hours. An interview was conducted on 07/13/2026 at 10:00 a.m. with S16LPN. She stated she had not performed the 10:00 a.m. PEG tube water flush for Resident #59 because he was out of his room. She stated Resident #59 had water flushes ordered every 4 hours to maintain his PEG tube.An interview was conducted on 07/13/2026 at 11:20 a.m. with S16LPN. She stated she had not performed the 10:00 a.m. PEG tube water flush for Resident #59 because he was out of his room. She stated Resident #59 had water flushes ordered every 4 hours to maintain his PEG tube.An interview was conducted on 07/13/2026 at 1:05 p.m. with S16LPN. She stated she had not performed the 10:00 a.m. or the 1:00 p.m. PEG tube water flush for Resident #59 because he was out of his room. She stated Resident #59 had water flushes ordered every 4 hours to maintain his PEG tube.An interview was conducted on 07/13/2026 at 3:07 p.m. with S16LPN. She stated she had not performed the 10:00 a.m. or the 1:00 p.m. PEG tube water flush for Resident #59 because he was out of his room. She stated Resident #59 had water flushes ordered every 4 hours to maintain his PEG tube.An interview was conducted on 07/14/2026 at 10:15 a.m. with S5LPN. She stated she had not performed the 10:00 a.m. PEG tube water flush for Resident #59 because he was out of his room. She stated Resident #59 had water flushes ordered every 4 hours to maintain his PEG tube.An interview was conducted on 07/14/2026 at 12:15 p.m. with S5LPN. She stated she had not performed the 10:00 a.m. PEG tube water flush for Resident #59 because he was out of his room. She stated Resident #59 had water flushes ordered every 4 hours to maintain his PEG tube. An interview was conducted on 07/14/2026 at 2:15 p.m. with S5LPN. She stated she had not performed the 10:00 a.m. nor the 1:00 p.m. PEG tube water flush for Resident #59 because he was out of his room. She stated Resident #59 had water flushes ordered every 4 hours to maintain his PEG tube.An observation and interview was conducted on 07/14/2026 at 3:10 p.m. with S5LPN. She stated she had not performed the 10:00 a.m. nor the 1:00 p.m. PEG tube water flush for Resident #59 because he was out of his room. She stated Resident #59 had water flushes ordered every 4 hours to maintain his PEG tube. Observed S5LPN perform a 100mL PEG tube water flush for Resident #59. S5LPN stated this was the first time she had flushed Resident #59's PEG tube today.An interview was conducted on 07/15/2026 at 11:50 a.m. with S2DON. She stated she expected nursing staff to flush Resident #59's PEG tube as ordered every 4 hours. She stated nursing staff had a window of 1 hour before and 1 hour after the scheduled time to flush Resident #59's PEG tube.

Based on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident status by failing to ensure a resident Minimum Data Set (MDS) was accurately coded for Pre-admission Screening and Resident Review (PASRR) for 1 (#102) of 3 sampled residents reviewed for PASRR. Findings: Review of Resident #102's Clinical Record revealed she was admitted to the facility on [DATE] with Form 142 Notification of Medical Certification approved by the state Level II Authority dated 08/27/2025 thru 08/26/2026. Review of Resident #102's Annual MDS with an ARD of 06/09/2026 revealed the following: Section A1500 PASRR was coded 0, which indicated the resident did not have a serious mental illness and/or mental retardation or a related condition. Section A1510 Level II PASRR conditions was blank. An interview was conducted with S15MDS on 07/15/2026 at 1:30 p.m. S15MDS verified Resident #102's Form 142 indicated approval by Level II PASRR authority effective 08/27/2025. She reviewed Resident #102's annual MDS assessment dated [DATE]. S2DON confirmed Section A1500 should have been coded as 1-Yes, and was not. An interview was conducted with S2DON on 07/15/2026 at 1:50 p.m. S2DON verified Resident #102's Form 142 indicated approval by Level II PASRR authority effective 08/27/2025. She reviewed Resident #102's annual MDS assessment dated [DATE]. S2DON confirmed Section A1500 should have been coded as 1-Yes, and was not.

Based on observations, interviews, and record reviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to provide sufficient evidence ongoing monitoring and evaluations were implemented to ensure corrective actions were put in place after identifying residents were not receiving showers. This deficient practice had the potential to affect all residents who required assistance with showering/bathing. Findings: Review of the facility's Quality Improvement Corrective Action Plan dated 01/12/2026, revealed the following, in part:Identified area for improvement: facility identified resident's not receiving showers consistent with their schedule. Actions to implement: 1. if resident is refusing shower, shower aid is to notify floor nurse and floor nurse will sign if resident refuses after checking. Resident may be offered a shower at a later time of day. 2. Shower sheets are turned in to S6CNA for review and a copy is given to S2DON. Objection Measures to evaluate plan effectiveness: S6CNA will monitor daily. A copy of shower sheets will also be placed.(no other words)Person Responsible for oversight: S6CNA Date to be completed: by March 12, 2026Ongoing starts 01/12/2026. Review of Resident #3's Clinical Record revealed he was re-admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemi-paralysis of Left Non-Dominant Side and Cerebral Infarction. Review of Resident #3's Quarterly MDS with an ARD of 12/18/2025 revealed a BIMS of 15, indicating he was cognitively intact. Further review revealed he required substantial/maximum assistance for showering. Review of Resident #3's Bath/Shower Log revealed his scheduled shower days were Mondays, Wednesdays, and Fridays. Further review revealed the following, in part:Wednesday 01/21/2026-blankMonday 01/26/2026-blankFriday 01/30/2026-blankMonday 02/16/2026-blank Review of the facility's written Shower Logs dated January 2026 through 02/18/2026 revealed no documentation for the dates listed above. Review of Resident #3's Nurse's Notes dated January 2026 through 02/18/2026 revealed no documentation of the resident refusing showers. On 02/19/2026 at 10:53 a.m., an observation and interview was conducted with Resident #3. His hair was observed to be oily and white flakes were observed at the top of his forehead and hairline. He stated he was supposed to get showers three times a week but hardly ever received showers three times a week and sometimes only once a week. He confirmed he did not receive a shower on Monday 02/16/2026. On 02/19/2026 at 9:48 a.m., an interview was conducted with S4CNA. She verified she was assigned to Resident #3 on 01/21/2026, 01/26/2026, 01/20/2026, and 02/16/2026. She stated there was no shower aid assigned those days. S4CNA stated she did not give Resident #3 a shower on those days, so he did not get one. On 02/19/2026 at 10:37 a.m., an interview was conducted with S3CNA. She stated she started working as the shower aid on Resident #3's hall at the beginning of February 2026. She stated she was pulled to work the floor on 02/16/2026 so she was unable to give Resident #3 a shower. She stated the resident's assigned CNA was supposed to give the residents a shower if the shower aid was pulled, but most of the time, their showers would not be completed. On 02/19/2026 at 11:14 a.m., an interview was conducted with S6CNA. She stated the assigned CNA should shower residents when the shower aid was pulled to work the floor. She provided three shower logs dated 01/12/2026, 01/17/2026, and 01/24/2026 for Resident #3. She stated these were the only shower logs filled out by the shower aid for the requested timeframe of 01/2026 through 02/18/2026. She reviewed Resident #3's shower log and confirmed there was no documentation he was showered or refused a shower on 01/21/2026, 01/26/2026, 01/30/2026, and 02/16/2026. She confirmed shower logs should be filled out by the CNA completing the showers and were currently not being completed. On 02/19/2026 at 11:27 a.m., an interview was conducted with S2DON. She stated the assigned CNA was responsible for resident's showers when there was no shower aid. She reviewed Resident #3's shower log and confirmed there was no documentation he was showered or refused a shower on 01/21/2026, 01/26/2026, 01/30/2026, and 02/16/2026. She confirmed, unless a resident refused a shower, the shower should be given. She stated she identified residents not receiving showers was an issue in January 2026 and started a QAPI. She stated she was unable to print a copy of the QAPI related to showers. The QAPI was reviewed with S2DON via laptop. After reviewing the QAPI, she confirmed the QAPI corrective actions were not being implemented. On 02/19/2026 at 12:33 p.m., an interview was conducted with S1ADM. S1ADM stated S2DON identified an issue with residents not getting showered last month in January. She stated S2DON started a QAPI related to resident showers. S1ADM was notified of investigation findings related to residents currently not receiving showered and shower logs currently not being completed. S1ADM confirmed the QAPI's corrective actions had not been implemented.

Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (#2) resident of 3 sampled residents.Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #2's Quarterly MDS with an Assessment Reference Date (ARD) of 01/12/2026 revealed Section C, question C0100 should brief interview for mental status be conducted, coded as 0 - no (resident is rarely/never understood). On 02/18/2026 at 11:50 a.m., an interview was conducted with Resident #2. Resident interview revealed Resident #2 was able to hear and understand my questions with no issue. Resident interview further revealed Resident #2 was able to voice answers to my questions with no issue. On 02/19/2026 at 9:51 a.m., an interview was conducted with S7SW. S7SW reviewed Resident #2's Quarterly MDS with an ARD of 01/12/2026. S7SW stated she was responsible for answering all questions of Section C. S7SW stated Resident #2 was able to be understood. S7SW stated coding question C0100 as 0 - no (resident is rarely/never understood) was inaccurate. S7SW stated an MDS assessment should be coded to accurately reflect a resident's status. On 02/19/2026 at 11:33 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #2's Quarterly MDS with an ARD of 01/12/2026. S2DON confirmed the MDS was not coded accurately for question C0100 and should have been.

Based on record review, observation, and interviews, the facility failed to ensure grievances were entered into the grievance log and followed through to resolution for 1 (#2) of 3 residents sampled for grievances, resulting in the potential for unresolved care concerns.Review of the facility's policy titled Grievance Policy and Procedure - Voicing and Resolution, revised date 11/2025, revealed the following, in part:Policy:Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents and other concerns regarding their stay. Procedure:3. Grievance will be written on the home's grievance/complaint report form.6. The home will keep a grievance/complaint log outlining each grievance/complain and the disposition of the complaint. 8. Home will upon resolution of grievance, follow-up in a timely manner to assure that resolution has been successful. Review of Resident #2's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses including Unspecified Focal Traumatic Brain Injury, Dementia with other Behavioral Disturbance, and Persistent Mood Affective Disorder. Review of Resident #2's Progress Note, dated 01/20/2026, revealed the following, in part:Created By: S7SWNote Text: Resident care plan meeting was held today. The only concern he had was bath times and not getting in timely manner. Addressed with CNA supervisor. Review of the facility's Grievance Logs, dated November 2025 to February 2025, revealed no entries for Resident #2. On 02/18/2026 at 8:40 a.m., an observation was made of Resident #2, in his room, eating breakfast while seated in his wheelchair. Resident #2's room noted to have a strong smell of urine. On 02/18/2026 at 12:39 p.m., an interview was conducted with S7SW. S7SW stated she was the grievance officer at the facility. S7SW reviewed Resident #2's progress note dated 01/20/2026. S7SW stated she considered Resident #2's bath concerns a grievance. S7SW stated she notified the CNA supervisor of the complaint. S7SW stated she did not complete a grievance form or log an entry on the grievance log and should have. S7SW stated she did not follow-up with Resident #2 to ensure his concern was resolved. On 02/19/2026 at 12:33 p.m., an interview was conducted with S1ADM. S1ADM stated S7SW was the grievance officer at the facility. S1ADM stated she considered any issues with care, including bath concerns, a grievance. S1ADM confirmed S7SW should have filled out a grievance form and followed-up to ensure Resident #2's grievance was resolved.

The facility failed to ensure it was administered in a manner that effectively used its resources for 1 (#61) of 4 (#6, #61, #85, and #103) residents reviewed for falls. The facility failed to have an effective system in place to ensure a care plan intervention of sitter at bedside was continuously implemented for Resident #61 to prevent falls. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. Resident #61 was sent to the emergency room for evaluation and head CT revealed a new subacute subdural hematoma. Resident #61 was then admitted to the neurological Intensive Care Unit through 05/27/2025. When Resident #61 returned to the facility, he only received staff supervision at bedside as the staffing schedule would allow which placed the resident at a likelihood to fall again and sustain serious injury, harm, impairment, or death. The Resident had another unwitnessed fall on 05/29/2025. S1ADM was notified of the Immediate Jeopardy on 06/12/2025 at 2:51 p.m. This deficient practice continued at the potential for more than minimal harm for any residents residing in the facility whom required increased supervision. The Immediate Jeopardy was removed on 06/13/2025 at 4:17 p.m., as confirmed by onsite verification through record review and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross Reference F656 and F689 Review of Resident #61's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included an admitting diagnosis of Traumatic Subdural Hemorrhage with Loss of Consciousness, Repeated Falls, Fracture of Unspecified Part of Neck of Right Femur, and Cerebral Edema. Review of Resident #61's 5 Day MDS with an ARD of 06/03/2025 revealed a BIMS of 9, which indicated the resident was moderately cognitively impaired. Further review revealed he was coded for history of falls and required moderate assistance with mobility. Review of Resident #61's most recent Care Plan revealed in part, the following: Problem: I am at risk for falls related to recent fall and history of subdural hematoma. Interventions: 05/03/2025 Fall - No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 Fall - No injuries observed. Non-skid footwear placed on resident, brought to hospital. 05/13/2025 Fall - Sitter at bedside for supervision. Educated staff on fall prevention. 05/18/2025 Fall - Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks every 1 hour monitoring to be initiated upon return. 05/29/2025 Fall - Neurological checks every 1 hour monitoring to be initiated upon return. 1:1 at bedside. 1:1 not present during fall, staff education on 1:1 protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Helmet as per order and non-skid footwear. Review of the Incident Log revealed Resident #61 had 4 unwitnessed falls and 1 witnessed fall since admission on [DATE]. Unwitnessed falls: 05/03/2025, 05/12/2025, 05/18/2025, and 05/29/2025. Witnessed falls: 05/13/2025. Review of Resident #61's Nurse's Notes dated 05/02/2025 revealed in part, the following: 5:39 p.m., Resident discharged from a prior rehab facility because resident had a recent subdural hematoma status post craniotomy with evacuation March 2025. Review of Resident #61's Incident Reports revealed in part, the following: 05/03/2025 Resident #61 found on floor. No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 CNA outside of room, heard thump. Resident #61 slid out of bed onto mattress. Non-skid footwear placed on resident. 05/13/2025 Resident #61 had a witnessed fall in his bathroom while getting assistance to use the toilet. Resident lost his balance, stumbled and fell backwards and hit his head. Resident was alert and noted to be bleeding from the back of his head. Resident was assessed and sent to hospital for further treatment. Neurological checks, 1 hour monitoring initiated. Fall mat placed back at bedside. Sitter at bedside for supervision. Staff educated on importance of fall prevention. 05/18/2025 S22CNA stated she had just stepped away from the room and returned less than a minute and Resident #61 was on floor. Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks, 1 hour monitoring to be initiated upon return. Review of hospital records for Resident #61 dated 05/18/2025 revealed in part, the following: [AGE] year old male patient with a past medical history of recent subdural hematoma (post craniotomy with subdural hematoma evacuation 03/22/2025) presented to hospital after being found down next to his bed sustaining an unwitnessed fall. Patient does have a hematoma and bruising on his right side of head. Compared to the prior study, CT of the head shows there is interval development of a subacute subdural hemorrhage with minimal acute component along the right cerebral convexity measuring 8 mm with subtle effacement of the adjacent right cerebral convexity sulci. The resident will be placed in the neurological Intensive Care Unit and admitted to neurosurgery for a higher level of care and closer neurological monitoring. Review of hospital Physical Therapy Evaluation and Treatment for Resident #61 dated 05/20/2025 revealed in part, the following: Assessment: [AGE] year old male admitted with a medical diagnosis of subdural hematoma. If patient does not discharge to moderate intensity therapy, patient will need 24/7 supervision due to frequent falls and decreased safety awareness/cognitive impairment. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/28/2025. Evaluation status post hospital stay at local hospital. Diagnosis: subdural hematoma. Plan: Subdural hematoma with recurrent falls and history of craniotomy: Readmit for skilled nursing services. Continue sitter at bedside. Review of Resident #61's Incident Reports revealed in part, the following: 05/29/2025 Resident #61 discovered on floor in room. NP instructed to continue monitoring as per protocol and report any changed from baseline. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Neurological checks, 1 hour monitoring initiated. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/31/2025. Patient just returned back to facility from the acute setting diagnosed with subdural hematoma. Yesterday, patient sustained a fall unwitnessed. Plan: Recurrent falls: continue sitter at bedside. Review of Resident #61's Nurse's Notes dated 05/29/2025 revealed in part, the following: 11:37 p.m. Resident discovered on floor in room. 1:1 staff supervision not present during fall, staff education on 1:1 protocol given. On 06/11/2025 at 10:53 a.m., an interview was conducted with S19ADON. She stated she was responsible for reviewing resident's falls, and adjusting or implementing care plan interventions after the falls. She explained after a fall, she would copy the Immediate Action Taken section in the incident report and paste it into the resident's care plan as the intervention. She stated after Resident #61's fall on 05/03/2025, the nurse implemented an intervention immediately after of sitter at bedside. S2ADON said post fall she copied that intervention from the incident report onto the current care plan as the implemented intervention. She stated this intervention was not intended to be ongoing, but she did not put an end date or duration to indicate that it should be stopped. She reviewed the incident logs and confirmed for the falls dated 05/12/2025, 05/18/2025, and 05/29/2025, a sitter was not at the bedside. She stated the facility was not obligated to provide sitters at all times, only when extra staff was available. She said if staff was available the facility would assign a staff member to sit with Resident #61 to assist with fall prevention. She said if an assigned staff member needed to take a break, they were entitled to their break and did not need to find a replacement to supervise Resident #61. She stated staff was doing the best they could to prevent Resident #61 from falling. On 06/11/2025 at 11:28 a.m., an interview was conducted with S20CNA. She stated she worked on Resident #61's hall on the night of 05/18/2025. She stated she did not recall anyone being assigned 1:1 staff supervision to Resident #61 when he fell that night. She stated on 05/18/2025, S22CNA walked out of Resident #61's room and he fell. She stated he started complaining of his neck hurting, she reported it to S23LPN and he was sent out to the ER. She stated when he first admitted to the facility, she was told he had a history of a brain bleed. She stated he was very active and constantly wanted to get out of bed. She stated staff sat with him when extra staff was available, but not every shift. On 06/11/2025 at 11:35 a.m., an interview was conducted with S21CNA. She stated Resident #61 attempted to get out of bed constantly, was impulsive, and fell often. She stated she had worked 1:1 staff supervision with him a few times, but someone was not always assigned to sit with him. She stated he would try to get up and fall if someone wasn't watching him. On 06/11/2025 at 1:15 p.m., an interview was conducted with S2DON. She stated after a resident had a fall, she expected S19ADON to follow up with the resident or nurse to find out what happened, then enter appropriate interventions in the care plan. She stated S19ADON should not have copied and pasted part of the incident report into the resident's care plan as the interventions. She stated when 'verbiage such as sitters at bedside was placed in the care plan, there should be a duration or timeframe documented. S2DON reviewed Resident #61's care plan and confirmed sitter at bedside was listed as an intervention with no duration or end date. S2DON explained Resident #61 was never supposed to have ongoing 1:1 staff supervision and it was just something we are doing to try to prevent him from falling. She stated she did not know S19ADON and S24CNA were scheduling sitters to supervise Resident #61 when extra staff was available. She stated she was aware Resident #61 was impulsive at times. She stated she was not aware S25NP recommended 1:1 staff supervision for Resident #61. On 06/11/2025 at 1:48 p.m., an interview was conducted with S25NP. She stated she was familiar with Resident #61. She stated her main concerns with the resident was lack of sleep and agitation at night. She stated having sitters at bedside has been the most effective intervention for fall prevention for him. She stated Resident #61 was impulsive, unsteady, and a fall risk. She stated staff should have eyes on him at all times. She stated her concern with him being left unsupervised for any period of time would be him falling and sustaining another head injury. On 06/11/2025 at 1:57 p.m., an interview was conducted with S24CNA. He stated Resident #61 was impulsive and would only sleep in 20 minutes increments, then wake up and try to get up. He stated most nights, someone was assigned to sit with him, but not always. On 06/13/2025 at 9:08 a.m., an interview was conducted with S23LPN. She stated she was working on 05/18/2025 when Resident #61 fell. She stated she could not remember if someone was assigned to sit with him that night. She stated if there was extra staff, someone was assigned to him, but if there was only 1 CNA scheduled on the hall, the CNA would sit outside of his room and try to watch him and the call lights. She stated if that CNA had to assist another resident or answer a call light, no one would watch Resident #61. She stated Resident #61 slept for very short periods of time, in 10-15 minute increments, and was pretty impulsive. She stated the resident did not have an order for 1:1 staff supervision, and the facility tried to put extra staff with him to prevent falls. On 06/13/2025 at 9:27 a.m., an interview was conducted with S22CNA. She stated Resident #61 was oriented sometimes, but he was also forgetful and confused. She stated he constantly got up and down out of bed. She stated she had been assigned to sit with him at times, but sometimes he did not have a sitter when she worked the hall. She stated when the resident fell the night of 05/18/2025, he did not have 1:1 staff supervision. She stated the intervention of sitters at bedside was put in place to help prevent Resident #61 from falling, but sitters were not at the bedside every night. On 06/13/2025 at 9:46 a.m., an interview was conducted with S26LPN. She stated Resident #61 was impulsive, and would not wait for help when he needed it. She stated on 05/29/2025, Resident #61 had an assigned sitter. She stated the assigned sitter, S24CNA, stepped out of his room and the resident fell. She stated Resident #61 was very quiet and very fast. She stated having 1:1 staff supervision for the resident prevented him from falling. On 06/13/2025 at 3:35 p.m., staff interviews revealed Resident #61 was admitted to the hospital on [DATE] after a follow-up head CT for further evaluation. The facility had implemented the following actions to correct the deficient practice: 1. On 06/11/2025, the sitter at bedside/l:1 monitoring was discontinued on the fall care plan. 2. On 06/12/2025, 100% review of the current fall care plans revealed no other resident had a fall care plan with sitter at bedside/on 1:1 monitoring. 3. On 06/12/2025, Resident #61 was admitted to the hospital following a medical appointment. In the event Resident were to return to the facility, 1:1 monitoring would be initiated. Resident #61 will be reassessed by the nursing staff and NP to determine the continuation of the 1:1 monitoring based on his needs. 4. If Resident #61 returns to the facility, he will receive a fall risk assessment to determine the appropriate interventions to be implemented. 5. Regional nurse provided education on 06/12/2025 to nursing administrative team, including the DON, ADON, Infection Preventionist/QA, and MDS, regarding fall prevention including adding, implementing, and monitoring effectiveness of appropriate interventions consistent with current professional standards. 6. Regional Nurse will monitor for compliance weekly for 4 weeks. 7. Any findings and plan will be taken through the facilities Quality Assurance Performance Improvement (QAPI) Process for review and revision as needed. 8. The facility asserts the likelihood for serious harm to any resident with a care plan of sitter at bedside/l:1 monitoring no longer exists as of 06/13/2025. 9. The facility will ascertain substantial compliance by 06/13/2025. Throughout the survey from 06/12/2025 to 06/13/2025, interviews and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on proper 1:1 monitoring and how to identify what residents required monitoring while following care plan interventions.

Based on interviews and record review, the facility failed to ensure residents received adequate supervision to prevent avoidable falls for 1 (#61) of 4 (#6, #61, #85, and #103) residents reviewed for falls. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. Resident #61 was sent to the emergency room for evaluation and head CT revealed a new subacute subdural hematoma. Resident #61 was then admitted to the neurological Intensive Care Unit through 05/27/2025. When Resident #61 returned to the facility, he only received staff supervision at bedside as the staffing schedule would allow which placed the resident at a likelihood to fall again and sustain serious injury, harm, impairment, or death. The Resident had another unwitnessed fall on 05/29/2025. S1ADM was notified of the Immediate Jeopardy on 06/12/2025 at 2:51 p.m. This deficient practice continued at the potential for more than minimal harm for any resident residing in the facility whom required increased supervision. The Immediate Jeopardy was removed on 06/13/2025 at 4:17 p.m., as confirmed by onsite verification through record review and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross Reference F656 Review of Resident #61's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included an admitting diagnosis of Traumatic Subdural Hemorrhage with Loss of Consciousness, Repeated Falls, Fracture of Unspecified Part of Neck of Right Femur, and Cerebral Edema. Review of Resident #61's 5 Day MDS with an ARD of 06/03/2025 revealed a BIMS of 9, which indicated the resident was moderately cognitively impaired. Further review revealed he was coded for history of falls and required moderate assistance with mobility. Review of Resident #61's most recent Care Plan revealed in part, the following: Problem: I am at risk for falls related to recent fall and history of subdural hematoma. Interventions: 05/03/2025 Fall - No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 Fall - No injuries observed. Non-skid footwear placed on resident, brought to hospital. 05/13/2025 Fall - Sitter at bedside for supervision. Educated staff on fall prevention. 05/18/2025 Fall - Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks every 1 hour monitoring to be initiated upon return. 05/29/2025 Fall - Neurological checks every 1 hour monitoring to be initiated upon return. 1:1 at bedside. 1:1 not present during fall, staff education on 1:1 protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Helmet as per order and non-skid footwear. Review of the Incident Log revealed Resident #61 had 4 unwitnessed falls since admission on [DATE]. Unwitnessed falls: 05/03/2025, 05/12/2025, 05/18/2025, and 05/29/2025. Review of Resident #61's Nurse's Notes dated 05/02/2025 revealed in part, the following: 5:39 p.m., Resident discharged from a prior rehab facility because resident had a recent subdural hematoma status post craniotomy with evacuation March 2025. Review of Resident #61's Incident Reports revealed in part, the following: 05/03/2025 Resident #61 found on floor. No injuries observed. Fall mat at bedside. Sitters initiated at bedside. 05/12/2025 CNA outside of room, heard thump. Resident #61 slid out of bed onto mattress. 05/18/2025 S22CNA stated she had just stepped away from the room and returned less than a minute and Resident #61 was on floor. Send to hospital for evaluation and treatment. Review of facility's Emergency Transfer Log revealed Resident #61 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of hospital records for Resident #61 dated 05/18/2025 revealed in part, the following: [AGE] year old male patient with a past medical history of recent subdural hematoma (post craniotomy with subdural hematoma evacuation 03/22/2025) presented to hospital after being found down next to his bed sustaining an unwitnessed fall. Patient does have a hematoma and bruising on his right side of head. Compared to the prior study, CT of the head shows there is interval development of a subacute subdural hemorrhage with minimal acute component along the right cerebral convexity measuring 8 mm with subtle effacement of the adjacent right cerebral convexity sulci. The resident will be placed in the neurological Intensive Care Unit and admitted to neurosurgery for a higher level of care and closer neurological monitoring. Review of hospital Physical Therapy Evaluation and Treatment for Resident #61 dated 05/20/2025 revealed in part, the following: Assessment: [AGE] year old male admitted with a medical diagnosis of subdural hematoma. Recommending moderate intensity therapy on discharge to increase safety and maximize functional outcomes. If patient does not discharge to moderate intensity therapy, patient will need 24/7 supervision due to frequent falls and decreased safety awareness/cognitive impairment. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/28/2025. Evaluation status post hospital stay at local hospital. Diagnosis: subdural hematoma. Plan: Subdural hematoma with recurrent falls and history of craniotomy: Readmit for skilled nursing services. Continue with sitter at bedside. Fall precautions. Review of Resident #61's Incident Reports revealed in part, the following: 05/29/2025 Resident #61 discovered on floor in room. NP instructed to continue monitoring as per protocol and report any changed from baseline. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/31/2025. Patient just returned back to facility from the acute setting diagnosed with subdural hematoma. Yesterday, patient sustained a fall unwitnessed. Plan: Recurrent falls: continue sitter at bedside. Review of Resident #61's Nurse's Notes dated 05/29/2025 revealed in part, the following: 11:37 p.m. Resident discovered on floor in room. 1:1 staff supervision not present during fall, staff education on 1:1 protocol given. On 06/11/2025 at 10:53 a.m., an interview was conducted with S19ADON. She stated Resident #61 had several falls since admission to the facility. She stated because of Resident #61's history of a subdural hematoma with craniotomy, after his fall on 05/03/2025, a sitter at bedside was initiated on his care plan. She reviewed the incident logs and confirmed for the falls dated 05/12/2025, 05/18/2025, and 05/29/2025, a sitter was not present at the bedside. She said if staff was available the facility would assign a staff member to sit with Resident #61 to assist with fall prevention. She said if an assigned staff member needed to take a break, they were entitled to their break and did not need to find a replacement to supervise Resident #61. She stated the facility was not obligated to provide sitters at all times, only when extra staff was available. On 06/11/2025 at 11:28 a.m., an interview was conducted with S20CNA. She said staff were assigned to supervise Resident #61 when enough staff was available to help prevent him from falling. She stated on the night of 05/18/2025, no one was assigned 1:1 staff supervision to Resident #61. She stated S22CNA walked out of Resident #61's room and he fell. She stated he started complaining of his neck hurting, she reported it to S23LPN and he was sent out to the ER. She stated he was very active and constantly attempted to get out of bed. On 06/13/2025 at 9:27 a.m., an interview was conducted with S22CNA. She stated she was familiar with Resident #61. She stated he constantly got up and down out of bed. She stated she had been assigned to sit with him at times to prevent falls, but sometimes he did not have a sitter when she worked the hall. She stated the night of 05/18/2025, he did not have 1:1 staff supervision. She stated she found the resident on the floor in front of the fall mat. She stated he complained of neck pain and was sent to the hospital. She stated the intervention of sitters at bedside was put in place to help prevent Resident #61 from falling, but sitters were not at the bedside every night. On 06/13/2025 at 9:08 a.m., an interview was conducted with S23LPN. She stated she was working on 05/18/2025 when Resident #61 fell. She stated S22CNA informed her she had just stepped away from the resident's room when he fell. She stated Resident #61 slept for very short periods of time, in 10-15 minute increments, and was pretty impulsive. She stated if there was only 1 CNA scheduled on the hall, no one would be assigned at bedside to supervise Resident #61. On 06/11/2025 at 1:57 p.m., an interview was conducted with S24CNA. He stated he was familiar with Resident #61. He stated Resident #61 would only sleep in 20 minutes increments, then would wake up and try to get up. He stated Resident #61 was impulsive. He stated he was sitting with Resident #61 on 05/29/2025 while the assigned sitter was on break. She stated he stepped out of Resident #61's room thinking the resident was asleep. He stated Resident #61 fell and was found right beside the mattress on the floor with no injuries. He stated the resident was sleeping when he left the room, and confirmed if he wouldn't have left the room, he could have prevented the resident from getting out of the bed and falling. He stated when staff was in the room with Resident #61, it prevented him from falling. On 06/13/2025 at 9:46 a.m., an interview was conducted with S26LPN. She stated she was familiar with Resident #61. She stated Resident #61 was impulsive, and would not wait for help when he needed it. She stated she was working on 05/29/2025 when Resident #61 was found on his floor. She stated she was shocked the resident fell because he had an assigned sitter that night. She stated the assigned sitter, S24CNA, stepped out of his room and did not notify her. She stated if the sitter needed to leave, the nurse should have been notified so the other CNA could have sat with him for supervision. She stated staff should not have left him since he was 1:1. She stated Resident #61 was very quiet and very fast. She stated having 1:1 staff supervision for the resident prevented him from falling. On 06/11/2025 at 1:48 p.m., an interview was conducted with S25NP. She stated she was familiar with Resident #61. She stated she could not recall the date sitters at bedside were implemented for Resident #61, but it had been a while. She stated having sitters at bedside had been the most effective intervention for fall prevention for him. She stated Resident #61 was impulsive, unsteady, and a fall risk. She stated she expected staff to keep eyes on him at all times. She stated her concern with him being left unsupervised for any period of time would be him falling and sustaining another head injury. On 06/11/2025 at 1:15 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #61's care plan and confirmed sitter at bedside was listed as an intervention for fall prevention with no duration or end date. S2DON stated Resident #61 was never supposed to have ongoing 1:1 staff supervision and stated it was just something we are doing to try to prevent him from falling when extra staff was available. She stated she was not aware S25NP recommended 1:1 staff supervision for Resident #61. She stated she was not aware S19ADON and S24CNA continued to schedule 1:1 supervision for Resident #61 when staff were available to prevent falls. On 06/13/2025 at 3:35 p.m., staff interviews revealed Resident #61 was admitted to the hospital on [DATE] after a follow-up head CT for further evaluation. The facility had implemented the following actions to correct the deficient practice: 1. On 06/11/2025, the sitter at bedside/l:1 monitoring was discontinued on the fall care plan. 2. On 06/12/2025, 100% review of the current fall care plans revealed no other resident had a fall care plan with sitter at bedside/on 1:1 monitoring. 3. On 06/12/2025, Resident #61 was admitted to the hospital following a medical appointment. In the event Resident were to return to the facility, 1:1 monitoring would be initiated. Resident #61 will be reassessed by the nursing staff and NP to determine the continuation of the 1:1 monitoring based on his needs. 4. If Resident #61 returns to the facility, he will receive a fall risk assessment to determine the appropriate interventions to be implemented. 5. Regional nurse provided education on 06/12/2025 to nursing administrative team, including the ADON, regarding fall prevention including adding, implementing, and monitoring effectiveness of appropriate interventions consistent with current professional standards. 6. The clinical staff received in-servicing by nursing administration on not leaving the room without relief when scheduled for 1:1 monitoring beginning on 06/12/2025 and will be completed 06/13/2025. Clinical staff will not be scheduled until receiving this in-service. 7. On 06/13/2025, the DON/designee reviewed recent falls in the daily weekday morning meetings. DON/designee will continue to monitor recent falls for appropriate interventions on weekdays for 4 weeks. 8. If the facility identifies a resident requiring sitter at bedside/1:1 monitoring this will be monitored by DON/designee weekly until this monitoring is no longer needed. 9. Any findings and plan will be taken through the facilities Quality Assurance Performance Improvement (QAPI) Process for review and revision as needed. 10. The facility asserts the likelihood for serious harm to any resident with a care plan of sitter at bedside/l:1 monitoring no longer exists as of 06/13/2025. 11. The facility will ascertain substantial compliance by 06/13/2025. Throughout the survey from 06/12/2025 to 06/13/2025, interviews and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on proper 1:1 monitoring and how to identify what residents required monitoring while following care plan intervention.

Based on record review and interviews, the provider failed to implement a comprehensive person-centered care plan to meet the needs of 2 (#61 and #84) of 25 sampled residents. The facility failed to ensure: 1. Staff consistently implemented an intervention of sitters at bedside for supervision for Resident #61; and 2. Staff scheduled an order neurology consultation for Resident #84. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. Resident #61 was sent to the emergency room for evaluation and head CT revealed a new subacute subdural hematoma. Resident #61 was then admitted to the neurological Intensive Care Unit through 05/27/2025. When Resident #61 returned to the facility, he only received staff supervision at bedside as the staffing schedule would allow which placed the resident at a likelihood to fall again and sustain serious injury, harm, impairment, or death. The Resident had another unwitnessed fall on 05/29/2025. S1ADM was notified of the Immediate Jeopardy on 06/12/2025 at 2:51 p.m. This deficient practice continued at the potential for more than minimal harm for the current 109 residents residing in the facility whom required a comprehensive person-centered care plan to meet their needs. The Immediate Jeopardy was removed on 06/13/2025 at 4:17 p.m., as confirmed by onsite verification through record review and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: 1. Review of Resident #61's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included an admitting diagnosis of Traumatic Subdural Hemorrhage with Loss of Consciousness, Repeated Falls, Fracture of Unspecified Part of Neck of Right Femur, and Cerebral Edema. Review of Resident #61's 5 Day MDS with an ARD of 06/03/2025 revealed a BIMS of 9, which indicated the resident was moderately cognitively impaired. Further review revealed he was coded for history of falls and required moderate assistance with mobility. Review of Resident #61's most recent Care Plan revealed in part, the following: Problem: I am at risk for falls related to recent fall and history of subdural hematoma. Interventions: 05/03/2025 Fall - No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 Fall - No injuries observed. Non-skid footwear placed on resident, brought to hospital. 05/13/2025 Fall - Sitter at bedside for supervision. Educated staff on fall prevention. 05/18/2025 Fall - Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks every 1 hour monitoring to be initiated upon return. 05/29/2025 Fall - Neurological checks every 1 hour monitoring to be initiated upon return. 1:1 at bedside. 1:1 not present during fall, staff education on 1:1 protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Helmet as per order and non-skid footwear. Review of the Incident Log revealed Resident #61 had 4 unwitnessed falls and 1 witnessed fall since admission on [DATE]. Unwitnessed falls: 05/03/2025, 05/12/2025, 05/18/2025, and 05/29/2025. Witnessed falls: 05/13/2025. Review of Resident #61's Nurse's Notes dated 05/02/2025 revealed in part, the following: 5:39 p.m., Resident discharged from a prior rehab facility because resident had a recent subdural hematoma status post craniotomy with evacuation March 2025. Review of Resident #61's Incident Reports revealed in part, the following: 05/03/2025 Resident #61 found on floor. No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 CNA outside of room, heard thump. Resident #61 slid out of bed onto mattress. Non-skid footwear placed on resident. 05/13/2025 Resident #61 had a witnessed fall in his bathroom while getting assistance to use the toilet. Resident lost his balance, stumbled and fell backwards and hit his head. Resident was alert and noted to be bleeding from the back of his head. Resident was assessed and sent to hospital for further treatment. Neurological checks, 1 hour monitoring initiated. Fall mat placed back at bedside. Sitter at bedside for supervision. Staff educated on importance of fall prevention. 05/18/2025 S22CNA stated she had just stepped away from the room and returned less than a minute and Resident #61 was on floor. Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks, 1 hour monitoring to be initiated upon return. Review of hospital records for Resident #61 dated 05/18/2025 revealed in part, the following: [AGE] year old male patient with a past medical history of recent subdural hematoma (post craniotomy with subdural hematoma evacuation 03/22/2025) presented to hospital after being found down next to his bed sustaining an unwitnessed fall. Patient does have a hematoma and bruising on his right side of head. Compared to the prior study, CT of the head shows there is interval development of a subacute subdural hemorrhage with minimal acute component along the right cerebral convexity measuring 8 mm with subtle effacement of the adjacent right cerebral convexity sulci. The resident will be placed in the neurological Intensive Care Unit and admitted to neurosurgery for a higher level of care and closer neurological monitoring. Review of hospital Physical Therapy Evaluation and Treatment for Resident #61 dated 05/20/2025 revealed in part, the following: Assessment: [AGE] year old male admitted with a medical diagnosis of subdural hematoma. He presents with the following impairments/functional limitations: weakness, impaired endurance, impaired self-care skills, impaired functional mobility, gait instability, impaired balance, impaired cognition, decreased coordination, decreased safety awareness, impaired cardiopulmonary response to activity. Required consistent cueing for safety throughout session. Recommending moderate intensity therapy on discharge to increase safety and maximize functional outcomes. If patient does not discharge to moderate intensity therapy, patient will need 24/7 supervision due to frequent falls and decreased safety awareness/cognitive impairment. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/28/2025. Evaluation status post hospital stay at local hospital. Diagnosis: subdural hematoma. Plan: Subdural hematoma with recurrent falls and history of craniotomy: Readmit for skilled nursing services. Continue with safety helmet and sitter at bedside. Fall precautions. Review of Resident #61's Incident Reports revealed in part, the following: 05/29/2025 Resident #61 discovered on floor in room. NP instructed to continue monitoring as per protocol and report any changed from baseline. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Neurological checks, 1 hour monitoring initiated. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/31/2025. Patient just returned back to facility from the acute setting diagnosed with subdural hematoma. Yesterday, patient sustained a fall unwitnessed. Patient was observed crawling around on the floor in his room. Plan: Recurrent falls: continue fall precautions. Monitor vital signs and neurological checks, continue safety helmet and sitter at bedside. Review of Resident #61's Nurse's Notes dated 05/29/2025 revealed in part, the following: 11:37 p.m. Resident discovered on floor in room. 1:1 staff supervision not present during fall, staff education on 1:1 protocol given. On 06/11/2025 at 10:53 a.m., an interview was conducted with S19ADON. She stated she was responsible for reviewing resident's falls, and adjusting or implementing care plan interventions after the falls. She stated Resident #61 had several falls since admission to the facility. She stated because of Resident #61's history of a subdural hematoma with craniotomy, after his fall on 05/03/2025, a helmet was ordered and sitter at bedside was initiated on his care plan. She reviewed the incident logs and confirmed for the falls dated 05/12/2025, 05/18/2025, and 05/29/2025, a sitter was not at the bedside. She stated the facility was not obligated to provide sitters at all times, only when extra staff was available. She stated the intervention added to the care plan on 05/03/2025 regarding a sitter at the bedside was an immediate intervention implemented by the nurse after the fall, and was not intended to be an ongoing intervention. She explained after a fall, she would copy the Immediate Action Taken section in the incident report and paste it into the resident's care plan as the intervention. She confirmed the sitter at bedside intervention did not have an end date or duration. She said if staff was available the facility would assign a staff member to sit with Resident #61 to assist with fall prevention. She said if an assigned staff member needed to take a break, they were entitled to their break and did not need to find a replacement to supervise Resident #61. She stated staff was doing the best they could to prevent Resident #61 from falling. On 06/11/2025 at 11:28 a.m., an interview was conducted with S20CNA. She stated she worked on Resident #61's hall on the night of 05/18/2025. She stated she did not recall anyone being assigned 1:1 staff supervision to Resident #61 when he fell that night. She stated on 05/18/2025, S22CNA walked out of Resident #61's room and he fell. She stated staff got him to his wheelchair and put him at the nurse's station. She stated he started complaining of his neck hurting, she reported it to S23LPN and he was sent out to the ER. She stated when he first admitted to the facility, she was told he had a history of a brain bleed. She stated he was very active and constantly wanted to get out of bed. She stated staff sat with him when extra staff was available, but not every shift. On 06/11/2025 at 11:35 a.m., an interview was conducted with S21CNA. She stated Resident #61 attempted to get out of bed constantly. She stated she had worked 1:1 staff supervision with him a few times. She stated when she sat with him, she had to keep eyes on him at all times as he was very impulsive and fell often. She stated she couldn't leave the room unless the resident was with her or someone else was watching him or he would try to get up and fall. On 06/11/2025 at 1:15 p.m., an interview was conducted with S2DON. She stated after a resident had a fall, she expected S19ADON to follow up with the resident or nurse to find out what happened, then enter appropriate interventions in the care plan. She stated S19ADON should not have copied and pasted part of the incident report into the resident's care plan as the interventions. She stated when 'verbiage such as sitters at bedside was placed in the care plan, there should be a duration or timeframe documented. S2DON reviewed Resident #61's care plan and confirmed sitter at bedside was listed as an intervention with no duration or end date. S2DON explained Resident #61 was never supposed to have ongoing 1:1 staff supervision and it was just something we are doing to try to prevent him from falling. She stated she did not know S19ADON and S24CNA were scheduling sitters to supervise Resident #61 when extra staff was available. She stated she was aware Resident #61 was impulsive at times. She stated since Resident #61 had not sustained a fall recently, she would be discontinuing the staff sitting with him. She stated she was not aware S25NP recommended 1:1 staff supervision for Resident #61. On 06/11/2025 at 1:48 p.m., an interview was conducted with S25NP. She stated she was familiar with Resident #61. She stated her main concerns with the resident was lack of sleep and agitation at night. She stated having sitters at bedside has been the most effective intervention for fall prevention for him. She stated Resident #61 was impulsive, unsteady, and a fall risk. She stated staff should have eyes on him at all times. She stated her concern with him being left unsupervised for any period of time would be him falling and sustaining another head injury. On 06/11/2025 at 1:57 p.m., an interview was conducted with S24CNA. He stated he was familiar with Resident #61. He stated Resident #61 would only sleep in 20 minutes increments, then wake up and try to get up. He stated Resident #61 was impulsive. He stated most nights, someone was assigned to sit with him, but not always. He stated he was sitting with Resident #61 on 05/29/2025, and stepped out of his room thinking the resident was asleep. He stated Resident #61 fell and was found right beside the mattress on the floor with no injuries. He confirmed when staff was in the room with Resident #61, it prevented him from falling. He stated the resident was sleeping when he left the room, and confirmed if he wouldn't have left the room, he could have prevented the resident from getting out of the bed and falling. On 06/13/2025 at 9:08 a.m., an interview was conducted with S23LPN. She stated she was working on 05/18/2025 when Resident #61 fell. She stated S22CNA informed her she had just stepped away from the resident's room when he fell. She stated she could not remember if someone was assigned to sit with him that night. She stated if there was extra staff, someone was assigned to him, but if there was only 1 CNA scheduled on the hall, the CNA would sit outside of his room and try to watch him and the call lights. She stated if that CNA had to assist another resident or answer a call light, no one would watch Resident #61. She stated Resident #61 slept for very short periods of time, in 10-15 minute increments, and was pretty impulsive. She stated the resident did not have an order for 1:1 staff supervision, and the facility tried to put extra staff with him to prevent falls. On 06/13/2025 at 9:27 a.m., an interview was conducted with S22CNA. She stated she was familiar with Resident #61. She stated sometimes he was oriented, but he was also forgetful and confused. She stated he constantly got up and down out of bed. She stated she had been assigned to sit with him at times, but sometimes he did not have a sitter when she worked the hall. She stated the night of 05/18/2025, he did not have 1:1 staff supervision. She stated she found the resident on the floor in front of the fall mat. She stated he complained of neck pain and was sent to the hospital. She stated the intervention of sitters at bedside was put in place to help prevent Resident #61 from falling, but sitters were not at the bedside every night. On 06/13/2025 at 9:46 a.m., an interview was conducted with S26LPN. She stated she was familiar with Resident #61. She stated Resident #61 was impulsive, and would not wait for help when he needed it. She stated she was working on 05/29/2025 when Resident #61 was found on his floor. She stated Resident #61 was found on the floor at about 11:37 p.m. She stated she was shocked the resident fell because he had an assigned sitter that night. She stated the assigned sitter, S24CNA, stepped out of his room and did not notify her. She stated the resident woke up and got out of bed during that time. She stated if the sitter needed to leave, the nurse should have been notified or the other CNA could have sat with him. She stated Resident #61 was very quiet and very fast. She stated having 1:1 staff supervision for the resident prevented him from falling. On 06/13/2025 at 3:35 p.m., staff interviews revealed Resident #61 was admitted to the hospital on [DATE] after a follow-up head CT for further evaluation. 2. Review of Resident #84's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Palsy, Extrapyramidal and Movement Disorder, and Other Seizures. Review of Resident #84's current Physician's Orders revealed the following: Start date: 04/02/2025 Schedule neurology appointment secondary to seizure-like activity. Review of Resident #84's current Care Plan revealed in part, the following: Problem: I have a seizure diagnosis and am at risk for injury. Interventions: Follow-up with neurology related to seizure-like activity. Review of Resident #84's Nurse Practitioner's notes revealed, in part: Created By: S25NP Created Date: 04/02/2025 at 11:04 a.m. Chief Complaint / Nature of Presenting Problem: Evaluation status post ER visit for seizure-like activity. 1. Seizure-like activity: Workup per ER unremarkable. Please consult neurology for evaluation and treatment. On 06/11/2025 at 9:01 a.m., an interview was conducted with S17TS. S17TS confirmed she was responsible for scheduling follow up appointments. S17TS reviewed her files and calendar. S17TS confirmed no neurology consult appointment had been made for Resident #84 and should have been. S17TS stated she was not aware of this appointment. S17TS stated the process is for an appointment slip to be placed on her door so she would follow-up with scheduling the appointments. On 06/12/2025 at 11:28 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #84's physician orders and care plan. S2DON was made aware, as of 06/11/2025, Resident #84's neurology consult from 04/02/2025 had not been scheduled. S2DON confirmed staff failed to implement the appropriate intervention per the comprehensive resident centered care plan. S2DON stated the process is for an appointment slip to be placed on S17TS's door so she would follow-up with scheduling the appointments. The facility had implemented the following actions to correct the deficient practice: 1. On 06/11/2025, the sitter at bedside/l:1 monitoring was discontinued on the fall care plan. 2. On 06/12/2025, 100% review of the current fall care plans revealed no other resident had a fall care plan with sitter at bedside/on 1:1 monitoring. 3. On 06/12/2025, Resident #61 was admitted to the hospital following a medical appointment. In the event Resident were to return to the facility, 1:1 monitoring would be initiated. Resident #61 will be reassessed by the nursing staff and NP to determine the continuation of the 1:1 monitoring based on his needs. 4. If Resident #61 returns to the facility, he will receive a fall risk assessment to determine the appropriate interventions to be implemented. 5. Regional nurse provided education on 06/12/2025 to nursing administrative team, including the ADON, regarding fall prevention including adding, implementing, and monitoring effectiveness of appropriate interventions consistent with current professional standards. 6. The clinical staff received in-servicing by nursing administration on not leaving the room without relief when scheduled for 1:1 monitoring beginning on 06/12/2025 and will be completed 06/13/2025. Clinical staff will not be scheduled until receiving this in-service. 7. On 06/13/2025, the DON/designee reviewed recent fall care plans in the daily weekday morning meetings. DON/designee will continue to monitor care plans for appropriate interventions on weekdays for 4 weeks. 8. Any findings and plan will be taken through the facilities Quality Assurance Performance Improvement (QAPI) Process for review and revision as needed. The facility asserts the likelihood for serious harm to any resident with a care plan of sitter at bedside/l:1 monitoring no longer exists as of 06/13/2025. 9. The facility will ascertain substantial compliance by 06/13/2025. Throughout the survey from 06/12/2025 to 06/13/2025, interviews and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on proper 1:1 monitoring and how to identify what residents required monitoring while following care plan interventions.

Based on record reviews and interviews, the facility failed to ensure all medical records regarding the residents' code status reflected the residents' wishes for 2 (#18 and #14) of 34 residents reviewed in the initial screening for advanced directives. Findings: Resident #18 Review of Resident #18's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #18's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, indicating she was cognitively intact. Review of Resident #18's Louisiana Physician Orders for Scope of Treatment (LaPOST) in physical hard chart, dated [DATE], revealed the following, in part: Cardiopulmonary Resuscitation (CPR): Box checked-CPR/Attempt Resuscitation Signed by Resident #18. Review of Resident #18's current Physician Orders revealed: [DATE] DNR (Do Not Resuscitate) Review of Resident #18's current Care Plan revealed the following, in part: Problem: Resident #18 advanced directive Do Not Resuscitate (DNR). Intervention: Verified and confirmed code status. An interview was conducted on [DATE] at 1:55 p.m. with S27LPN. She stated in the event of a code for Resident #18 she would find the code status in her physical hard chart. After S27LPN reviewed Resident #18's physical hard chart, she confirmed Resident #18's LaPost dated [DATE] stated Full Code status, and she would start CPR. After further review of Resident #18's electronic physician orders, she confirmed a DNR order dated [DATE]. She confirmed Resident #18's DNR order did not match the LaPost and should have. An interview was conducted on [DATE] at 2:03 p.m. with S18SW. S18SW stated she was responsible for all residents' code status changes and initiated the LaPost documentation as needed. After S18SW reviewed Resident #18's current physician orders and LaPost dated [DATE], she confirmed the DNR order dated [DATE] does not match the LaPost and should have. An interview was conducted on [DATE] at 2:05 p.m. with S12WC. S12WC stated she was responsible for placing admit code status and change of code status documentation in the residents' physical hard charts and audited residents' code statuses weekly for accuracy. After S12WC reviewed Resident #18's current physician orders and LaPost dated [DATE], she confirmed the DNR order dated [DATE] does not match and should have. An interview was conducted on [DATE] at 3:28 p.m. with S2DON. After S2DON reviewed Resident #18's current physician orders and LaPost dated [DATE], she confirmed the DNR order dated [DATE] does not match the LaPost and should have. Resident #14 Review of Resident #14's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #18's current Physician Orders revealed: [DATE] Full Code Review of Resident #14's current Care Plan revealed the following, in part: Problem: Resident #14 had an advance directive with wishes to be a Full Code. Review of Resident #14's physical hard chart revealed a LaPost dated [DATE] indicating Resident #14 was a DNR. Further review revealed an advance directive form dated [DATE] indicating Resident #14 was a Full Code. An interview was conducted on [DATE] at 1:03 p.m. with S6LPN. She reviewed Resident #14's physical hard chart and stated there was a LaPost dated [DATE] indicating DNR code status and an advance directive form dated [DATE] indicating Full Code status. She stated during a code she would look at the advance directive form or LaPost form, whichever form was filed on top in the advance directive tabbed section of the physical hard chart. She stated based on the above mentioned documentation seen in the physical hard chart for Resident #14, Resident #14's wishes for code status would be DNR. An interview was conducted on [DATE] at 1:05 p.m. S12WC stated she was responsible for updating the residents' code status which she received from the admissions coordinator. S12WC confirmed she would take the updated code status LaPost and advanced directive form and place it in the physical hard chart and remove the old one. She confirmed only the most current code status should be in the chart. An interview was conducted on [DATE] at 3:10 p.m. with S2DON. She stated in the event of a code she expected staff to refer to the physical hard chart to determine accurate code status. She confirmed when an advance directive code status was updated or changed, she expected the new advance directive to be placed on the chart and the old advance directive to be discarded. She reviewed Resident #14's physical hard chart and confirmed the LaPost dated [DATE] indicated a DNR code status and an advance directive form dated [DATE] indicated Full Code status. S2DON stated the multiple inconsistent documentation in the physical hard chart could lead to confusion for nursing staff in the event of a code.

Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff: 1. Properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during direct care with Peripherally Inserted Central Catheter (PICC) line for 1 of 1 (#206) residents whom required PICC line care; and 2. Performed appropriate Standard PPE glove precautions during incontinence care for 1 of 1 (#18) residents observed for incontinence care. Findings: 1. Review of the facility's policy with a review date of 04/2025, titled, Enhanced Barrier Precaution Policy revealed the following, in part: 1. Gown and gloves will be used during high-contact care activities for residents at increased risk (residents with indwelling medical devices). Review of Resident #206's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed she currently had a PICC line inserted. Review of Resident #206's current Physician Orders revealed the following, in part: Start date-06/04/2025 Ertapenem 1 gram vial. Mix and infuse 1gm/100mL normal saline. Intravenously every day for 7 days. An observation was made on 06/10/2025 at 10:15 a.m. of Resident #206's door to her room. A sign was observed on the door which read EBP along with a caddy of gloves and gowns. Review of the facility's sign titled Enhanced Barrier Precautions revealed the following instructions, in part: Enhanced Barrier Precautions. Providers and staff must wear gloves and a gown for the following high contact resident care activities: device care or use: central line. An observation was made on 06/10/2025 at 10:18 a.m. of S6LPN administering Ertapenem infusion for Resident #206. S6LPN did not wear a gown during flushing or infusion of medication for Resident #206. An interview was conducted on 06/10/2025 at 10:20 a.m. with S6LPN. S6LPN confirmed Resident #206 had an EBP sign and caddy with gowns and gloves on her door. S6LPN stated she did not have to wear a gown while providing direct care to Resident #206's PICC line. 2. Review of Resident #18's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included: Neuromuscular Dysfunction of Bladder. An observation was made on 06/10/2025 at 1:11 p.m. of S11CNA providing incontinence care for Resident #18. S11CNA applied gloves, changed Resident #18's urine and feces soiled brief, cleaned her perineal area with wipes and disposed the soiled brief in the trash. S11CNA then, without changing gloves or performing hand hygiene, applied skin barrier cream, retrieved a clean brief and applied it to Resident #18. S11CNA then removed soiled gloves, performed hand hygiene, and exited the room. An interview was conducted on 06/10/2025 at 4:41 p.m. with S11CNA. S11CNA confirmed the process of incontinence care included to change his soiled gloves and perform hand hygiene after he performed incontinence care and before barrier cream applied and touching a clean brief. An interview was conducted on 06/12/2025 at 1:15 p.m. with S2DON. S2DON stated she expected all staff to wear a gown and gloves when providing direct care to a resident with a PICC line and residents requiring EBP. S2DON stated after handling urine and feces soiled brief and providing perineal care for residents, she would expect the staff to remove soiled gloves and perform hand hygiene before applying skin barrier cream and handling a clean brief.

Based on interviews and record review, the facility failed to ensure resident's assessments accurately reflected the resident's status by failing to ensure a resident's Minimum Data Set (MDS) was accurately coded for Pre-admission Screening and Resident Review (PASRR) for 1 (#90) of 2 (#29 and #90) sampled residents reviewed for PASRR. Findings: Review of Resident #90's Clinical Record revealed he was admitted to the facility on [DATE] with a 142 Form Notification of Medical Certification with an approval for admission by the state Level II Authority dated 06/30/2024. Review of Resident #90's annual MDS with an Assessment Reference Date (ARD) of 01/31/2025 revealed Section A1500 PASRR: Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition, was coded as 0. No. Section A1510 Level II PASRR conditions were blank. An interview was conducted with S14MDS on 06/11/2025 at 1:55 p.m. S14MDS verified Resident #90's Form 142 indicated Resident #90 was approved for nursing home admission by Level II authority effective 06/30/2024. She reviewed Resident #90's annual MDS assessment dated [DATE]. S14MDS confirmed Section A1500 should have been coded as 1-Yes, and was not. An interview was conducted with S2DON on 06/11/2025 at 2:00 p.m. S2DON verified Resident #90's Form 142 indicated Resident #90 was approved for nursing home admission by Level II authority effective 06/30/2024. She reviewed Resident #90's annual MDS assessment dated [DATE]. S2DON confirmed Section A1500 should have been coded as 1-Yes, and was not.

Based on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation as required for 1 (#29) of 2 (#29 and #90) sampled residents records reviewed for PASRR. Findings: Review of Resident #29's Clinical Record revealed Resident #29 was admitted to the facility on [DATE] with a diagnosis, which included Bipolar Disorder. Further review revealed additional medical diagnoses of Major Depressive Disorder (02/20/2025) and Generalized Anxiety Disorder (05/07/2025). Further review of the Clinical Record revealed no documentation of a Level II PASRR evaluation. On 06/11/2025 at 11:30 a.m., an interview was conducted with S13BOM. She stated when a resident acquired a new mental health diagnosis either S13BOM or S1ADM submitted a request to the state agency for a PASRR Level II referral. She reviewed the PASRR Level I on file for Resident #29 dated 06/09/2023. She confirmed Resident #29 had acquired the above listed diagnoses since the last Resident Review submission. She confirmed a Resident Review form should have been submitted for evaluation and determination for Level II services and was not. On 06/11/2025 at 11:35 a.m., an interview was conducted with S1ADM. She reviewed the PASRR Level I on file for Resident #29 dated 06/09/2023. She confirmed Resident #29 had acquired the above listed diagnoses since the last Resident Review submission. She confirmed a Resident Review form should have been submitted for evaluation and determination for Level II services and was not.

Based on interviews and record review, the facility failed to meet the following Hospice requirements by failing to maintain a system to ensure a Hospice resident's Hospice Binder contained the most recent Hospice Plan of Care and a current Recertification of Terminal Illness for 1 of 1 (#56) residents reviewed for Hospice care. This deficient practice had the potential to affect any of the 10 residents receiving Hospice services in the facility. Findings: A review of the facility's signed Hospice Services Agreement with Resident #56's Hospice agency, undated, revealed, in part, the following: 4. Responsibilities of Facility 4.14.4 Obtain the following information from Hospice: 4.14.4 (a) The most recent Hospice Plan of Care specific to each Hospice Patient. 4.14.4 (c) Physician Certification and Recertification of the Terminal Illness specific to each Hospice Patient. A review of Resident #56's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #56 was a patient of a local Hospice agency with Certification Periods of 10/01/2024 through 12/29/2024 and 03/20/2025 through 05/28/2025. A review of Resident #56's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/07/2025 indicated she was assessed to have a Brief Interview for Mental Status (BIMS) score of 00, which indicated Resident #56 had severe cognitive impairment. Further review revealed, in part, K1. Hospice Care - Yes. A review of Resident #56's Hospice Binder revealed, in part, the most recent Recertification of Terminal Illness (CTI) present in the Hospice Binder was for the Certification Period of 03/30/2025 through 05/28/2025. A review of Resident #56's Hospice Plan of Care, performed on 06/10/2025 at 3:50 p.m., revealed, in part, the most recent Plan of Care present in the Hospice Binder was printed on 04/07/2025 for the Certification Period of 03/30/2025 through 05/28/2025. A review of Resident #56's Hospice Plan of Care, performed on 06/12/2025 at 11:30 a.m., revealed, in part, the most recent Plan of Care present in the Hospice Binder was printed on 04/07/2025 for the Certification Period of 03/30/2025 through 05/28/2025. An interview was conducted on 06/12/2025 at 11:50 a.m. with S1ADM. S1ADM reviewed the Hospice Binder for Resident #56. S1ADM confirmed the binder did not contain the current Physician Recertification or updated Plan of Care.

Based on record reviews and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented and complete for 1 (#17) of 25 residents reviewed in the final sample. Findings: Resident #17 Review of Resident #17's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses including: Bipolar disorder, PTSD, Fibromyalgia, Major Depressive Disorder, Anxiety Disorder, Legal Blindness, Insomnia, Type 2 Diabetes, and Long Term Use of Insulin Review of Resident #17's Current Physician Orders revealed the following in part: Oxycodone-acetaminophen tablet 10-325 mg - Give 1 tablet by mouth every 8 hours as needed for severe pain Trazodone hcl tablet 100 mg - Take 1 tablet by mouth at bedtime Monitor targeted behavior of anxiety - every shift Monitor targeted behavior related to depression - every shift Monitor target behaviors related to insomnia - every shift Duloxetine hcl capsule delayed release particles 30 mg - Give 1 capsule by mouth one time a day for target behavior: refusal of care at times, related to depression. Monitor side effects of Cymbalta related to depression - every shift Review of Resident #17's MAR for April and June 2025 revealed the following, in part: 04/10/2025 - Novo Log Flex Pen Subcutaneous Solution Pen-injector 100 unit/ml - Inject as per sliding scale before meals at 4:00 p.m. - not documented as administered. 04/10/2025 - Novo Log Flex Pen Subcutaneous Solution Pen-injector 100 unit/ml - Inject 4 units subcutaneously at 4:30 p.m. - not documented as administered. 04/12/2025 Novo Log Flex Pen Subcutaneous Solution Pen-injector 100 unit/ml - Inject 4 unit subcutaneously two times a day related to Type 2 diabetes mellitus - 7:30 a.m. & 4:30 p.m. - not documented as administered. 04/12/2025 - Novo Log Flex Pen Subcutaneous Solution Pen-injector 100 unit/ml - Inject as per sliding scale before meals - 12:00 p.m. and 2:00 p.m. - not documented as administered. 04/12/2025 - Jardiance Oral tablet 10 mg - one tablet by mouth one time a day at 10:00 a.m. - not documented as administered. 04/12/2025 - Prozac Oral Capsule - Give 20MG by mouth one time a day 10:00 a.m. dose - not documented as administered. 04/12/2025 - Gabapentin Oral Capsule 100MG - Give 2 capsules two times daily at 10:00 a.m. - not documented as administered. 04/12/2025 - Promethazine HCl Tab 25 MG - give three times daily at 2:00 p.m. - not documented as administered. 04/12/2025 - Elevate Left Upper Extremity while in bed every shift - day shift not documented. 04/12/2025 - Monitor side effects of Prozac related to depression and behavior every shift - day shift not documented as being monitored. 04/12/2025 - Monitor target behaviors related to insomnia - every shift - day shift not documented as being monitored. 04/12/2025 - Monitor targeted behavior of anxiety - every shift - day shift not documented as being monitored. 04/12/2025 - Monitor targeted behavior related to depression - every shift - day shift not documented as being monitored. 04/12/2025 - Observe for signs and symptoms of abnormal bleeding/bruising - every shift - day shift not documented as observed. 04/12/2025 - Pain Monitoring - Assess for pain - every shift - day shift not documented as assessed. 04/12/2025 - Respiratory virus assessment #2 assess for signs of respiratory virus - every shift - day shift not documented as assessed. 04/12/2025 - Respiratory virus assessment #1 (cough of shortness of breath) - every shift - day shift not documented as assessed. 04/12/2025 - SPO2/temperature - every shift - day shift not documented as assessed. 06/06/2025 - Novo Log Flex Pen Subcutaneous Solution Pen-injector 100 unit/ml - Inject 4 unit subcutaneously two times a day related to Type 2 diabetes mellitus at 4:30 p.m. - not documented as administered. 06/06/2025 - Novo Log Flex Pen Subcutaneous Solution Pen-injector 100 unit/ml - Inject as per sliding scale - three times daily - 12:00 p.m. and 4:00 p.m. not documented as administered. 06/06/2025 - Promethazine Hcl Tab 25MG - three times daily - 2:00 p.m. dose not documented as administered. 06/06/2025 - Monitor side effects of Cymbalta related to depression - every shift - day shift not documented as monitored. 06/06/2025 - Monitor target behaviors related to insomnia - every shift - day shift not documented as monitored. 06/06/2025 - Monitor targeted behavior related to depression - every shift - day shift not documented as monitored. 06/06/2025 - Monitor targeted behavior of anxiety - every shift - day shift not documented as monitored. 06/06/2025 - Observe for signs and symptoms of abnormal bleeding/bruising - every shift - day shift not documented as observed. 06/06/2025 - Pain Monitoring - Assess for pain - every shift - day shift not documented as assessed. 06/06/2025 - Respiratory virus assessment #2 assess for signs of respiratory virus - every shift - day shift not documented as assessed. 06/06/2025 - Respiratory virus assessment #1 (cough of shortness of breath) - every shift - day shift not documented as assessed. 06/06/2025 - SPO2/temperature - every shift - day shift not documented as assessed. On 06/11/2025 at 10:05 a.m., an interview with review of June 2025 MAR was conducted with S10RN. S10RN confirmed she was caring for Resident #17 on 06/06/2025. S9RN stated the above for mentioned medications, assessments, and observations should have been documented, and were not. On 06/11/2025 at 2:08 p.m., an interview was conducted with S9RN. S9RN confirmed she was caring for Resident #17 on 04/10/2025 and 04/12/2025. S9RN stated the above for mentioned medications, assessments, and observations should have been documented, and were not. On 06/11/2025 at 3:15 p.m., an interview was conducted with S2DON. S2DON reviewed April 2025 and June 2025 MAR's and confirmed the above mentioned medications, assessments, and observations were not documented, and should have been.

Based on record review, observations, and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to follow physician orders for 1 (#84) of 25 residents reviewed in the final sample. Findings: Review of Resident #84's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Palsy, Extrapyramidal and Movement Disorder, and other Seizures. Review of Resident #84's current Physician's Orders revealed the following: Start date: 04/02/2025 - Seizure precautions. Review of Nurse Practitioner Progress notes revealed, in part: Created By: S25NP Created Date: 04/02/2025 11:04:20 Chief Complaint / Nature of Presenting Problem: Evaluation status post ER visit for seizure-like activity 1. Seizure-like activity: Workup per ER unremarkable. Seizure precautions please. On 06/10/2025 at 2:30 p.m., an observation was made of Resident #84 resting in bed. Resident noted to have two pillows behind his head and one wedge pillow under his left side. Bed noted to be in a high position. On 06/10/2025 at 3:18 p.m., an observation was made of Resident #84's bed and environment with S2DON. During the observation, S2DON confirmed Resident #84's bed was noted in a high position. On 06/10/2025 at 3:20 p.m., an interview was conducted with S2DON. S2DON stated the facility did not have a policy related to seizure precautions. S2DON confirmed seizure precautions were not in place for Resident #84 and should have been. On 06/11/2025 at 10:43 a.m., an interview was conducted with S25NP. S25NP confirmed she cared for Resident #84. S25NP confirmed she ordered seizure precautions for Resident #84. S25NP stated Resident #84's seizure precautions should have included positioning the resident's bed in the lowest position.

Based on observations and interview, the facility failed to: 1. Post the names, addresses, and telephone numbers of pertinent state agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and 2. Post a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation for all required postings reviewed. This deficient practice had to the potential to affect all 109 residents residing in the facility. Findings: On 06/09/2025 at 8:10 a.m., an initial tour of the facility was conducted. A list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit was not observed to be posted in the facility. Further observation revealed a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of a state or federal nursing facility regulation was not observed to be posted. On 06/09/2025 at 1:20 p.m., a tour was conducted with S1ADM. She confirmed a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit was not posted in a form and manner accessible to residents, or resident representatives, and should have been. She further confirmed a statement for how a resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation was not posted, and should have been.

Based on observations, interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to prevent entrapment of 1 (#1) of 4 (#1, #6, #7, #8) residents reviewed for safe use of bed rails. The facility failed to: 1. Assess residents for risk of entrapment prior to installing a bed rail; 2. Attempt appropriate alternatives prior to installing a bed rail; 3. Assess mattress for compatibility with bed frame; 4. Ensure ongoing maintenance of bed rails for 38 bed rails found to be loose, have gaps between the railing and mattress, and/or broken; 5. Ensure staff responded appropriately in emergency situations, when Resident #1 was found with his head entrapped between the mattress and bed rail. On [DATE] at 11:17 p.m., An Immediate Jeopardy occurred for resident #1 when the resident' head was found entrapped between the air mattress and the bed rail, and staff failed to immediately notify the nurse. When the nurse arrived to the resident's room at 11:23 p.m., six minutes later, the resident as found with his head in an extended position between the bed and the mattress with his body lying parallel to the bed on the floor. When the resident was lowered to the floor and transferred to bed, he was found to be unresponsive and pulseless. CPR was initiated and EMS was contacted. The resident was transported to the hospital by EMS at 11:52 p.m. and he expired on [DATE] at 3:17 a.m. S1ADM was notified of an Immediate Jeopardy situation on [DATE] at 3:52 p.m. The Immediate Jeopardy was removed on [DATE] at 1:04 p.m., when the facility submitted an Immediate Jeopardy Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Plan of Removal included the following: 1. On (MONTH) 30, 2019 the facility assessed the residents with air filled mattresses (#6, #7, and #8) and implemented protective interventions as needed. The mattress and bed frame for residents (#6, #7, #8) were changed to ensure proper fitting between mattress and frame. 2. All residents with air-filled mattresses have the potential to be affected by this deficient practice. The facility ordered an Entrapment Measurement Tool to assist staff in assessing risk for entrapment. Using the Entrapment Measurement Tool, the DON and Wound Care nurse will ensure that each resident is appropriately assessed for entrapment risk prior to distributing an air filled mattress. Ongoing assessment will be completed on monthly. 3. Residents with air filled mattress will be reviewed weekly by the wound care nurse. 4. Findings will be reported to the facility's QAPI committee on a quarterly basis and as needed. 5. Direct care staff will be in-serviced on [DATE], upon hire, annually, and as needed regarding immediate reporting of concerns/issues related to air-filled mattresses, by the Staff Development Coordinator/designee. Learning effectiveness will be evaluated by discussions, return-demonstrations, performance observations, and/or a written test. Staff have not been trained in proper handling of emergency situations: 1. On (MONTH) 30, 2019 the Staff Development Coordinator in-serviced staff on the proper handling of emergency situations. 2. All residents have the potential to be affected by this deficient practice. The facility will ensure that all staff are in-serviced by (MONTH) 8, 2019. Topics to be covered include: [MEDICAL CONDITION], Choking, and Care of the Fallen Resident. Staff's learning outcome will be assessed by completion of a post-test and/or drills. In-services will completed twice daily, at shift change, to ensure all staff are in-serviced prior to providing care. Staff not having been in-serviced prior to (MONTH) 8, 2019, will not be permitted to work until completing a 1:1 in-service. 3. The NFA/DON will ensure all staff are in-serviced. Emergency Situation response will be incorporated into the facility's Staff Development Program upon hire, annually, or as needed. 4. Staff Development Coordinator will provide written documentation to NFA/DON, to ensure all current employees have been in-serviced by the date certain. A written summary will be presented, discussed, and reviewed during the facility's quarterly QAPI committee meeting. Issues/concerns requiring immediate attention may be addressed by a QAPI call meeting. 5. The facility will meet substantial compliance by (MONTH) 8, 2019. Current findings of 38 bed rails not appropriately attached to beds. 1. On (MONTH) 30, 2019 the 38 of the facility's 123 beds identified to have bed rails not appropriately attached the corrective maintenance. 2. All the residents have the potential to be affected by this deficient practice. The facility will ensure all beds, with bed rails attached, are without disrepair. 3. The facility's administrative staff will audit the remaining 85 beds to ensure proper attachment of bed rails, by (MONTH) 31, 2019. The nursing staff will review the recently completed Side Rail assessments for all the current residents for completion and accuracy. The nursing staff will also physically observe all residents to ensure assessment interventions have been implemented by (MONTH) 31, 2019. 4. The facility' maintenance staff will audit all beds to identify maintenance needs, monthly. Findings will be reported to the NFA, upon completion. A Side Rail assessment will be completed prior to placing side rails, and if placed, at least quarterly and with significant change. The Staff Development Coordinator will in-service licensed nursing staff on the correct completion of side rail assessments, prior to implementing the use of side rails for a resident currently without side rails. Housekeeping will be in-serviced by the housekeeping supervisor to make environmental observations while cleaning - being sure to report any maintenance concerns. The facility's administrative staff will implement the use of Safety Rounds to ensure routine identification of safety concerns. The nursing staff will re-evaluate each resident's need for bed rails utilizing an objective set of criteria - not to supersede clinical judgement, nor ignore the facility' commitment to resident-centered care. The deficient practice remains at a level of potential for harm for residents #6, #7, #8 and the 90 residents identified by the facility as currently using bed rails. Findings: Cross Reference F700 On [DATE] at 8:15 p.m. a tour of the facility was conducted by the survey team with S3RegADM, S2DON, S5LPN, and S13LPN. There were 38 occupied beds in the facility with bed rails that were loose, had gaps between the railing and mattress that the surveyor was able to place her arm and/or broken. Findings were verified by 3RegADM, S2DON, S5LPN, and S13LPN. Resident #1 Review of the clinical record revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS of 6 Severe Cognitive Impairment Section G: resident required one person physical assist with bed mobility and transfers. The resident was totally dependent for toileting and was incontinent of bowel and bladder. Ambulation did not occur. On [DATE] at 9:30 p.m. an interview was conducted with S5LPN, the CN working the night of [DATE]. He was asked to describe the incidents of the evening. S5LPN stated that at 8:30 p.m. the resident fell and a Code Yellow (facility code for falls) was called. He stated the resident was sitting up on the floor with his back against the bed. S5LPN stated later that night between 11:15 p.m. and 11:30 p.m. S7CNA approached him quickly and was told the resident had fallen. He stated he found the resident with his lower body on the floor on a fall mat, bedside rails in the up position. S5LPN stated the resident's head was against the bed rail hyperextended backward and his skin color was purple. S5LPN stated he and S7CNA moved the resident to the bed, noticed he had no pulse, and started CPR. He stated the local fire department arrived and continued CPR, intubated the resident, and transferred him to the hospital. He stated on [DATE] at 3:45 a.m. the ER called the facility and stated resident #1 had expired. On [DATE] at 9:50 p.m. an interview was conducted with S7CNA, who notified S5LPN of the resident's fall on [DATE]. S7CNA stated between 11:00 p.m. and 11:18 p.m. S6CNA told me go tell S5LPN that man is on the floor. S7CNA stated she went to the room and put on the light. The resident was on the (L) side of the bed with the bed rail along his jawline and his head tilted back. The resident was blue in color. S7CNA stated I ran to get S5LPN, told him what S6CNA said and that the resident was blue in color. S7CNA stated she and S5LPN put the resident in the bed, got the crash cart, started CPR and oxygen. On [DATE] at 11:05 a.m. S3RegADM was asked if S2DON shared with him the issues the team found on [DATE] involving the 38 beds with problematic bed rails. He stated I guess you all found some gaps. S3RegADM was informed there were gaps, loose rails, and rails that broke off the beds when touch by staff. S3RegADM stated I had just looked for gaps, in hindsight I should have but didn't shake them. On [DATE] at 2:20 p.m. the facility's video of the resident's hallway on the night of [DATE] was reviewed with S1ADM . The video dated [DATE] was reviewed from 7:50 p.m. until 11:52 p.m. and revealed the following in part: 11:17 p.m. S6CNA steps in doorway, doesn't turn on the light and walks down the hall toward the front of the facility out of view of the camera. 11:21 p.m. S7CNA steps in to room, turns on light, exits and walks toward adjoining hall out of view of the camera 11:23 p.m. S5LPN and S7CNA return and enter the room 11:24 p.m. Code Blue called 11:31 p.m. EMS arrived 11:52 p.m. EMS departs with resident. After review of the video an interview was conducted with S1ADM. He was asked what time had S6CNA looked into resident #1's room. He verified it was at 11:17 p.m. that S6CNA stepped in doorway. He was asked if S6CNA entered the room, turned on the light, or assisted the resident. S1ADM verified S6CNA did not enter the room, did not turn on the light and did not assist the resident. S1ADM verified S6CNA walked away from the resident's room. He was asked how much time lapsed before the resident was assisted. S1ADM verified that 6 minutes lapsed (11:17 p.m. to 11:23p.m.) from the time S6CNA saw the resident on the floor until S5LPN and S7CNA entered room. An observation of the bed resident #1 was in on [DATE] when the incident occurred was now in another room, and in use by resident #6. Observations revealed both ½ rails were in the up position. There was a gap noted between the mattress and the (L) bed rail that the surveyor could place her arm in-between. Resident #6 was on an air mattress. On [DATE] at 11:15 a.m. a list of residents using the same type of bed and air mattress as resident #1 was requested by the survey team. Residents #6, #7, and #8 were identified by the facility. On [DATE] at 3:10 p.m. an interview was conducted with S2DON. S2DON verified the facility had no polices or procedures related to bed rails or staff response to emergencies. He was asked if after the incident of [DATE], involving Resident #1, had the staff had been trained on emergency responses for residents who have fallen or were in distress. S2DON verified no training had been done regarding staff's response to emergencies prior to the team's entry on [DATE]. He was asked if alternatives to bed rail use was conducted prior to a resident being placed in a bed. S2DON stated most of the beds in the facility had bed rails on them, so when residents were admitted they were placed in the bed with rails already attached. He verified residents had not been assessed for alternatives to bed rail use prior to the incident of [DATE] or since. On [DATE] at 3:45 p.m. an interview was conducted with S1ADM. He was asked to describe his interventions after the incident of [DATE] involving Resident #1. He stated he reviewed the incident with S5LPN. He notified S3RegADM and S4RegBDM and together they came up with a QA plan. He stated we starting looking at gaps between mattresses and bed rails. He stated another bed assessment was done by S16MSup and S3RegADM. S1ADM stated by the end of the week S2DON came up with a Side Rail assessment sheet which he verified had not been completed to determine which residents needed bed rails or not. In regards to the 38 beds identified by the survey team as problematic, S1ADM stated we were so focused on gaps and the FDA check list, we didn't think to grab the rails to see how sturdy the rails were. S1ADM verified the facility had no documented inspections of bed frames, mattresses, or bed rails since (MONTH) of (YEAR).

Based on observations, interviews and record reviews, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation, and to assess the beds' mattresses for compatibility with the bed frames for 4 of 4 (#1, #6, #7, #8) residents using an air mattress. The facility further failed to ensure all bed rails were in good repair. On [DATE] at 11:17 p.m., an Immediate Jeopardy occurred for resident #1 when the resident' head was found entrapped between the air mattress and the bed rail, and staff failed to immediately notify the nurse. When the nurse arrived to the resident's room at 11:23 p.m., six minutes later, the resident was found with his head in'an extended position between the bed and the mattress with his body lying parallel to the bed on the floor. When the resident was lowered to the floor and transferred to the bed, he was found to be unresponsive and pulseless. CPR was initiated and EMS was contacted. The resident was transported to the hospital by EMS at 11:52 p.m. and he expired on [DATE] at 3:17 a.m. S1ADM was notified of an Immediate Jeopardy situation on [DATE] at 3:52 p.m. The Immediate Jeopardy was removed on [DATE] at 1:04 p.m., when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Plan of Removal included the following: Residents are not appropriately assessed to use an air-filled mattress and are at risk for entrapment: 1. On (MONTH) 30, 2019 the facility assessed the residents with air filled mattresses (#6, #7, and #8) and implemented protective interventions as needed. The mattress and bed frame for residents (#6, #7, #8) were changed to ensure proper fitting between mattress and frame. 2. All residents with air-filled mattresses have the potential to be affected by this deficient practice. The facility ordered an Entrapment Measurement Tool to assist staff in assessing risk for entrapment. S2DON stated the tool would be put into use immediately. Using the Entrapment Measurement Tool, the DON and Wound Care nurse will ensure that each resident is appropriately assessed for entrapment risk prior to distributing an air filled mattress. Ongoing assessment will be completed monthly. 3. Residents with air filled mattress will be reviewed weekly by the wound care nurse. 4. Findings will be reported to the facility's QAPI committee on a quarterly basis and as needed. 5. Direct care staff will be in-serviced on [DATE], upon hire, annually, and as needed regarding immediate reporting of concerns/issues related to air-filled mattresses, by the Staff Development Coordinator/designee. Learning effectiveness will be evaluated by discussions, return-demonstrations, performance observations, and/or a written test. Current findings of 38 bed rails not appropriately attached to beds. 1. On (MONTH) 30, 2019, the 38 of the facility's 123 beds identified to have bed rails not appropriately attached the corrective maintenance. 2. All the residents have the potential to be affected by this deficient practice. The facility will ensure all beds, with bed rails attached, are without disrepair. 3. The facility's administrative staff will audit the remaining 85 beds to ensure proper attachment of bed rails, by (MONTH) 31, 2019. The nursing staff will review the recently completed Side Rail assessments for all the current residents for completion and accuracy. The nursing staff will also physically observe all residents to ensure assessment interventions have been implemented by (MONTH) 31, 2019. 4. The facility' maintenance staff will audit all beds to identify maintenance needs, monthly. Findings will be reported to the NFA, upon completion. A Side Rail assessment will be completed prior to placing side rails, and if placed, at least quarterly and with significant change. 5. The Staff Development Coordinator will in-service licensed nursing staff on the correct completion of side rail assessments, prior to implementing the use of side rails for a resident currently without side rails. Housekeeping will be in-serviced by the housekeeping supervisor to make environmental observations while cleaning - being sure to report any maintenance concerns. The facility's administrative staff will implement the use of Safety Rounds to ensure routine identification of safety concerns. The nursing staff will re-evaluate each resident's need for bed rails utilizing an objective set of criteria - not to supersede clinical judgement, nor ignore the facility' commitment to resident-centered care. The deficient practice remains at a level of potential harm for residents #6, #7, #8 and the 90 residents identified by the facility as currently using bed rails. Findings: On [DATE] at 8:15 p.m., a tour of the facility was conducted by the survey team with 3RegADM, S2DON, S5LPN, and S13LPN. There were 38 occupied beds in the facility with bed rails that were loose, had gaps between the railing and mattress that the surveyor was able to place her arm and/or broken. These findings were verified by 3RegADM, S2DON, S5LPN, and S13LPN. Resident #1 Review of the clinical record revealed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed a BIMS of 6 indicating severe cognitive impairment Section G: Resident required one person physical assist with bed mobility and transfers. The resident was totally dependent for toileting and was incontinent of bowel and bladder. Ambulation did not occur. Review of the care plan revealed the following: I may use half rails up x 2 while in bed to enable me to turn & reposition, assist staff with ADL's & transfers and to promote my independence. [DATE] - fall - All beds assessed entrapment risks Review of the physician's orders [REDACTED]. May use half side rails up x 2 while in bed to enable resident to turn and reposition, assist staff with ADL's & transfers and to promote independence, Monitor Q shift. There was no documentation on the (MONTH) 2019 physician's orders [REDACTED]. Review of the Side Rail assessment dated [DATE] revealed, in part, the following: Cognitive Deficit: Yes Visual deficits: Yes Able to get out of bed safely: No Able to get in and out of bed: Yes History of Falls: Yes Problems with balance and poor trunk control: Yes Medications requiring safety precautions: Yes ([MEDICATION NAME]. [MEDICATION NAME]) Interventions (check all that apply) Frequent Monitoring: Unchecked Put to bed when fatigued: Checked Meaningful Pleasurable activity: Unchecked Reminders to use call light: Checked Recommendations: Side rails are indicated and serve as an enabler to promote independence. Half Rails: Left and Right Review of the nurses' notes revealed the following: [DATE] 1:58 a.m. Late entry due to down time. [DATE] at approximately 11:20 p.m. S7CNA, notified charge nurse and floor nurse that resident had fallen out of bed. Code yellow called, upon entering room this nurse (S5LPN) and S7CNA observed resident laying partially out of bed with legs and lower body on the floor, upper body on the bed with head in an extended position between mattress and side rail of bed. Resident was purple in color and not responsive. S7CNA and myself lowered resident to floor, gasp of air noted. Resident was placed in bed per this nurse (S5LPN) and S7CNA. No pulse noted, no respirations noted, resident remained unresponsive. Code blue called, resident noted to be full code. CPR initiated per this nurse. Assigned nurse, S8LPN as well as other nurses: S11LPN, S12LPN, and S13LPN responded to code blue. O2 was applied per Ambu bag, O2 Sats remained low, 50 - 80. As code progressed faint thready pulse noted during rate check per pulse oximeter rate was in upper 100s during the rate check. CPR continued until EMS arrived. EMS continued code. 17 minutes into code rate and rhythm was noted per paramedic. Resident transferred onto EMS stretcher and left facility, to (Hospital). On [DATE] at 9:30 p.m. an interview was conducted with S5LPN, the CN working the night of [DATE]. He was asked to describe the incidents of the evening. S5LPN stated that at 8:30 p.m. the resident fell and a Code Yellow (facility code for falls) was called. He stated the resident was sitting up on the floor with his back against the bed. He stated the bed alarm had not worked, so he replaced the alarm and verified it was functioning. S5LPN stated later that night between 11:15 p.m. and 11:30 p.m. S7CNA approached him quickly and stated the resident had fallen. He stated he found the resident with his lower body on the floor on a fall mat, bedside rails in the up position. S5LPN stated the resident's head was against the bed rail hyperextended backward and his skin color was purple. S5LPN stated he and S7CNA moved the resident to the bed, noticed he had no pulse, and started CPR. He stated the local fire department arrived and continued CPR, intubated the resident, and transferred him to the hospital. He stated on [DATE] at 3:45 a.m. the ER called the facility and stated resident #1 had expired. On [DATE] at 9:50 p.m. an interview was conducted with S7CNA, who notified S5LPN of the resident's fall on [DATE]. S7CNA stated between 11:00 p.m. and 11:18 p.m. S6CNA told me go tell S5LPN that man is on the floor. S7CNA stated she went to the room and put on the light. The resident was on the (L) side of the bed with the bed rail along his jawline and his head tilted back. The resident was blue in color. S7CNA stated I ran to get S5LPN, told him what S6CNA said and that the resident was blue in color. S7CNA stated she and S5LPN put the resident in the bed, got the crash cart, started CPR and oxygen. Review of the medical records from the hospital revealed the following: admitted : [DATE] 12:06 a.m. Discharge Disposition: [DATE] Expired 6:34 a.m. Reason for Visit: [MEDICAL CONDITION], unspecified cause Principal Dx: [MEDICAL CONDITION], unspecified cause Other DX: Multiple fractures of ribs, right side. Traumatic Pneumothorax. Measures prior to arrival: 3 epi, 1 [MEDICATION NAME]. Total time arrest to arrival: 16 - 30 minutes. MD Notes revealed in part: Family made aware of multiple chest fractures and decided against chest tubes in light of multiple medical problems, and his age of 87. Patient was made comfort care by family. He was extubated and [MEDICATION NAME] discontinued. He had non -rebreather placed and was given 2 doses of [MEDICATION NAME], within minutes the patient succumbed/ asystole at 3:17 a.m. with granddaughter at bedside. Patient was pronounced by me - S15MD Resident #6 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the following: Section C: Severely Cognitively Impaired Section G: Total Dependence Review of the Side Rail assessment dated [DATE] revealed side rails were not indicated. On [DATE] at 11:35 a.m. the survey team was accompanied by S1ADM, S2DON, S3RegADM, and S4RegBDM to make observations of Resident #6's bed. Half rails were noted on the left and right sides of the bed in the up position. A gap between the air mattress and bed rails was observed. S3RegADM verified Resident #6's bed and mattress were the same ones Resident #1 used the night of [DATE]. The gaps were measured by S2DON as a 5 cm gap between the (L) bed rail and the air mattress and a 4.5 cm gap between the (R) bed rail and the air mattress. Resident #7 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the following: Section C: BIMS of 6 Severe Cognitive Impairment Section G: 1 person assist for mobility/ADLs Review of the Side Rail assessment dated [DATE] revealed side rails were indicated and served as an enabler to promote independence. On [DATE] at 11:35 a.m. the survey team was accompanied by S1ADM, S2DON, S3RegADM, and S4RegBDM to make observations of resident #7's bed. Half rails x 2 were noted on the bed in the up position. Spaces between the air mattress and the (L) and (R) bed rails were observed allowing the surveyor to place her arm in- between and was verified by S1ADM, S2DON, S3RegADM, and S4RegBDM. Resident #8 Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the following: Section C: BIMS of 15 Cognitively Intact Section G: 1 person assist for mobility/ADLs Review of the Side Rail assessment dated [DATE] revealed continue side rails, resident uses for bed mobility. On [DATE] at 11:35 a.m. the survey team was accompanied by S1ADM, S2DON, S3RegADM, and S4RegBDM to make observations of resident #8's bed. Half rails x 2 were noted on the bed in the up position. Spaces between the air mattress and the (L) and (R) bed rails were observed allowing the surveyor to place her arm in-between and was verified by S1ADM, S2DON, S3RegADM, and S4RegBDM. On [DATE] at 3:10 p.m. an interview was conducted with S2DON. He was asked if alternatives to bed rail use was assessed prior to a resident being placed in a bed. S2DON stated most of the beds in the facility had bed rails on them, so when residents were admitted they were placed in the bed with rails already attached. He verified residents had not been assessed for alternatives to bed rail use prior to the incident of [DATE] or since. He was asked to review the Side Rail assessment done on resident #1 and was asked if it included an assessment to determine if the type of bed used was appropriate for the air mattress used. S2DON stated No. He verified the type of bed and air mattress used by resident #1 was made by different manufacturers. S2DON was asked what the Q Shift monitoring of bed rails on the MAR included. He stated the monitoring included noting if the rails were in the up position while the residents were in bed, if the rail malfunctioned, or a resident was entrapped. He was asked if the Q Shift monitoring, documented on the MAR by the nurses, included assessment for gaps between the mattress and bed rail or proper fit of the mattress on the bed frame. S2DON stated No. On [DATE] at 3:45 p.m. an interview was conducted with S1ADM. In regards to the 38 beds identified by the survey team as problematic, S1ADM stated we were so focused on gaps and the FDA check list, we didn't think to grab the rails to see how sturdy the rails were. S1ADM verified the facility had no documented inspections of bed frames, mattresses, or bed rails since (MONTH) of (YEAR).

Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent an avoidable fall for 1(#2) of 5(#1,#2,#3,#4,#5) sampled residents. The facility failed to: 1) Ensure that a resident (#2) identified by the facility as at risk for falls, consistently received staff assistance with transfer and toileting. 2) Ensure that interventions were put in place to provide adequate supervision for a resident (#2) identified by the facility as legally blind, fluctuations in cognition, non-compliant with waiting for assistance with transfers and a history of un-witnessed falls in the facility. 3) Determine the cause and factors surrounding each fall sustained by a resident (#2) to prevent future falls. This failed practice resulted in a harm to the resident on 9/17/16 when the resident fell while attempting to transfer himself to the toilet without staff assistance. The staff were notified by the resident and a physical therapist that he needed to use the toilet. The resident sustained [REDACTED]. Findings: A review of the facility's Fall Policy & Procedure revealed the following: As part of the initial assessment, the Charge Nurse/Nursing staff will identify individuals with a history of falls and risk factors for subsequent falling. The staff will evaluate and document falls that occur while the individual is in the facility. The staff nurse will complete an Incident/Accident (I&A) Reporting Form The fall care plan shall be updated immediately after a fall. Staff will attempt to define possible cause. Based on the preceding assessment, the staff will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation ( for example, if the individual continues to try to get up and walk without waiting for assistance). The staff will monitor the individual's response to interventions intended to reduce falling. If the individual continues to fall, the staff will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will reevaluate the continued relevance of current interventions. Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling Identifying Causes of a Fall: Following a fall the nursing staff will begin to try to identify possible or likely causes of the incident. Staff will evaluate chains of events or circumstances preceding a recent fall, for example: Time of day of the fall; What was the resident doing; Whether the resident was standing, walking, reaching, or transferring from one position to another; Whether the resident was among other persons or alone; Whether the resident was trying to go to the toilet; Whether any environmental risk factors were involved; and Whether there is a pattern of falls for this resident . A review of the clinical record for Resident #2 revealed the resident was [AGE] years of age, admitted to the facility on [DATE] for physical rehabilitation after surgical repair of a right hip fracture. The resident had [DIAGNOSES REDACTED]. The resident required the use of a wheelchair for mobility and staff assist with transfer and ADLs. The resident was unable to be interviewed as he was discharged from the facility on 9/17/16. Review of the facility's Activities Department Initial assessment dated [DATE] revealed the following: Used to walk 6 miles every morning before breaking his hip. Review of Resident#2's Admission Assessment MDS with an ARD (Assessment Reference Date) of 9/13/16, revealed the resident was assessed by the facility, in part, as follows: Section C - Cognition: BIMS Score: 12 Section G - Functional Status: a) Transfer: Extensive assist, resident involved in activity - two person physical assist; c) Balance (moving from seated to standing position - Not steady, only able to stabilize with staff assistance. A review of Resident #2's Care Plan revealed, in part, the following: Initial Care Plan Assessment, 9/1/16 Psychosocial Mental: Alert, Oriented x 1 Bowel & Bladder: Incontinent Fall Risk: Yes Fall Risk Approaches: Verbal Reminders (call light), Visual checks every 2 hours . every 1 hour Care Plan, Problem Onset 9/1/16 Fracture of neck of Right Femur, Right hip surgical wound upon admission to facility. Care Plan, Problem Onset: 9/5/16 Potential to fall related to unsteady gait Approaches include: Verbal reminders not to ambulate or transfer without assistance; Use self-releasing safety device when resident is in wheelchair; Analyze previous falls by resident to determine whether pattern/trend can be addressed; Monitor resident's mental status; Keep call light within reach at all times; Encourage to call for assistance as needed; Fall: 9/5/16 at 12:45am - Resident lying on his back with pillow under his head near the door - Bed alarm placed Fall 9/5/16 at 5:20pm - Resident lying supine on floor - Alarming self-release Velcro belt placed; Fall 9/13/16 - Attempted to get out of wheelchair and into his roommate's bed and fell - Wheelchair modification Fall 9/17/16 - Attempted to toilet self without assistance, right foot got caught in foot rest and resident fell on right hip - Hospital admission for right hip fracture, foot rests removed. A review of the Resident Incident Reports regarding Resident #2 revealed the following: Date/Time: 9/17/16, 10:16am Incident Type: Found on floor - Non-Witnessed Equipment: Wheelchair Location: Bath Injury: Abrasion/Fracture Medical Risk Factors possibly related to incident: Fall history, Confusion/Disorientation, Bowel & Bladder Urgency Narrative of incident and description of injuries: Resident attempted to toilet self without assistance, right foot got caught in foot rest and resident fell on right hip. Date/Time: 9/5/16, 5:20pm Incident Type: Found on floor - Non-Witnessed Equipment: Geri-chair Location: Unit Lobby Injury: None apparent Medical Risk Factors possibly related to incident: Fall history, Inability to understand directions, Confusion Narrative of incident and description of injuries: Upon entering station 2 lobby, resident lying supine on floor next to geri-chair, resident complained of right leg pain and due to recent surgery on right upper leg resident was sent to hospital for evaluation. Date/Time: 9/5/16, 1245am Incident Type: Found on floor - Non-Witnessed Location: Resident's room Injury: None apparent Medical Risk Factors possibly related to incident: Fall history, Inability to understand directions, Confusion, Fracture, Incontinency Narrative of incident and description of injuries: A resident passing by nurses' station stated a man is down on the floor in that room. Upon entering the room, resident was lying on his back with pillow under his head near the door, he had no clothes on, his bedside table was under his right leg. A review of the Departmental Notes - Nursing regarding Resident #2 revealed the following: 9/17/16, Late entry from 10:15am - Resident attempted to toilet self in bathroom in his room. Resident alarm sounding, resident yelled help multiple times this nurse went into bathroom and found resident on right side. Resident stated I heard it pop, it's my hip again. NP notified with new orders for stat portable right hip X-ray. Complained of pain 10/10, right leg externally rotated and shortened. Resident assisted x 2 CNAs back into wheelchair and back into bed. X-ray taken with noted distal hip fracture. New orders for resident to be sent to hospital. On 10/4/16 at 1:15pm an interview was conducted with S13CNA. She stated that she had cared for Resident #2 during his stay at the facility. She stated he needed assistance to go to the toilet and he could tell you when he had to urinate or have a bowel movement. She stated that I was told he would try to go to the toilet on his own. She stated that the resident wasn't on a toileting schedule, we would ask him if he had to use the bathroom and he would ask me to take him if he needed to use the toilet and we would take him. He knew when he had to urinate and he could express that. He could walk, he needed to be guided because he was blind. She stated that he did get confused at times and was more confused after supper around 5:00pm-6:00pm. She stated that he was on fall precautions. She stated that his bed and wheelchair had alarms so we would know if he tried to get up. A review of the Rehabilitation Screening/Referral Form dated 9/17/16 regarding Resident #2 revealed the following: Fall Intervention/Prevention: Patient already on caseload to address deficits. Patient at increased risk for falls due to weakness from hip fracture and poor safety/judgement. A review of the PT Daily Treatment Note dated 9/17/16 regarding Resident #2 revealed the following: Patient performed therapeutic exercises to develop strength, endurance, range of motion and flexibility for increased functional independence with ADLs. Skilled instruction and cues were provided throughout. On 10/3/16 at 10:05 am an interview was conducted with S8PT. S8PT stated that some moments Resident #2 was clear and other times he was confused. She stated that he would remove his chair seatbelt. She stated that his vision was impaired and he had problems with urinary retention. She stated that after a week of therapy, he was participating more, he was a bit stronger, he was getting better. He was more compliant, he was coming out of his pain, his strength was improving. On 10/3/16 at 10:05am an interview was conducted with S9OT. S9OT stated that we find that a lot of our residents have problems with anesthesia causing confusion. Sometimes they forget that they fell and don't remember that they had surgery. On 10/3/16 at 10:22am an interview was conducted with S10Therapy Sup. She stated that Resident #2 would sometimes wear a watch, it was one of those that when he pressed it, it would say the time. She stated that Resident #2 was not compliant with waiting for staff, he felt that he could do things without help. She stated that the chair alarm alerts staff that a person is already in motion. She stated that once the person is up, the alarm goes off. S10Therapy Sup. stated that there is no documentation of what time Resident #2 went to therapy on 9/17/16 or what time the therapist the resident in the doorway of his room. A review of the typed statement from S7PT dated 9/22/16 revealed the following: On 9/17/16, I assisted Resident #2 out of bed into his wheelchair and escorted him to the therapy gym. The resident received therapeutic exercise and gait training. After PT, I escorted him back to his room in his wheelchair with alarm seat belt donned. The resident was placed in his doorway outside his room. I pressed call button, along with finding CNA and informing her the resident was requesting to use the bathroom. At that time, I informed the resident that the CNA will be coming to assist him shortly. At that time, I returned to the PT gym. On 10/3/16 at 1:41pm an interview was conducted with S11LPN. She stated that she worked with Resident #2 on 9/17/16. She stated that he did not receive pain medication prior to physical therapy. She stated that after he fell , he received Norco 10/325 at 10:30am for pain to his right hip. She stated that he fell at 10:15am. She stated that he went to therapy and the therapist brought him back and told me that the resident had to go to the bathroom. She stated that she did not know what time the resident was placed at the doorway of his room. She stated that therapy puts residents in view of the staff if they are a fall risk. She stated that the resident was sitting in the doorway and she was in the hall giving medicines. He told me he had to go to the bathroom, I told him to let me give the medicine I was on and then I would be back to help him. She stated that the two aides working on her hall were making rounds at the other end of the hall. She stated that before she could get back to the resident, she heard his chair alarm sounding and the resident yelling help. She stated that when she got in his room, he said my hip hurts, I hurt my hip, my hip popped. She stated that it was the same hip he had surgery on. She stated that he had the lap belt on because he would get up and try to walk on his own, he wasn't compliant. We would ask him if he had to go to the bathroom every 2 hours. If he was up in his wheelchair we would take him to the bathroom, if he was in bed we would give him the urinal. She stated that he could kind of see things, his vision was blurry. She stated that he was a fall risk. She stated to prevent falls for him, he had bed and seat belt alarms, frequent monitoring, toileting every 2 hours and check to see if he needed assistance. She stated that he would try to sit up and walk by himself. She stated that he came and went with confusion. On 10/4/16 at 2:00pm, S5Adm. stated that she checked the facility's cameras for 9/17/16. She stated that it was 15 minutes between the time the therapist brought Resident #2 back to his room, placed him in the doorway of his room, went to the nurse and the time everyone ran to Resident #2's room. On 10/3/16 at 2:30pm an interview was conducted with S12LPN. She stated that she investigated resident falls. She stated that the Incident Report is the investigation into the fall. She stated that Resident #2 was a fall risk when he was admitted because of his hip fracture. She reviewed the Incident Reports of 9/5/16 at 12:45am and 5:20pm, 9/13/16 and 9/17/16. She stated that the investigation into how a fall occurs is to review the narrative of the Incident Report. She stated that Resident #2's fall on 9/5/16 at 5:20pm did not state why or how the resident ended up on the floor. She stated that he was already in a visible area, but the report did not indicate what the circumstances were surrounding his fall. She stated that she could not tell from reading the narrative if the resident was confused. She stated that he was in a high traffic area in the lobby, but she couldn't tell if anyone was around. She stated that the report says un-witnessed. She stated that she did not know what type of footwear he had on and did not know why or how he got out of the chair. She stated we put an alarm on his wheelchair as an intervention for this fall. She stated that on 9/17/16 at 10:16am, he went to the toilet without assistance and his foot got caught in the footrest. She stated that the therapist told the nurse that he had to use the toilet. She stated that the nurse was passing out medications and the CNAs were changing another resident and the nurse told the resident it would be a minute or two before she could to him. She stated no there is no documentation on the Incident Report of what time Resident #2 came back from therapy. She stated that we put the alarm belt on his chair because he was not asking for help. S12LPN verified she had no additional documentation to provide regarding investigation of Resident #2's falls other than the Incident Reports. On 10/4/16 at 11:10am an interview was conducted with S12LPN. She stated that no one is really assigned to watch the residents in the lobby, it is possible that someone could fall and not be seen there. She stated that increased supervision was not included in Resident #2's Care Plan for falls. On 10/3/16 at 3:19pm an interview was conducted with S4DON. She stated that the fall investigation is to learn the circumstances surrounding a fall occurrence. She stated that when a fall occurs the nurse writes a summary, we like to go and interview the resident to see how the fall happened and determine if they asked for assistance. She reviewed the Incident Reports of falls regarding Resident #2. She stated that she could not determine how he fell while reviewing the Incident Report of 9/5/16 at 5:20pm. She reviewed the Incident Report of 9/17/16. She stated that she could not state what type shoes he had on when he fell . She stated that it wasn't included in the report. She stated he tried to toilet himself without staff assistance on 9/17/16. She confirmed the staff was notified that the resident had to use the toilet. She stated that the nurse or the aides could have toileted him or asked other staff if they were busy on 9/17/16. She stated that they had enough staff available to assist the resident to the toilet.