Every finding on record at Regency House of Alexandria

Based on observation, interview, and record review the facility failed to ensure privacy and dignity during the provision of care for 1 (Resident #2) of 3 sampled residents. The facility failed to maintain Resident #2's dignity during wound care and ADL care by leaving the privacy blinds open, exposing Resident #2 to an outside view. Findings:Review of the facility's undated policy titled Promoting/Maintaining Resident Dignity read in part.It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Review of Resident #2's medical record revealed an admission date of 06/18/2026, with diagnoses that included in part.Cerebral Infarction due to Thrombosis of the Left Middle Cerebral Artery, Acute Respiratory Failure with Hypoxia, Dysphagia, Aphasia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Anemia in Chronic Kidney Disease, End Stage Renal Disease, Epilepsy, and Muscle Weakness. Review of Resident #2's Quarterly MDS with an ARD of 07/17/2026, revealed a BIMS score of 99, indicating Resident #2 was unable to complete the interview. Resident #2 was dependent on staff for assistance with all ADLs. On 08/05/2026 at 9:57 a.m., an observation of Resident #2 during sacral wound care revealed Resident #2's brief had been completely removed while the room's privacy blinds remained open, exposing Resident #2 to an outside view. S4TXNurse confirmed the privacy blinds had not been closed during the provision of wound care, but stated they should have been. On 08/05/2026 at 10:40 a.m., an observation of Resident #2 during ADL care revealed C6CNA removed Resident #2's clothing, leaving Resident #2 wearing only a brief while the rooms privacy blinds remained open. Resident #2's bare chest was exposed to an outside view. On 08/05/2026 at 10:50 a.m., an interview with S3AdminSupport acknowledged the privacy blinds remained open during Resident #2's wound care and ADL care. S3AdminSupport confirmed Resident #2 was exposed to an outside view and stated the privacy blinds should have been closed during the provision of care to maintain Resident #2's dignity. On 08/05/2026 at 11:47 a.m., an interview with S1CorporateRN confirmed the privacy blinds to Resident #2's room should have been closed during wound care and ADL care to maintain Resident #2's dignity.

Based on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs and preferences by failing to ensure the resident was able to attend physical therapy in the gym for 1 (Resident #3) of 3 sampled residents. Findings:Review of the undated facility policy title Promoting/Maintaining Resident Self-Determination, revealed in part, The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interest and preferences. Review of Resident #3's record revealed an admit date of 07/10/2026 with diagnoses that included in part, Critical Illness Myopathy, Acute On Chronic Systolic (Congestive) Heart Failure, Other Specified Sepsis, Other Abnormalities Of Gait and Mobility, Major Depressive Disorder, Recurrent, Mild, Acute Cystitis Without Hematuria, and Muscle Wasting and Atrophy. Resident #3's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/12/2026 revealed in part a BIMS (Brief Interview for Mental Status) score of 15 and that the resident required substantial/maximal assistance for bed positioning and was dependent for transfers and mobility. Interview on 08/05/2026 at 9:10 a.m. with Resident #3 revealed that the facility staff did not use a mechanical transfer lift to assist her from the bed to the wheelchair to attend physical therapy in the gym on 08/04/2026. Resident #3 stated that it was her preference to attend physical therapy in the gym. Resident #3 stated that she was told that the lift was not available by the aide. Resident #3 added that if they do not get her up for therapy, she stays in her bed all day. Resident #3 confirmed that she had remained in bed all day on 08/04/2026. Interview on 08/05/2026 at 9:17 a.m. with S5PT revealed that Resident #3 did not come to the gym for physical therapy on 08/04/2026. S5PT stated that Resident #3 had not been assisted out of her bed to her wheelchair due to no available mechanical lift and so limited physical therapy was performed Resident #3's room, with the resident remaining in bed. S5PT stated that Resident #3 told her the lift was unavailable. A review of the physical therapy documentation for Resident #3 revealed that the time spent with Resident #3 on 08/04/2026 was only 15 minutes as opposed to 30 to 45 minutes normally spent on her physical therapy. Interview on 08/05/2026 at 11:47 a.m. with S1CorporateRN revealed that the aide assigned to the resident failed to return to transfer Resident #3 when the mechanical lift became available so that the resident could attend physical therapy in the gym but should have.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (#2 & #3) of 3 sampled residents. The facility failed to provide incontinent care and failed to turn and reposition the residents in accordance with their needs and established plans of care. Findings:Resident #2: Review of the facility's undated policy titled Turning and Repositioning, read in part. It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols for turning and repositioning. 1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned. 2. Turning and repositioning is a primary responsibility of nursing assistants. 4. The frequency of turning and repositioning will be documented in the resident's plan of care. Review of Resident #2's medical record revealed an admission date of 06/18/2026, with diagnoses that included in part.Cerebral Infarction due to Thrombosis of the Left Middle Cerebral Artery, Acute Respiratory Failure with Hypoxia, Dysphagia, Aphasia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, Anemia in Chronic Kidney Disease, End Stage Renal Disease, Epilepsy, and Muscle Weakness. Review of Resident #2's Quarterly MDS with an ARD of 07/17/2026, revealed a BIMS score of 99, indicating Resident #2 was unable to complete the interview. Resident #2 was dependent on staff for assistance with ADLs, was incontinent of bowel and bladder, and had a stage 2 pressure injury. Review of Resident #2's comprehensive care plan, revised 07/29/2026, revealed an intervention to reposition Resident #2 every two to three hours and as needed for comfort and pressure relief. Review of Resident #2's Braden Scale assessment, dated 07/22/2026, revealed a score of 9, identifying Resident #2 as being at very high risk for pressure ulcer development. Review of a grievance dated 07/23/2026 revealed an allegation that Resident #2 was not turned and repositioned timely during the night shift on 07/22/2026. On 08/04/2026 at 1:47 p.m., an interview with S2DON confirmed she reviewed the facility's camera footage from the night of 07/22/2026. S2DON acknowledged the footage showed CNAs provided care to Resident #2 at 11:15 p.m. on 07/22/2026, and no staff entered Resident #2's room again until 4:52 a.m. on 07/23/2026, a period of 5 hours and 37 minutes. S2DON confirmed Resident #2 was not turned and repositioned or provided incontinent care at least every two to three hours, but should have been. On 08/04/2026 at 2:40 p.m., interview with S1CorportateRN revealed the facility's expectation was for staff to attempt to turn and reposition residents at least every two hours. S1CorportateRN confirmed there was no evidence of an attempt to turn and reposition or provide incontinent care to Resident #2 every two hours, as required by the facility's policy and expected practice, but should have been. Resident #3 Review of the undated facility policy title Provision of Quality Care, revealed in part, Policies and procedures will reflect current professional standards of practice. Review of Resident #3's record revealed an admit date of 07/10/2026 with diagnoses that included in part, Critical Illness Myopathy, Acute on Chronic Systolic (Congestive) Heart Failure, Other Specified Sepsis, Other Abnormalities of Gait and Mobility, Major Depressive Disorder, Recurrent, Mild, Acute Cystitis Without Hematuria, and Muscle Wasting and Atrophy. Review of Resident #3's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/12/2026 revealed in part a BIMS (Brief Interview for Mental Status) score of 15 indicating cognition intact. Resident #3 requires substantial/maximal assistance for bed positioning and is dependent for transfers and mobility. Resident #3 is always incontinent of bowel and bladder requiring care to prevent skin breakdown and infection. Review of the grievance filed by Resident #3 on 07/30/2026 revealed the resident had stated that no one checked on her the whole night of 07/29/2026. Interview on 08/05/2026 at 9:10 a.m. with Resident #3 confirmed that no one had checked on her the night of 07/29/2026. Resident #3 stated she was concerned because she had chronic and frequent urinary tract infections and needed to be provided with incontinent care regularly. On 08/05/2026 at 1:30 p.m. with S7 Admin, a review of the facility's video recording showed Resident #3's entrance door to her room from the hallway beginning on 07/29/2026 at 4:30 p.m. and ending on 07/30/2026 at 4:32 a.m. revealed in part. observations of the following staff interactions: on 07/29/2026 at 6:50 p.m., a staff member taking supplies for care into Resident #3's room and exiting Resident #3's room with a clear, trash bag filled with linen from the room; on 07/29/2026 at 7:21 p.m., a medication cart with a nurse was observed and this nurse went into Resident #3's room and returned back to the medication cart; on 07/30/2026 at 2:29 a.m., a staff member briefly opened Resident #3's door with no observations of supplies being bought into the room or removed during this brief encounter; on 07/30/2026 at 4:20 a.m., a nurse was observed entering Resident #3's room and left out; on 07/30/2026 at 4:32 a.m., an aide was observed entering Resident #3's room with supplies for care and she exited with a clear, trash bag filled with linens. Surveyor observed no staff members opened, entered, or exited Resident #3's entrance door of the hallway on 07/29/2026 from 7:21 p.m. to 2:29 a.m. on 07/30/2026. Resident #3 was not seen or observed for approximately 7 hours. During this review of video recording with S7Admin, it was agreed upon with surveyor the number of times staff saw or observed Resident #3 in her room. S7Admin stated he could not identify the staff members who entered Resident #3's room at the times indicated above by their names based off of the video recording. Interview on 08/05/2026 at 2:40 p.m. with S1Corporate RN and S8ADON revealed the facility does not have a specific policy on how often resident rounding should occur, other than best practices. S1CorporateRN and S8ADON agreed that best practices should be interpreted to mean rounding should occur every two hours on residents in the facility. S1CorporateRN and S8ADON confirmed rounding, including incontinent care and repositioning, was not performed by any staff during the overnight shift from 07/29/2026 at 7:21 p.m. to 07/30/2026 at 2:29 a.m. for Resident #3 but should have been.

Based on interviews and record review, the facility failed to ensure direct care staff consulted with the Physician or Nurse Practitioner for 1 (#3) of 4 (#1, #2, #3, #4) sampled residents reviewed. The facility failed to notify the Physician or Nurse Practitioner when Resident #3 refused to go to dialysis on 06/15/2026 and 06/19/2026.Findings:Review of the undated facility's policy titled Hemodialysis revealed in part.10. The facility will communicate with the attending physician, dialysis facility and/or nephrologist of any canceled or postponed dialysis treatments and document any responses to the changes in treatment in the medical record. The facility will coordinate with the dialysis facility for rescheduling the resident's dialysis treatment if canceled.On 07/07/2026 at 11:53 a.m., Review of the Clinical Record for Resident #3 revealed he was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney ESRD (End Stage Renal Disease), Dependence on Renal Dialysis, and Anemia in Chronic Kidney Disease. On 07/07/2026 at 12:43 p.m., review of the Quarterly MDS with an Assessment Reference Date of 05/21/2026 for Resident #3 revealed he had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was cognitively intact. Review also revealed Resident #3 had a diagnosis of Renal Insufficiency, Renal Failure, and ESRD.On 07/07/2026 at 12:45 p.m., review of the Care Plan with an initiated date of 05/27/2026 revealed in part.Interventions: I frequently refuse dialysis.On 07/07/2026 at 12:48 p.m., review of the Progress' Notes for Resident #3 revealed there was no documentation of the Physician or Nurse Practitioner being notified of Resident #3 refusing dialysis on 06/15/2026 and 06/19/2026. In an interview on 07/07/2026 at 3:25 p.m. with S4 NP revealed she was not made aware of Resident #3 refusing dialysis on 06/15/2026 and 06/19/2026 but should have been.In an interview on 07/07/2026 at 3:45 p.m. with S2 DON confirmed the nurses did not notify the Physician or Nurse Practitioner of Resident #3 refusing dialysis on 06/15/2026 and 06/19/2026 but should have.

Based on record review and interview, the facility failed to develop and maintain a comprehensive, person-centered care plan with measurable goals and individualized interventions for 3 (Resident #1, Resident #2, and Resident #3) of 4 sampled residents. Findings: Review of the undated facility's policy titled Comprehensive Care Plans, revealed in part.Policy Explanation and Compliance Guidelines: 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment. Resident #2 Review of Resident #2's medical record revealed an admission date of 05/29/2026 with diagnoses, which included Alcohol Abuse with Intoxication, Cognitive Communication Deficit, History of Falling, and Wedge Compression Fracture of T5-T6 Vertebra. Review of Resident #2's Quarterly MDS with an Assessment Reference Date of 06/01/2026. On 07/07/2026, a review of Resident #2's comprehensive care plan, initiated on 06/01/2026 with a next review date of 09/03/2026 revealed the care plan was incomplete. In an interview on 07/07/2026 at 5:10 p.m., S5 LPN revealed she completes care plans and MDS for the facility. S5 LPN stated Resident #2's person centered comprehensive care plan was incomplete. S5 LPN stated she is behind on completing care plans for the facility and is currently in the process of updating and completing them. Resident #3 Review of Resident #3's medical record revealed he was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney ESRD (End Stage Renal Disease), Dependence on Renal Dialysis, and Anemia in Chronic Kidney Disease. Review of Resident #3's Quarterly MDS with an Assessment Reference Date of 05/21/2026. On 07/07/2026, a review of Resident #3's comprehensive care plan, initiated on 05/27/2026 with a target completion date of 08/02/2026 revealed the care plan was incomplete. In an interview on 07/07/2026 at 2:09 p.m. S2DON revealed Resident #2 and Resident #3's person centered comprehensive care plans were incomplete and not completed within 7 days after the completion of the comprehensive MDS assessment. Resident #1 Review of Resident #1's medical record revealed an admission date of 06/11/2026 and a re-entry date of 07/08/2026. Diagnoses included, in part, Cognitive Communication Deficit, Fracture of an unspecified part of the neck of the left femur, Chronic Kidney Disease stage 5, dependence on renal dialysis, and malformation of coronary vessels. Review of Resident #1's comprehensive care plan, initiated on 06/12/2026 with a next review date of 09/28/2026, revealed the care plan was incomplete. Specifically, the care plan was not comprehensive, lacked person-centered measurable goals, and did not include individualized interventions to address the resident's identified needs. During an interview on 07/08/2026 at 2:00 p.m., S2 DON reviewed Resident #1's care plan and confirmed it was incomplete.

Based on interview and record review, the facility failed to follow professional standards for food service safety by failing to document food temperatures for each meal prior to tray assembly. This deficient practice had the potential to affect all 42 residents who received meals prepared in the kitchen.Review of the facility's undated policy titled Record of Food Temperatures revealed, in part, that it is the facility's policy to record food temperatures daily to ensure foods are served at proper temperatures before trays are assembled. The policy further directed staff to measure and record the temperature of each food item and milk at every meal on a temperature log.On 07/09/2026 at 11:30 a.m., observation of the dining room during lunch service revealed two residents who reported their meals were not warm.On 07/09/2026 at 12:08 p.m., food temperature logs for the previous 30 days were requested. S3DietaryManager stated the facility transitioned to a new dietary documentation platform approximately two weeks earlier and implemented a new food temperature logging system. S3DietaryManager stated all food temperature logs from the previous system had been discarded and only documentation from the new system was available.On 07/09/2026 at 12:16 p.m., review of the documentation provided by S3DietaryManger revealed food temperature logs for Menu Cycle Days 15, 16, and 17 (breakfast, lunch, and dinner) and Day 18 breakfast only. The logs contained menu cycle days but did not include calendar dates. S3DietaryManger stated 07/09/2026 corresponded to Menu Cycle Day 26 and confirmed dietary staff had been in-serviced on the new documentation process on 07/08/2026.During an interview on 07/09/2026 at 12:30 p.m., S3DietaryManager stated she checked food temperatures prior to serving lunch that day but failed to document them, but should have. S3DietaryManager confirmed the logs provided for Menu Cycle Days 15 through 18 were the only food temperature records available. S3DietaryManger further confirmed there was no documentation for meals served prior to Menu Cycle Day 15 or for Menu Cycle Days 18 through 26, although food temperatures should have been documented for every meal.During an interview on 07/09/2026 at 1:22 p.m., S1Administrator confirmed dietary staff were expected to document food temperatures for every meal and maintain those records in the kitchen. S1Administrator stated he could not verify whether documentation had been completed until speaking with the Dietary Manager.On 07/09/2026 at 1:35 p.m., S1Administrator confirmed the facility transitioned to a new dietary documentation platform approximately two weeks earlier and that dietary staff were not trained on the new documentation process until 07/08/2026. S1Administrator further confirmed there were no food temperature logs available for any meals prior to Menu Cycle Day 15 or for Menu Cycle Days 18 through 26, although those records should have been maintained.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to food items served for 1 (Resident #1), and failed to provide a nutritional supplement as ordered for 1 (Resident #2) of 3 Sampled Residents.Findings: Observation on 06/01/2026 at 9:39 a.m. of the facility's posted lunch menu near the dining area revealed the following: Lunch: Smothered chicken, mashed potatoes, carrots, roll, and dessert.Observation on 06/02/2026 at 11:50 a.m. of the facility's posted lunch menu near the dining area revealed the following: Lunch: Chili with beans, rice, California blended vegetables, cornbread and dessert. Resident #1Record Review revealed Resident #1 was admitted to the facility on [DATE]. Resident #1 had diagnoses that included in part. Alzheimer's disease, Dysphagia, Anxiety, Pain, and Dementia.Review of Resident #1's Quarterly MDS with an ARD of 02/25/2026 revealed a BIMS of 00. Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance from staff for eating.Review of Resident #1's current physician orders read in part.Regular diet, pureed texture, thin liquid consistency. 03/04/2026Telephone interview on 06/01/2026 at 10:14 a.m. with Resident #1's RP (Responsible Party) revealed she had concerns of Resident #1 not being served all food items when he received his meal from the kitchen. Resident #1's RP stated resident was on a pureed diet and had weight loss.Observation on 06/02/2026 at 12:20 p.m. of Resident #1's lunch tray revealed he was served 1 serving of pureed chili and 1 serving of pureed vegetables. Observation of the tray revealed there was no pureed dessert or pureed cornbread served as per the menu. Interview with private sitter at the time of observation revealed this was how the kitchen sent Resident #1's tray and what staff had presented to him.Interview on 06/02/2026 at 12:32 p.m. with S2LPN revealed she observed Resident #1's lunch tray and confirmed the resident was not served and did not receive all meal items, but should have. Resident #2Record Review revealed Resident #2 was admitted to the facility on [DATE]. Resident #2 had diagnoses that included in part. Alzheimer's disease, Dementia, and Dysphagia.Review of Resident #2's Quarterly MDS with an ARD of 04/12/2026 revealed a BIMS of 99. Resident #2 had severely impaired cognition. Resident #2 required partial/moderate assistance from staff for eating.Review of Resident #2's current physician orders read in part.Frozen Nutrition Supplement every 24 hours for weight loss with lunch. 04/17/2026Regular diet, pureed texture, thin liquid consistency. 01/16/2025Observation on 06/01/2026 at 11:48 a.m. revealed Resident #2 was in the facility dining room with private sitter assisting resident with lunch meal service. Observation revealed Resident #2 was not served a frozen nutrition supplement with lunch.Observation on 06/02/2026 at 11:50 a.m. revealed Resident #2 was in the facility dining room with private sitter assisting resident with lunch meal service. Observation revealed Resident #2 was not served a frozen nutrition supplement with lunch. Interview with private sitter revealed she had never seen Resident #2 receive a frozen nutritional supplement with lunch.Interview on 06/02/2026 at 12:36 p.m. with S3DietaryCook revealed a review of Resident #2's dietary card that was served with lunch meal. S3DietaryCook confirmed Resident #2 did not receive a frozen nutritional supplement with lunch. Interview on 06/02/2026 at 12:40 p.m. with S1DON confirmed Resident #1 should have been served all menu items for lunch and Resident #2 should have been served a frozen nutritional supplement with lunch as ordered, but had not.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #34) of 29 sampled residents. The facility failed to ensure respiratory equipment was properly labeled. Findings:Review of Resident #34's medical record revealed an admit date of 01/12/2026 with diagnoses which included in part.Chronic Obstructive Pulmonary Disease, Pneumonia Unspecified Organism, Acute on Chronic Diastolic (Congestive) Heart Failure and Chronic Kidney Disease Unspecified.Review of Resident #34's 03/2026 Physician Orders read in part.Change O2 (oxygen) Mask/Nasal Cannula and tubing weekly; every night shift every Wednesday and as needed. O2 (oxygen) at 2 liters per minute via nasal cannula for diagnosis Chronic Obstructive Pulmonary Disease.Observation on 03/02/2026 at 7:58 a.m. revealed Resident #34 sitting on the side of her bed with oxygen infusing via nasal cannula. Resident #34's oxygen tubing and oxygen canister were undated. Resident #34 stated she did not know when the oxygen tubing had been changed.Interview on 03/02/2026 at 8:07 a.m. with S4 IP Nurse confirmed Resident #34's oxygen tubing and oxygen canister were not dated but should have been.

Based on observation, interview and record review the facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received 1:1 supervision as ordered for 1 (Resident #7) of 1 resident reviewed for accidents.Findings: Review of the facility's policy titled, Accidents and Supervision with a review date of 12/31/2024 revealed in part, Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. defined by type and frequency and b. based on the individual resident's assessed needs and identified hazards in the resident environment. Review of Resident #7's medical record revealed he was admitted to facility on 06/10/2025 and had diagnoses that included in part Traumatic Subdural Hemorrhage with Loss of Consciousness, Major Depressive Disorder, Unspecified Dementia, severe, with Psychotic Disturbance, and Other Alzheimer Disease. Record review of Resident #7's Quarterly MDS with an ARD of 12/31/2025 reveled Resident #7 had a BIMS of 08, which indicated moderate cognitive impairment. Record review of Resident #7's 03/2026 physician orders revealed: 02/26/2026-1:1 supervision while resident is awake and line of sight supervision while sleeping. Resident will be reevaluated every 24 hours for continued supervision needs. 03/02/2026-Level of Supervision 1:1 every shift for behaviors Review of Resident #7's Care plan revealed description of: I am at risk for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, violent behavior toward staff. Intervention: 1:1 Supervision (initiated 03/02/2026). I am at risk wanderer related to violent behavior, combative, verbally abusive towards staff, and refuses care. Intervention: 1:1 supervision started on 02/25/2026 while awake and line of sight. (Revised 03/02/2026). Record review of the facilities progress notes revealed in part . 02/25/2026 notified Psych NP of Resident #7 behaviors and recent incidents including discharge from behavioral facility, combative behavior with another resident, and combative, aggressive behaviors with staff today. Observation on 03/02/2026 at 8:13 a.m. revealed Resident #7 sitting in day area in wheelchair unsupervised. Resident #7 was at the edge of his wheelchair when a staff member helped him back up in his wheelchair. Staff member then proceeded to walk off and left Resident #7 sitting alone, unsupervised. Observation on 03/02/2026 at 11:36 a.m. revealed Resident #7 sitting at a dining table with two other residents unsupervised. Observation on 03/02/2026 at 1:46 p.m. revealed Resident #7 sitting alone, unsupervised at the end of a hallway in his wheelchair. Interview on 03/02/2026 at 1:50 p.m. with S2 ADON observed Resident #7 sitting alone, unsupervised at the end of the hallway. S2 ADON revealed Resident #7 had been having some behaviors and required 1:1 supervision. S2 ADON confirmed Resident #7 was left unsupervised, but shouldn't have been. Interview on 03/02/2026 at 2:00 p.m. with S5 Corporate Nurse revealed Resident #7's 1:1 supervision was revised today to reflect 1:1 supervision at all times, even during sleeping hours. S5 Corporate Nurse revealed that Resident #7 should have been on 1:1 supervision but was not.

Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive person-centered plan of care for each resident and ensure that care and services were furnished to attain the resident's highest practicable physical, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 (Resident #34 and #51) of 29 sampled residents by the facility failing to:1. Develop and implement a plan of care related to Resident #34's oxygen use.2. Develop and implement a plan of care related to Resident #51's Hospice service. Resident #34Review of Resident #34's medical record revealed an admit date of 01/12/2026 with diagnoses which included in part.Chronic Obstructive Pulmonary Disease, Pneumonia Unspecified Organism, Acute on Chronic Diastolic (Congestive) Heart Failure and Chronic Kidney Disease Unspecified.Review of Resident #34's 03/2026 Physician Orders read in part.Change O2 Mask/Nasal Cannula and tubing weekly; every night shift every Wednesday and as needed. O2 at 2 liters per minute via nasal cannula for diagnosis of Chronic Obstructive Pulmonary Disease.Review of Resident #34's care plan revealed no documented evidence of a care plan related to Resident #34's oxygen use.Interview on 03/03/2026 at 10:10 a.m. with S7 MDS/CP Nurse confirmed Resident #34 did not have a care plan related to her oxygen use, but should have.Resident #51Review of Resident #51's medical record revealed an admit date of 12/25/2025 with diagnoses that included in part.Type II Diabetes, Moderate Protein-Calorie Malnutrition, Dysphagia, Congestive Heart Failure and Anemia.Review of Resident #51's 03/2026 Physician Orders read in part.Admit to Hospice for Protein-Calorie Malnutrition with an order dated 10/28/2025.Review of Resident #51's care plan revealed no documented evidence of a care plan related to Resident #51's Hospice service.Interview on 03/03/2026 at 12:20 p.m. with S4 IP Nurse confirmed Resident #51 did not have a care plan related to his Hospice service, but should have.

Based on record review and interview, the facility failed to ensure nursing staff had the appropriate knowledge and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan. The facility failed to verify the presence of a Louisiana nursing license prior to hire for 1 (S12 LPN) of 2 licensed nurses whose employee records were reviewed.Interview on 03/03/2026 at 9:50 a.m. with S12 LPN revealed she began working in the facility on 03/02/2026. S12 LPN revealed she was supposed to be orienting with the nurse who was pulled to do treatments. S12 LPN revealed she had been orienting with S6 RN, but S6 RN had been reassigned to perform resident treatments. S12 LPN revealed she was assigned residents and was waiting for a login for the computer.Review of S12 LPN's employee record revealed a hire date of 03/02/2026. Further review failed to reveal verification of a Louisiana nursing license prior to hire.Interview with S8 HR 03/04/2026 at 8:23 a.m. revealed verification of Louisiana nursing license was printed and placed into the employee record of all licensed nurses prior to hire. S8 HR confirmed the facility did not have verification of S12 LPN's Louisiana nursing license prior to hire, but should have.

Based on record review and interview, the facility failed to ensure an annual performance review was completed for 1 (S11 CNA) of 3 CNAs whose employee records were reviewed.Review of S11 CNA's employee record revealed a hire date of 09/16/2024. Further review failed to reveal an annual performance review.Interview with S8 HR on 03/04/2026 at 8:23 a.m. revealed S11 CNA had an initial performance review on 02/24/2025. S8 HR confirmed S11 CNA did not have an annual performance review, but should have.

Based on observation and interview, the facility failed to post the required nurse staffing data for licensed and unlicensed nursing staff directly responsible for resident care on a daily basis at the beginning of each shift.Observation on 03/03/2026 at 9:32 a.m. revealed a Staff Reporting Form dated 03/02/2026 posted on a clipboard at the nurse's station. Interview with S2 ADON on 03/03/2026 at 9:34 a.m. revealed the Staff Reporting Form was to be posted on a daily basis, at the beginning of each shift. S2 ADON confirmed the Staff Reporting Form for 03/03/2026 had not been posted, but should have been. Observation on 03/03/2026 4:02 p.m. revealed a Staff Reporting Form dated 03/02/2026 posted on a clipboard at the nurse's station. A Staff Reporting Form dated 03/03/2026 was not posted.Observation on 03/04/2026 8:11 a.m. revealed a Staff Reporting Form dated 03/02/2026 posted on a clipboard at the nurse's station. Staff Reporting Forms dated 03/03/2026 and 03/04/2026 were not posted.Observation on 03/04/2026 11:11 a.m. revealed a Staff Reporting Form dated 03/02/2026 posted on a clipboard at the nurse's station. Staff Reporting Forms dated 03/03/2026 and 03/04/2026 were not posted.

Based on observation and interview, the facility failed to ensure that the planned menus were followed to meet the nutritional needs of the residents requiring a pureed diet. The facility failed to follow the established recipe during the preparation of pureed foods, which did not ensure the nutritional adequacy of the meals provided to residents who required a pureed diet. This had the potential to affect a total of two residents who received pureed diets. Findings:Review of a policy with a revision date of 09/01/2024 titled Puree Food Preparation read in part.It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance.5. Do not use water as an additive to prepare puree foods.7. Puree Food Preparation Guidelines per Serving:Meats: Add 1 teaspoon of beef broth or beef gravyVegetables (leaf, stem, or flower): Add 2 teaspoons of mashed potato flakes On 03/02/2026 at 11:11 a.m., an observation was made of S3DM preparing pureed diets. S3DM added several scoops of cabbage, three pieces of bread, and an unmeasured amount of water into the food processor. The mixture was processed to a pudding-like consistency.Next, S3DM added several scoops of pinto beans, three pieces of bread, and an unmeasured amount of water into the food processor. The mixture was processed to a pudding-like consistency.Lastly, S3DM added several pieces of fried pork chops, four pieces of bread, and an unmeasured amount of water into the food processor. The mixture was processed to a pudding like consistency. Review of the recipes for pureed cabbage, beans, and fried pork chops read in part. Measure the number of servings using the regular prepared recipe portion. Drain well to minimize the use of thickener to obtain appropriate consistency.Add liquid if needed (ex: reserved liquid, broth, milk, gravy, or sauce). Note: Water should not be used as a liquid when preparing puree foods.If needed, gradually add thickener (ex: mashed potato flakes, cream of rice or commercial thickener) until desired consistency is met. On 03/02/2026 at 11:35 a.m., interview with S3DM confirmed that the standardized recipes were not followed when preparing the pureed foods. S3DM stated the facility had established pureed recipes; however, the recipes were not readily available to the kitchen staff and would need to be printed. S3DM confirmed that water or bread should not have been used when preparing puree foods and acknowledge that the recipes were not followed during the pureeing process but should have been.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure open food items stored in the pantry and refrigerator were dated with an open date. This deficient practice had the potential to affect 43 residents who received meals served from the kitchen. Findings:An observation on 03/02/2026 at 6:08 a.m. of the facility pantry and refrigerator revealed one undated, open package of brown gravy mix, one undated, open bag of potato chips, and one undated, open package of sliced ham. On 03/02/2026 at 6:20 a.m., S3DM confirmed all opened food items stored in the pantry or refrigerator should be labeled with the date the item was opened. S3DM further confirmed that the items listed above should have been labeled with an open date, but were not.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help to prevent the development of communicable diseases and infection for 1 (Resident #49) of 1 resident reviewed for infection control. The facility failed to ensure:EBP were utilized as ordered; andA peripheral IV site was changed every 3 days.Review of the facility's policy titled Enhanced Barrier Precautions revised 09/01/2024 revealed, in part. 2b) An order for enhanced barrier precautions will be obtained for residents with.feeding tubes. 3a) Implementation of Enhanced Barrier Precautions: make gowns and gloves available immediately near or outside of the resident's room. Face protection may also be needed if performing activity with risk of splash or spray. 3b) PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. 4d) High-contact resident care activities include providing hygiene. 6) Therapists should use gown and gloves when working with resident on EBP.if they anticipate prolonged, close body contact where MDRO transmission is possible.Review of the facility's policy titled Nursing Management Manual dated 03/24/2024 revealed, in part.7) Peripheral IV sites are changed every three days unless otherwise ordered by the physician.Review of the facility's policy titled Infection Prevention and Control Program revised 09/01/2024 revealed, in part.4a) Standard Precautions: All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. 4c) All staff shall use PPE according to established facility policy governing the use of PPE.Review of Resident #49's electronic medical record revealed an initial admission date of 01/03/2026 with diagnoses including Extended Spectrum Beta Lactamase Resistance, Dysphagia, Gastrostomy Status, Resistance to Multiple Antibiotics, and Cognitive Communication Deficit.Review of Resident #49's current Physicians Orders revealed Enhanced Barrier Precautions during all high contact resident care and Enteral Feed Order of Jevity 1.5 at 50mL/hr via pump, dated 01/14/2026.Observation of Resident #49 on 03/02/2026 at 1:45 p.m. revealed tube feeding was infusing at 50mL/hour. No gowns or masks noted inside Resident #49's room or outside the door to his room. An undated IV site was noted to the distal dorsal surface of Resident #49's left arm.Observation on 03/02/2026 at 1:58 p.m. revealed S2 ADON entered Resident #47's room, without donning PPE, adjusted the head of his bed and repositioned his pillows. Interview was conducted with S2 ADON at that time. S2 ADON assessed the IV site upon request and confirmed the IV site was not dated, but should have been. S2 ADON confirmed Resident #47 was ordered to have EBP and she should have donned PPE prior to providing any direct care, but did not. Review of Resident #47's Health Status Note dated 02/25/2026 at 10:45 p.m. revealed, in part.IV restarted in left forearm.Observation on 03/02/2026 at 2:22 p.m. revealed S13 ST entered Resident #47's room, donned gloves, and proceeded to perform oral care and speech therapy while leaning over resident and against bedding. S13 ST did not don a gown or mask. Interview with S13 ST on 03/02/2026 at 2:29 p.m. revealed she knew a resident was on EBP if there was a sign on the door and a three-drawer bin containing PPE was outside the door. S13 ST confirmed Resident #47 did not have an EBP sign on his door, or a bin with PPE outside his door.Interview with S4 IP on 03/03/2026 at 2:40 p.m. confirmed staff should have donned and gown and gloves when providing high-contact care activities for Resident #47. S4 IP confirmed Resident #47's IV should have been labeled with the date and time it was inserted, and should have been removed after 72 hours to decrease risk of infection, but was not.

Based on record review and interview, the facility failed to establish a grievance policy to ensure the prompt resolution of all grievances for 2 (#2 and #8) of 29 sampled residents. The facility failed to:Establish a grievance policy which identified a Grievance Official;Establish a grievance policy which included the contact information of the Grievance Official with whom a grievance can be filed; andMaintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.This deficient practice had the potential to effect all 44 residents residing in the home.Review of the facility's policy titled, Resident and Family Grievances revised 09/01/2024 revealed, in part. (1) (Name and Title) has been designated as the Grievance Official and can be reached at (list contact information), and (11) Evidence demonstrating the results of all grievances will be maintained for a period of no less than 3 years from the issuance of the grievance decision.Resident #2Review of Resident #2's electronic medical record revealed an admission date of 04/21/2023 with diagnoses including Alzheimer's Disease, Dementia, and Oropharyngeal Dysphagia.Interview with Resident #2's RP on 03/03/2026 at 9:41 a.m. revealed she met with S1 ADM the previous week to complain about the consistency of Resident #2's food.Review of the facility's Monthly Grievance Log for 02/2026 failed to reveal a grievance for Resident #2.Resident #8Review of Resident #8's electronic medical record revealed an admission date of 02/04/2026 with diagnoses including Metabolic Encephalopathy, Alzheimer's Disease, Dementia, Anxiety, Major Depressive Disorder, and Abnormalities of Gait and Immobility.Interview with Resident #8's RP on 03/03/2026 at 1:59 p.m. revealed he previously complained to staff because Resident #8's call light was not within reach.Review of the facility's Monthly Grievance Log for 01/2026 and 02/2026 failed to reveal a grievance for Resident #8.Interview with S1 ADM on 03/04/2026 at 10:10 a.m. revealed Resident #8's family previously complained about her toilet not working, her bed remote not working, her toilet not being cleaned, and her call light not being within reach. S1 ADM revealed when residents or their families complained to him, he documented the information on a sticky note, which he discarded after he went and corrected it myself. S1 ADM confirmed he did not maintain any documentation of Resident #8's RP's grievances, but should have.Interview with S1 ADM on 03/04/2026 at 2:30 p.m. confirmed the facility's Resident and Family Grievances policy did not identify a Grievance Official, or include the contact information of the Grievance Official, but should have. S1ADM confirmed he met with Resident #2's RP last week and she complained about the consistency of his food. S1 ADM confirmed he did not maintain evidence demonstrating the result of the grievance, but should have.

Based on interview and record review, the facility failed to ensure a resident's comprehensive care plan was revised after a change in the residents advance directive status for 1 (Resident #22) of 29 sampled residents.Findings: Review of Resident #22's medical record revealed an admission date of 01/16/2026 with diagnoses of Unstable Burst Fracture of Second Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing and Type 2 Diabetes Mellitus with Diabetic Nephropathy. Review of the 5 day Medicare Minimum Data Set (MDS) for Resident #22 revealed a Brief Interview Mental Status (BIMS) score of 14, indicating intact cognition. Review of Care Plan for Resident #22 with an initiate date of 01/20/2026 revealed in part. Advanced Directives: I have the following advance directive of full code. Review of Louisiana Physician Orders for Scope of Treatment (LaPOST) for Resident #22 revealed in part. Do Not Resuscitate (DNR). Review of Resident #22's medical record failed to reveal an order for an advance directive. Interview with S2 ADON on 03/04/2026 at 10:48 a.m., S2 ADON confirmed Resident #22's code status was a full code in the Care Plan, but should have been Do Not Resuscitate (DNR).

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to follow physician's orders for 1 (Resident #10) of 29 sampled residents. Findings: Review of the facility's policy titled, Medications Administration on 04/30/2025 with a review date of 09/01/2024 read in part .Policy: Medications are administered as ordered by the physician and in accordance with professional standards of practice. Review MAR (Medication Administration Record) to identify medication to be administered. Compare medication source (bubble pack, vial, etc.,) with MAR to verify medication dose. Observation on 03/03/2026 at 8:21 a.m. revealed S6 RN performed medication administration for Resident #10. Observation revealed S6 RN placed 8 tablets into medication cup for administration. S6 RN compared medication blister packs to MAR on screen and proceeded to administer the medications to Resident #10. Medication administered to Resident #10 at the time of observation was Duloxetine HCl (Hydrochloride) Oral Capsule Delayed Release Sprinkle 60 mg (milligram). Review of Resident #10's facesheet revealed an admit date [DATE] with diagnoses that included in part . Major Depressive Disorder and Generalized Anxiety Disorder. Review of Resident #10's 03/2026 physician orders read in part.Duloxetine HCl Capsule Delayed Release Particles 30 mg (order date of 02/04/2026). Duloxetine HCl Oral Capsule Delayed Release Sprinkle 60 mg discontinued 02/03/2026. Review of Resident #10's 03/2026 eMAR (Electronic Medication Administration Record) revealed S6 RN documented she administered Duloxetine HCl Capsule Delayed Release Particles 30 mg. Interview on 03/03/2026 at 1:14 p.m., S6 RN unlocked medication cart and reviewed blister pack with this surveyor that read Duloxetine HCl Oral Capsule Delayed Release Sprinkle 60 mg and confirmed she administered it this morning to Resident #10. S6 RN confirmed that Resident #10 should have received the correct medication dosage of Duloxetine HCl 30 mg according to physician's orders, but did not.

Based on interview and record review, the facility failed to provide care and services that met professional standards of quality for 1(Resident #1) of 3 residents by failing to ensure controlled medications that were ordered for Resident R1 were not administered to Resident #1. The facility census was 47.Findings: Review of the facility's policy and procedure dated 09/01/2024, and titled Medication Administration read in part.Policy: Medications are administered by licensed nurses . as ordered by the physician and in accordance with professional standards of practice.Policy Explanation and Compliance Guidelines:10. Ensure that the six rights of medication administration are followed:a. Right Residentf. Right documentation12. Compare medication source (bubble pack, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.23. Correct any discrepancies and report to nurse manager. Review of Resident #1's medical record revealed an admit date of 11/18/2025 with the following diagnoses: Chronic Obstructive Pulmonary Disease Unspecified, Type II Diabetes Mellitus with Diabetic Neuropathy, Unspecified Asthma, Unspecified Dementia Severe with Agitation, Presence of Right Artificial knee Joint, Opioid Dependence and Anxiety Disorder. Review of Resident #1's admission MDS with a Target Date of 11/28/2025 revealed a BIMS score of 14 (indicating intact cognition). Resident #1 required set up or clean up assistance for eating, toileting, bathing and transfers. Resident #1 was independent with personal hygiene, and upper body dressing. Review of Resident #1's Baseline care plan dated 11/18/2025 and updated on 11/28/2025 revealed in part.Pain-monitor medications, side effects and effectiveness, Provide comfort and care. Review of Resident #1's Physician Orders dated 12/2025 read in part.Order dated 11/18/2025 by physician: Hydrocodone-Acetaminophen Oral Tablet 10-325 Milligrams (Hydrocodone-Acetaminophen Give 1 tablet by mouth every six hours as needed for pain.Interview on 12/15/2025 at 9:44 a.m. with S2 DON revealed she was called by S1 Administrator and S4 RN Weekend Supervisor that Resident #1 was out of his pain medication. S2 DON stated Resident #1 received Hydrocodone-Acetaminophen 10-325 Milligrams 1 every six hours PRN pain. S2 DON revealed Resident #1's family was at the facility and heard S3 LPN say she would borrow the pain medication from Resident R1 to give to Resident #1. S2 DON revealed she notified the physician and explained the above situation. Interview on 12/16/2025 at 10:30 a.m. with S3 LPN revealed she provided care for Resident #1 on the 6:00 a.m. to 6:00 p.m. shift. S3 LPN revealed Resident #1 was cooperative and took his medications without difficulty. S3 LPN stated Resident #1 complained of mild back pain at times, but did not request pain medications daily. S3 LPN revealed she was off duty on 12/03/2025 and 12/04/2025, and returned back to work on 12/05/2025. S3 LPN stated on 12/05/2025 she was informed by S5 LPN that Resident #1 was out of his pain medication, but it had been ordered. S3 LPN revealed when she returned to work on 12/06/2025 Resident #1's pain medication had not been delivered from the pharmacy on 12/05/2025. S3 LPN stated Resident #1 was reporting pain of a 4 to his lower back and his family was upset because the facility did not have his pain medication available. S3 LPN stated she borrowed a Hydrocodone-Acetaminophen 10/325 Milligram pill from Resident R1 and administered it to Resident #1. S3 LPN stated she knew she shouldn't have. Interview on 12/16/2025 at 3:45 p.m. with S2 DON confirmed the facility failed to have Resident #1's PRN pain medication (Hydrocodone-Acetaminophen 10-325 mg one by mouth every six hours as needed for pain) available and it should have been, that S3 LPN had borrowed pain medication from Resident R1 and administered it to Resident #1, and she shouldn't have. Interview on 12/17/2025 at 10:30 a.m. with S4 RN Supervisor revealed on 12/06/2025 S3 LPN informed her that Resident #1 was out of his pain medication. S4 RN supervisor stated she looked in the computer and saw Resident #1 had been out of his Hydrocodone-Acetaminophen 10-325 Milligrams PRN pain medication for a few days. S4 RN Supervisor stated she could not pull it from the ER kit because she didn't have a prescription. S4 RN Supervisor stated S3 LPN later informed her she had administered Resident R1's Hydrocodone-Acetaminophen 10-325 MG PRN pain medication to Resident #1. S4 RN Supervisor stated she informed S3 LPN to never borrow a resident's medication to administer to another resident. S4 RN Supervisor stated she then notified the Administrator and DON of the situation.

Based on observation, record review and interview the facility failed to ensure that a resident at high risk for falls received adequate supervision and assistance devices to prevent accidents for 1 (#29) of 3 (#14, #29 and #30) residents reviewed. According to the Resident Census and Conditions of Residents form provided by the facility and dated 2/13/2017, the facility's total census was 48 residents. The failed practice resulted in an actual harm situation when resident #29 on 1/24/2017 fell from her wheelchair and fractured her left hip. Resident #29, who was identified by the facility as being at high risk for falls, sustained a fall on 11/17/2016, 11/22/2016, 12/06/2016, 1/1/2017, 1/6/2017, 1/21/2017, and 1/23/2017. There was no evidence that increase supervision or monitoring was done to prevent or decrease falls for this resident. The resident fell again on 1/24/2017 and sustained a fracture to her left hip according to a CT scan dated 1/27/2017. Findings: Observations on 2/13/2017 at 10:20 a.m., 2/14/2017 at 10:30 a.m. and 2/15/2017 at 8:40 a.m. revealed resident #29 sitting in her wheelchair. The resident was not observed to have any safety devices in place. Review of resident #29's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set assessment with an Assessment Reference Date of 1/13/2017 revealed the resident was assessed as being able to ambulate with limited assistance of one person. Further review revealed resident #29 used a walker and wheelchair for ambulation; however, she was identified as not having a steady gait; only able to stabilize with staff assistance. The assessment revealed a Brief Interview Mental Status (BIMS) summary score of 3, which indicated the resident's cognition was severely impaired. Further review revealed the resident's ability to understand others was limited to simple, direct communication only. Review of a Morse Fall Scale dated 1/13/2017 revealed resident #29 had a high score of 75, indicating she was High Risk. Further review of the Fall Scale revealed the resident had fallen before, her gait was impaired and she would overestimate or forget her limits. Review of the resident's current Care Plan with target date of 4/6/2017 revealed the resident had impaired cognitive function/dementia or impaired thought process r/t Alzheimer's Dementia. Further review revealed she was at High Risk for falls related to deconditioning, Alzheimer's disease, Dementia, and Parkinson's disease. The Care Plan revealed the resident walked using the walker, and sustained actual falls on 11/17/2016, 11/22/2016, 12/06/2016, 1/1/2017, 1/6/2017, 1/21/2017, 1/23/2017, and 1/24/2017. Further review of the Care Plan revealed the following Interventions/Tasks: anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it; CNA for assistance as needed; the resident needs prompt response to all requests for assistance; educate the resident/family/caregiver about safety reminders and what to do if a fall occurs; follow facility fall protocol: assess for any injury, give wound care to any wounds; assess ROM; do neuron assessment for any witnessed head injury; un-witnessed fall assist to bed, wheelchair or chair, and address resident's current needs; advise physician and family. Review of resident #29's medical record revealed an Interim Care Plan was completed after each fall; that addressed what to do after each fall to keep the resident safe until S 1 DON was made aware. There was no documentation of evidence of increased supervision and monitoring of the resident to prevent further falls. Review of the Acute Charting Nurses Notes for January 2017 revealed the following entries: 1/1/2017 at 6:28 a.m.: resident on floor in room, grasping walker; staff witnessed resident hit head on the wall after resident attempted to get up off floor. Resident very confused; staff assisted resident and placed resident on bed. No visible injuries noted. 1/6/2017 at 12:30 p.m.: resident on floor in dayroom, the resident stated she wanted to lie down in bed because she was tired. Head to toe assessment done. No injures present. Neurochecks in progress. The resident transferred from floor and helped to bed with call light in reach. Safety ensured. 1/21/2017 at 11:28 a.m.: resident was in wheelchair in hallway. She was pulling herself along the wall rail to go to her room and slid out of wheelchair onto floor. Resident had no complaints of pain, dizziness, headache, or nausea. The resident stated that she did not hit her head, but neuron assessments started as a precaution. Vitals B/P 181/96, Resp. 18, Pulse 87, Temp. 98.1 oral. No injuries visible at this time; will continue to monitor. 1/23/2017 at 4:00 p.m.: summoned to resident room via Activities Aide. She stated resident #29 tried to sit down in her wheelchair and missed the wheelchair. The resident sat on her buttocks holding left hip, no head trauma noted, no skin tears present, head to assessment initiated, resident complaint of hip pain, minimal movement to abduction and adduction range of motion to left leg, V/S T-98.2, P-84, R-22, and B/P 144/86 resident transferred back to wheelchair, MD notified with new orders for x-ray to left hip, responsible party notified, local imaging notified, will continue to monitor. Review of the Physician order [REDACTED]. Review of an imaging report dated 1/23/2017 revealed in the Impression section: Lucent line between the trochanters is noted, fracture cannot be excluded, given the history. Consider repeat left hip series and/or CT scan of the pelvis with particular attention to the left hip. Review of Communication with family/POA on 1/23/2017 at 5:39 p.m. revealed a note that read call to resident #29's daughter, to advise that the X-ray came back, and while there was nothing frankly fractured nor displaced, there was a shadow on the bone and the radiologist recommends a CT of her hip. Advised daughter this could be done tomorrow, through a local imaging company. Daughter stated to get appointment and call her with appointment time. Review of the physician's orders [REDACTED]. Further review revealed physician's orders [REDACTED]. Review of Communication with family/POA on 1/24/2017 at 9:40 a.m. revealed S 1 DON informed resident #29's daughter of her appointment on 1/27/2017 for a CT. There was no appointment time documented. The note revealed the resident's daughter wanted to keep the appointment for the CT, if the resident was not in any distress. Review of the Acute Charting Nurses' Notes dated 1/24/2016 at 5:00 p.m. revealed the nurse was summoned to resident's room via visitor, visitor stated I think this lady is on the floor, resident on knees on bedside, no head trauma present, no skin tears, pain to left leg noted, resident transferred back to bed, MD and RP, V/S B/P- 138/78, T- 98.2, P-70, and R 20; will continue to monitor. Review of a Communication with Physician form dated 1/27/2017 at 2:53 p.m. revealed resident #29 was complaining of left leg pain. Further review of the form revealed documentation of a left hip fracture and resident #29's private physician was notified. Review of a Physician Order's dated 1/27/2017 at 3:30 p.m. revealed an order to transfer resident #29 to the local emergency room for a left hip fracture. Interview on 2/14/2017 at 2:30 p.m. with S3 LPN revealed the resident fell on [DATE] and was sent to the hospital for an x-ray; however, the x-ray did not show anything. She revealed the resident appeared to be in pain, and she would yell at times. S3 LPN stated the resident was sent back to the ER for an x-ray, and the x-ray showed a fracture to the left hip. Further interview with S3 LPN revealed the resident had a bed/chair alarm; however, staff had to transfer the alarm from the bed to the chair. Interview on 2/15/2017 at 8:40 a.m. with S4 CNA revealed the resident had a bed alarm; but, she was not aware of a chair alarm. Interview on 2/15/2017 at 8:50 a.m. with S5 LPN revealed resident #29 was sitting in the day room on 1/23/2017 when she slide out of her wheelchair. S5 LPN revealed resident #29 was holding her left hip and complaining of pain at the time of the fall. Further interview revealed she was sent to the ER to have her left hip x-rayed. S5 LPN stated that the resident had another fall on 1/24/2017 when she was trying to get out of the bed. S5 LPN confirmed resident #29 had sustained several falls. But, he was aware of the interventions that were implemented after each fall. Interview on 2/15/2017 at 8:55 a.m. with S 1 DON revealed resident #29 had a fall on 1/23/2017 and on 1/24/2017. S 1 DON stated the resident had a bed/chair alarm as an intervention at the time of the falls. Interview on 2/15/2017 at 8:58 a.m. with S6 CNA revealed resident #29's had a bed/chair alarm. Further interview revealed staff was responsible for transferring the bed alarm to the wheelchair. S6 CNA stated she did not get resident #29 out of bed on this morning (2/15/2017; the resident was gotten up on night shift. Interview on 2/15/2017 at 9:03 a.m. with S7 OT revealed the resident was very confused at times. Further interview with S7 OT stated that the resident was ambulatory with assistance. Interview on 2/15/2017 at 10:21 a.m. with S2 DON revealed an interim care was done after each fall to keep the resident safe until she was made aware of the fall. S 1 DON stated she did not have a monitoring tool in place to monitor residents with bed/chair alarm; however, it was everyone's job to monitor the residents for safety. Telephone interview on 2/15/2017 at 1:40 p.m. with S8 CNA who was the resident's CNA and worked the night shift revealed she was never instructed to transfer the resident's bed alarm to the wheelchair when she was gotten up. Attempted telephone contact with the evening shift LPN's and CNA's who cared for resident #29, and the night shift LPN's and CNA's who cared for the resident was unsuccessful.