**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff followed care plan interventions and perform accurate assessments on residents related to bed mobility assistance for three residents (#5, #6, and #7) out of three residents sampled.On 07/25/2025 Staff A, Certified Nursing Assistant (CNA), independently rolled Resident #5 onto her side in bed to perform incontinence care. Staff A, CNA left Resident #5 unattended in bed to collect supplies. Resident #5 fell out of the bed while unattended and suffered a right hip fracture which required a transfer to a higher level of care and surgical repair.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to residents and resulted in the determination of Immediate Jeopardy on 08/07/2025. The findings of Immediate Jeopardy were determined to be removed on 08/08/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm.Findings Included: 1. During an interview on 08/06/2025 at 8:32 a.m., Resident #5 stated she had a fall a couple months after she was admitted to the facility. Resident #5 stated she was supposed to always have two people assisting her with care. She stated she requested a bigger bed. She stated, Sometimes they come in with two people and sometimes they just come in with one person. She stated, they set up a chair on the side of the bed for her to hold onto because they told her they could not use side rails. She stated, The chair slides while I'm holding onto it. She stated she requested a bigger bed a few times after a fall and was told they would order it, and it never came until after her most recent fall (07/25/2025). She stated, This last fall I broke my hip in two places and had to have surgery. The CNA came in to change me by herself, she rolled me onto my side, she put my legs with one on top of the other, the CNA went to grab something off of the dresser and I told her I was slipping, and she told me, You will be okay, I told her again that I was slipping and then I fell off of the bed. I only got the bigger bed now because I fell. The aides were upset that they were taking so long, to get me a bigger bed because they all knew I was at risk. Review of Resident #5's admission record revealed an initial admission date of 04/05/2025 and a re-admission date of 07/28/2025. Resident #5 was admitted to the facility with diagnoses to include: displaced apophyseal fracture of left femur (a break in the growth plate area of the large bone of the upper leg), initial encounter for closed fracture (08/04/2025), displaced fracture of greater trochanter (a bony prominence located on the upper part of the thigh bone) of right femur, initial encounter for closed fracture (07/28/2025), spondylolysis (a stress fracture in a vertebra), cervical (neck) region (09/21/2024), unspecified fall, subsequent encounter (09/21/2024), muscle weakness (generalized) (09/21/2024), other abnormalities of gait and mobility (09/21/2024), morbid (severe) obesity due to excess calories (09/21/2024), and repeated falls (09/21/2024). Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE] revealed in Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of Section GG-Functional Abilities revealed Resident #5 had an impairment on one side to her upper and lower extremity. Resident #5 required substantial/maximal assistance revealing helpers do more than half the effort. Helpers lift or hold trunk or limbs and provides more than half the effort for rolling left and right. Sitting to lying (the ability to move from sitting on side of bed to lying flat on the bed, lying on side of bed), Resident #5 was dependent, meaning helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident #5's care plan dated 08/03/2024 revealed: Focus: ADL Self-Care and/or mobility deficit. Needs assistance with ADL's Initiated on 09/23/2024.Interventions included: BED MOBILITY-Total ASSIST X 2 TRANSFERS-Total ASSIST with Hoyer X 2TOILETING-Total ASSIST X 2DRESSING-Total ASSIST X 2BATHING-Total ASSIST X 2 Review of Resident #5's Intervention/Task for July revealed one person assistance was provided for ADL-Bed Mobility on 07/26/2025 (day shift), 07/28/2025 (evening shift), 07/30/2025 (day shift), 07/31/2025 (evening shift), 08/01/2025 (day shift), 08/02/2025 (evening shift), 08/03/2025 (day shift and evening shift), 08/05/2025 (evening shift), 08/07/2025 day shift). A review of the physician order summary for Resident #5 revealed: Right hip Xray 2 views due to status post fall pain. Start Date 07/26/2025.Send to ER (emergency room) for further eval and treat. Start Date 07/27/2025. Review of Resident #5's progress notes revealed: -07/28/2025 at 7:47 p.m. Fall Risk Evaluation Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: Alert (oriented x 3) OR comatose. Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. Residents had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Notes: Post right hip surgery 7/27/25 Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 15.0.-07/28/2025 6:05 p.m. Nursing Note Note Text: readmitted a [AGE] year-old female from [Acute Care Hospital] via stretcher accompanied by 2 Emergency Medical Services (EMS) staff.Surgical incision to right hip clean, dry with dressing intact, with PICO [a single-use, portable negative pressure wound therapy system designed to promote wound healing] dressing functioning well. Patient also has skin tear to right lower leg with sutures in place. Bruising noted to right knee/ right[sic] lower leg. Discoloration and flaking noted BIL [bilateral] feet.-07/27/2025 12:00 a.m. Nursing Note Late Entry:Note Text: Result of X ray[sic] right hip reported to ARNP [Advanced Practical Nurse Practitioner] with order received for resident to be sent to ER [Emergency Room] for further eval and treat. DON [Director of Nursing] notified. This writer called [Family Member] 2x [twice] left message, awaiting for call back. Facility protocol followed. Resident transported to ER via 911.-07/26/2025 07:38 a.m. Radiology Note Note Text: Patient complained of pain of 7 on right hip/pelvis area s/p [status post] fall last evening. Administered PRN [as needed] pain pill. Notified provider on call.received order for STAT (immediate) xray[sic] to right hip/pelvis area 2 views. [Mobile Radiology Company] services needed due to pt [patient] being bed bound.-07/26/2025 3:52 p.m. Nursing Note Note Text: Bariatric [bed] delivered to [room number], resident in new bed without difficulty. Resident[sic] says new bed is comfortable.-07/25/2025 4:56 p.m. Interdisciplinary (IDT) Note Late Entry:Note Text: Resident reviewed by IDT for s/p [status post] fall on 7/25. Resident found by the floor nurse lying on floor on her back next to bed. CNA reported she was providing incontinent care and stepped away to get a towel; during that time, resident rolled off the bed. Head-to-toe assessment completed; no visible injuries noted. Pt [patient] was complaining of left shoulder pain. Neuro checks initiated. NP [Nurse Practitioner] notified; new orders received for STAT [immediate] left shoulder x-ray and one-time dose of oxycodone for pain. Message left for [Family Member] return call regarding notification of family. Interventions: Wider bed ordered for resident. Staff re-educated on following Kardex instructions; emphasized requirement for two-person assist as documented. STAT x-ray of Left shoulder and one time dose of oxycodone was ordered.-7/25/2025 6:27 p.m. Nursing Note Note Text: Called to room by CNA. Observed resident lying on the floor on her back side next to bed. Resident states she rolled off of the side of the bed. Head to toe assessment completed. Complaints of left shoulder pain. No visible sign of injury. Neuro checks initiated. Returned to bed using [mechanical lift] with multiple staff present. [ARNP] notified. New order for STAT left shoulder xray[sic] and one time dose of oxycodone for pain. Message left for [Family Member] to return call to facility.-07/25/2025 7:15 p.m. Nursing Note Note Text: Spoke with [Employee of Bed Supplier]. Bariatric bed to be delivered 7/26 before 11:45am. Resident made aware. Review of Resident #5's Hospital Discharge Records dated 07/27/2025 revealed: Procedure History: Arthroplasty Hip Bipolar (a surgical procedure replaces the damaged femoral head with a prosthetic implant) (Right), (07/27/2025), Open Reduction Internal Fixation Hip (surgical procedure used to treat hip fractures by realigning the bone and securing it with internal hardware) (Right) (07/27/2025). During a phone interview on 08/06/2025 at 12:57 p.m., Staff A, CNA stated on 07/25/2025 she went to provide Resident #5 with care. She said, I rolled [Resident #5] onto her side in the bed, and I went to grab a towel from the dresser. While I was grabbing the towel [Resident #5] slipped off the bed. I usually take everything I need with me. She stated there was not a rail on the bed for the resident to hold onto. Staff A stated Resident #5 holds onto the top of the dresser for support, and It is difficult to roll her sometimes. She stated, I ran out and started screaming for the nurse. I grabbed her a pillow for her head while we were waiting for someone to come in the room. She stated Resident #5 said her hip was hurting after the fall. Staff A stated the nurse did an assessment and then they put Resident #5 back in bed. She said, I don't know if [Resident #5] went out to the hospital or not. I thought [Resident #5] was a one person assist. We look in the Kardex to tell you how many people a resident requires to provide care. She stated after the incident, the Director of Nursing (DON) did a one-on-one in-service. She said, It was something on falls being careful and being aware. During an interview on 08/06/2025 at 10:38 a.m., Staff B, Licensed Practical Nurse (LPN), stated on 07/25/2025 she did wound care in the morning and worked on the floor from 3:00 p.m.-11:00 p.m. She was called to Resident #5's room by Staff A, CNA, and Resident #5 was on the floor lying on her back between the two beds. Staff A, CNA told her she was in the middle of changing her when she walked to the dresser to grab towels and the resident fell. Staff B stated the aide told her, The weight of her body flipped her to the other side of the bed. [Staff A, CNA], was the only aide in the room. [Resident #5] was supposed to have two people assisting her. She did a head-to-toe assessment on Resident #5. Staff B stated, I did not move the right shoulder much because I know she has had long term pain in that shoulder. Her legs are big, and [Resident #5] cannot hold them up on her own. I lifted both of her legs, and she did not have any pain at that time. There was no redness, swelling or bruise at the time of the assessment. Resident #5 was only complaining of left shoulder pain. She stated she got orders for STAT (emergent) left shoulder Xray. She said Resident #5 never complained of hip pain on the shift. She stated she called the doctor and asked if the pain medication could be given early. She stated when she got back to work on Monday, she was told Resident #5 went out to the hospital for her hip. She stated at the time of the fall Resident #5 had a regular size standard bed. Staff B stated, We talked about getting her a bariatric bed a long time ago. Resident #5 was able to hold herself over by holding onto the nightstand next to the bed or the armoire on the other side. If she was in a bariatric bed she would not be able to reach the nightstand to hold herself up, so we did not get her the bariatric bed. She said Resident #5 does not use her right arm for anything anymore. She stated, The bed she had [at the time of the fall] did not have anything for her to hold onto. She said Resident #5 does not move; she can't reposition herself or anything. There was some room on each side of the bed, if she was a moveable person she would not be able to move much. Residents who need a bariatric bed just need to bring it up to the managers, and they would get them one. There really is not a system in place for determining when a resident needs a bariatric bed. The unit manager can call and request a bariatric bed if they feel a resident needs it. She said, If we need more room to turn the resident we would request for one. But usually, it is a customer service thing when a resident requests for it. During an interview on 08/06/2024 at 3:56 p.m., the Director of Nursing (DON) stated she did the reportable investigation for Resident #5's fall. On 07/25/2025 at 4:30 p.m. Staff A, CNA was providing incontinent care for Resident #5. Resident #5 was on her side in the bed. Staff A, CNA went to grab the towels off the dresser. Resident #5 legs began to slide down. Resident #5 told Staff A, CNA she was starting to slide and Staff A, CNA could not intercept her fast enough, resulting in Resident #5 falling to the floor. Resident#5 was assessed by the nurse and complained of left shoulder pain. They did an Xray of the left shoulder and it was negative for a fracture. The next day (07/26/2025), Resident #5 started complaining of right hip pain, they did an Xray, and it was positive for a hip fracture. The results came back close to midnight, and Resident #5 was sent to the hospital for further evaluation. Resident #5 was admitted to the hospital and underwent a right hip arthroplasty on 07/27/2025. The DON stated the resident returned back to the facility on [DATE]. During the investigation, she interviewed staff and other residents to see if there were any concerns with Staff A, CNA's care. No residents or other staff had concerns with Staff A, CNA's care. She provided education to all staff related to making sure they have all of their items in reach when providing care. If they need to grab something while providing care residents should be placed back on the bed. They ordered a wider bed for Resident #5, and it was delivered the next day (07/26/2025). They updated Resident #5's Kardex for her to be a two person assist with everything. The DON stated, There is not anything that is black or white to determine what type of assistance a resident needs while providing care. It can be determined by therapy; some people can do more than others. There are a lot of factors, there is not a guide. The DON stated Resident #5 had another event in October 2024. During this event Resident #5's legs were hanging over the side of the bed, they had to assist her down to the floor and then put her back in bed. She said, According to the 10/14/2024 interdisciplinary team (IDT) note it says Resident #5 is a two person assist with incontinence care. I thought this was referring to when Resident #5 was using the bathroom and holding onto the bar. She said bed mobility is how many people it takes to move people in bed. At the time her bed mobility was a one person assist, and her transfer status was two person assist. She stated, There was some confusion, because the two-person changing brief was not under the activities of daily living (ADL) part of the Kardex and her bed mobility in ADL's said Resident #5 was a one person assist. When the care plan was updated in October of 2024, it updated under a different part of the Kardex. She said Resident #5 needing to be a two-person assist for brief changing was only on the safety part of the Kardex. Staff A, CNA was following the ADL Kardex. Residents use different things to hold onto while care is being provided. They can use furniture, she said, Their chair would be up against their bed, or chairs that have handrails, or whatever is there for them to grab onto. If they have a scoop mattress they can hold onto that, it depends on the resident. We try to use trapezes; we try other interventions other than side rails. We don't like to utilize bed rails, she said, It is frowned upon to use them since the initiative for no bed rails. In our setting they don't want us to use the bed rails. If a resident uses bedrails, an evaluation is done for the adaptive rails, and we put them on. The CNA's document under tasks when they perform an activity for a resident. If the task is marked off as one person assist, then one person assists with that activity. We did not substantiate the allegation because everyone was under the impression she was a one person assist with the bed mobility. 2. During an interview on 08/06/2025 at 2:51 p.m., Resident #6 stated she thought she was supposed to have two people assisting her but usually it is only one person assisting. She stated she holds onto the mattress and sheets when she has to turn, especially when she turns on her right side because she has little to no movement on her left side and there has been several times where she feels like she is going to fall head first off of the bed. She stated when that happens the aide usually runs around and moves her upper body back into position, so she does not fall. She stated she wishes there was something sturdier to hold on to, so she was more comfortable with turning. Review of Resident #6's admission record revealed an admission date of 03/26/2024 and diagnoses to include hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (03/26/2024), morbid (severe) obesity due to excess calories (03/26/2024), flaccid hemiplegia affecting left nondominant side (03/26/2024). Review of Resident #6's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition. Review of Section GG-Functional Abilities revealed, Resident #6 had an impairment to one side of her upper and lower extremity. Resident #6 required Substantial/maximal assistance, helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for Roll left and right and sit to lying. Resident #6 was dependent helper who does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for Lying to sitting on side of bed, sit to stand, chair/bed to chair transfer and tub/shower transfer. Review of Resident #6's Care Plan, dated 04/09/2025, revealed the following:Focus: ADL Self-Care and/or mobility deficit. Needs assistance with ADL's at risk of developing complications associated with decreased ADL self-performance related to: Cognitive impairment, disease process/condition, weakness. Date Initiated 08/06/2025 Revision Date 08/06/2025Interventions: Encourage and assist to turn and reposition, shifting weight to enhance circulation. Date Initiated: 08/06/2025Provide assistance/supervision as needed: Bed Mobility-Assist x2Transfers-Assist x2 mechanical liftToileting-Assist x 2Dressing-Assist x1Bathing-Assist x2Grooming-Assist x1Eating-SupervisionDate Initiated 08/06/2025 Revision on: 08/06/2025 Review of Resident #6's Visual/Bedside Kardex as of 08/06/2025 revealed: Safety: check for toileting needs; ensure proper footwear; give verbal cues as needed; observe for bleeding gums, nosebleeds, unusual bruising, tarry black stools, pink or discolored urine to nurse and/or MD.Resident care:Encourage residents to report any signs of bleeding or bruising; monitor for side effects IE: abdominal or stomach pain, bloody or cloudy urine; nail care; observed skin rash for increased spread or signs of infection; place items in easy reach and Orient to placement; place items used in easy reach IE water, telephone, call lights; report changes in visual status PRN; resident prefers to have: now male CNA's; splint: apply left [NAME] guard and AM. Remove left [NAME] guard at DHS. Where daily as tolerated. Two person assist with turning and repositioning. Bladder/bowel:assist with toileting and peri care as needed; never mind frequent checks for incontinence; incontinence care as needed; monitor BM's and document; the relocation would be preventative skin care as ordered; keep will be clean dry and odor free daily. Review of Resident #6's Interventions/Task log revealed: ADL-Bed Mobility was provided with a one person assist on 07/25/2025 (day and night shift), 07/26/2025 (day and night shift), 07/27/2025 (day, evening, and night shift), 07/28/2025 (day shift), 07/29/2025 (day and night shift), 07/30/2025 (day and night shift), 08/01/2025 (day and night shift), 08/02/2025 (night shift), 08/03/2025 (night shift), 08/04/2025 (night shift), 08/04/2025 (night shift), 08/05/2025 (evening and night shift), 08/06/2025 (day and night shift). 3. During an interview on 08/06/2025 at 2:59 p.m., Resident #7 stated he usually has only one person but occasionally, there's a second person to assist him. He stated when they turn him he tries to reach down and hold the metal bar underneath the mattress but due to his Multiple Sclerosis (MS) he has very little strength in his hands and often is very uncomfortable and makes him nervous about falling. The resident stated he has asked multiple people about getting some siderails but has been told by everyone he does not qualify. Review of Resident #7's admission record revealed an admission date of 07/26/2023. Resident #7 was admitted to the facility with diagnoses to include: Multiple Sclerosis (07/26/2023), Muscle wasting and atrophy (07/27/2023), Muscle weakness (07/27/2023), Unspecified lack of coordination (07/27/2023), Functional quadriplegia (07/26/2023), and need for assistance with personal care (07/26/2023). Review of Resident #7's Quarterly MDS, dated [DATE], revealed in Section C-Cognitive Patterns a BIMS of 15 out 15 indicating intact cognition. Review of Section GG-Functional Abilities revealed Resident #7 had an impairment to both sides of his upper and lower extremities. Resident #7 was dependent; helper does all the effort. Residents does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity for Roll left and right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, and tub shower transfer. Review of Resident #7's Care Plan, dated 07/26/2023, revealed the following: Focus: Resident's ADL needs include assist with bed mobility; transfers; locomotion/walking; dressing; toileting; personal hygiene; bathing. Date Initiated: 07/27/2023Interventions: The resident cannot transfer without help. The resident will need total mechanical lift with 2 persons assist for transfers. Date Initiated: 07/27/2023The resident needs help to move and reposition in the bed. Will need one or two person assistance to change position or scoot up in bed. This may involve some lifting of the legs or boosts. Date Initiated: 07/27/2023Provide assistance/supervision as needed: Bed Mobility-Assist x1Transfers-Assist x2 mechanical liftToileting-Assist x 1Dressing-Assist x2Bathing-Assist x1Grooming-Assist x1Eating-Setup AssistDate Initiated 08/07/2025 Revision on: 08/07/2025 Review of Resident #7's Visual/Bedside Kardex as of 08/06/2025 revealed: Safety: Check for toileting needs; encourage appropriate footwear; keep adaptive equipment within reach; scoop mattress.Resident Care: CPAP as ordered; nail care; O2 as ordered for OSA/SOB; place items used in easy reach i.e. water, telephone, call lights; use Broda chair.Bladder/Bowel:assessed with toileting and peri care as needed; document bowel movements daily; frequent checks for incontinence; incontinence care as needed; monitor BM's and document; preventative skin care is ordered; will be clean dry and odor free daily.Bed Mobility:ADL-Bed Mobility; The resident needs help to move and reposition in the bed. Will need one or two person assistance to change position or scoot up in bed. This may involve some lifting of the legs or boosts. Turn and reposition frequently as needed.Bathing:ADL-bathing type showers Wednesday and Saturday 7:00 a.m. to 3:00 p.m.; The residents needs help getting in and out of the shower and may be able to wash their face or upper body but need assistance washing the rest, including their feet. During an interview on 08/06/2025 at 8:50 a.m., Staff E, CNA stated she knows a resident requires a one or two person assist when they are heavy or aggressive. During an interview on 08/06/2025 at 8:58 a.m., Staff F, CNA stated she looks in the computer, Kardex under resident care to tell her if a Resident is a one or two person assist. During an interview on 08/07/2025 at 3:46 p.m., Staff G, CNA, stated the facility provided education recently. The education reminded them to look at the Kardex under resident care to know if a resident needs one or two person assistance with ADL care. During an interview on 08/07/2025 at 3:47 p.m., Staff C, Certified Nursing Assistant (CNA), stated she had received education about the Kardex, specifically where to look for one or two person assist for her residents. She goes into the Kardex under Resident Care, and she can find one or two person assist. She said they provided this education to her yesterday and during her orientation in the beginning of July when she was hired. During an interview on 08/07/2025 at 3:51 p.m., Staff D, CNA stated she did receive education two weeks ago on where to look for resident care needs like how many aides are needed to assist with bed mobility, she looks at the Kardex under Resident Care and if she cannot find what she needs she will go ask the nurse. During an interview on 08/07/2025 at 3:52 p.m., Staff H, CNA stated they provided education last week and taught us how to get into the electronic record. She said if they need to know if a resident is a one or two person assist they look under patient care on the Kardex. During an interview on 08/07/2025 at 10:29 a.m., the Director of Rehab (DOR) stated when a resident is admitted to the facility they get an evaluation and a screening completed by therapy. For residents in Long Term Care, they screen them to determine their bed mobility. They review the residents records, speak with the resident and family to determine their prior level of care. We observe them to see if they can perform the action we are evaluating. After the evaluation we tell the nurse. Therapy does not update or document on the care plan. Resident #5 was seen by therapy most recently on 02/27/2025 thru 06/27/2025. She required a max assistance, she really needed a lot of assistance with everything. She has been dependent since 09/21/2024. Resident #7 has MS, and he does not like to participate in therapy. We have picked him up several times. He was last seen in May of 2025. Resident #7 is dependent for bed mobility since his admission in 2023. He is a big guy if the CNA's feel like they need a two person they could use two people. Resident #6 has been dependent since her admission in 2024. The DOR stated when they do the quarterly or annual assessments they use the Task report to show what type of assistance the CNA's have been using for care. If a resident is all over the board we will do an evaluation to determine what their current level of care assistance is. If we determine a different level of care, we communicate it to the CNA and the nurse. It is up to the CNA to determine if they can provide the care for the residents by using one person or two and what is safe for them and the residents. Review of the facilities policy dated October 2022 titled person-centered comprehensive care plan revealed,Guideline:It is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and time frames to meet their preferences and goals, and address the guest/residents nursing, medical, physical, mental, and psychosocial needs. The comprehensive care plan will be developed within seven days after completion of the comprehensive assessment and no more than 21 days after admission. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest/resident's condition. The interdisciplinary team will work collaboratively with the guest/resident, responsible party and/or family members to develop a comprehensive person-centered care plan that encompasses each guest/resident personal preferences, goals, and objectives. The comprehensive person-centered care plan will be developed based on the minimum data set (MDS) to assess the guest/residence clinical condition, cognitive and functional status, and use of services. The comprehensive care plan will address the following: services to be furnished to attain or maintain the guest/residents highest practicable physical, mental, and psychosocial well-being. PASARR recommendations (if applicable) Guest/resident goals for admission and desired outcomes Guest/resident preferences for future discharge referrals to local community resources needs and strengths of the guest/resident culturally competent care and services/preferences trauma informed care/interventions potential triggers guest/residents refusal of care or services and centers action to provide education to guest/resident and or representative Facility immediate actions to remove the Immediate Jeopardy included: -Resident #5 had a comparison review of their most recent completed MDS section GG, which included input from the multidisciplinary team with their current ADL care plan/Kardex interventions, and her plan of care was updated to accurately reflect the amount of ADL assistance and type of support for bed mobility and toileting/incontinence care on 7/29/2025. -The care plan specialist/designee reviewed all residents ADL care plan/Kardex utilizing input from the resident's medical record, gg evaluations, staff interviews including therapy documentation as applicable, on 8/6/25 and 8/7/25, which included 1- or 2-person support to clarify the minimum number of people required to safely perform the task. These process changes included guidance for the safest level of ADL support. 13 residents had the level of support assistance revised. For the remainder of the residents the care plan specialist/designee revised the Kardex to place the ADL level of assistance and number of staff support under one section resident care to create a uniform view for nursing assistants to decrease opportunities for error on 8/6/2025. -Director of education/designee educated all nursing staff (CNAs and nurses) on pulling up the care plan and Kardex interventions to identify the correct ADL level assistance and type of support required with a return demonstration. This education was initiated on 7/25/25 on-going for new employees -The DON/designee on 8/8/25 conducted an observational audit of nursing staff providing ADL care at the bedside or completed an ADL documentation review of 15 (10 %) nursing staff providing resident ADL care to ensure appropriate support and safety measures were followed according to the resident's care plan or Kardex. Any identified concerns were corrected immediately with staff utilizing corrective education. Verification of the facility's removal plan was conducted by the survey team on 08/08/2025.On 08/08/2025 interviews with facility staff was conducted for 4 RN's, 9 CNA's, and 2 LPN's to verify education and training had been completed related to topics to include:-Reviewing Kardex before caring for Resident, Safety and Resident Care, prior to providing any care and document accordingly. All staff were able to voice understanding of the policies and processes required to provide competent care to residents. The staff interviewed have worked across all shifts. -A review of the sign in sheets was conducted to verify education and training was completed as outlined in the IJ removal plans. Based on verification

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to prevent a fall with serious injury for one resident (#5) out of three residents sampled for accidents. On 07/25/2025 Staff A, Certified Nursing Assistant (CNA), independently rolled Resident #5 onto her side in bed to perform incontinence care. Staff A, CNA left Resident #5 unattended in bed to collect supplies. Resident #5 fell out of the bed while unattended and suffered a right hip fracture which required a transfer to a higher level of care and surgical repair.This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to residents and resulted in the determination of Immediate Jeopardy on 08/07/2025. The findings of Immediate Jeopardy were determined to be removed on 08/08/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm.Findings included: During an interview on 08/06/2025 at 8:32 a.m., Resident #5 stated she had a fall a couple months after she was admitted to the facility. Resident #5 stated she was supposed to always have two people assisting her with care. She stated she requested a bigger bed. She stated, Sometimes they come in with two people and sometimes they just come in with one person. She stated, they set up a chair on the side of the bed for her to hold onto because they told her they could not use side rails. She stated, The chair slides while I'm holding onto it. She stated she requested a bigger bed a few times after a fall and was told they would order it, and it never came until after her most recent fall (07/25/2025). She stated, This last fall I broke my hip in two places and had to have surgery. The CNA came in to change me by herself, she rolled me onto my side, she put my legs with one on top of the other, the CNA went to grab something off of the dresser and I told her I was slipping, and she told me, You will be okay, I told her again that I was slipping and then I fell off of the bed. I only got the bigger bed now because I fell. The aides were upset that they were taking so long, to get me a bigger bed because they all knew I was at risk. Review of Resident #5's admission record revealed an initial admission date of 04/05/2025 and a re-admission date of 07/28/2025. Resident #5 was admitted to the facility with diagnoses to include: displaced apophyseal fracture of left femur (a break in the growth plate area of the large bone of the upper leg), initial encounter for closed fracture (08/04/2025), displaced fracture of greater trochanter (a bony prominence located on the upper part of the thigh bone) of right femur, initial encounter for closed fracture (07/28/2025), spondylolysis (a stress fracture in a vertebra), cervical (neck) region (09/21/2024), unspecified fall, subsequent encounter (09/21/2024), muscle weakness (generalized) (09/21/2024), other abnormalities of gait and mobility (09/21/2024), morbid (severe) obesity due to excess calories (09/21/2024), and repeated falls (09/21/2024). Review of Resident #5's Quarterly Minimum Data Set (MDS), dated [DATE] revealed in Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of Section GG-Functional Abilities revealed Resident #5 had an impairment on one side to her upper and lower extremity. Resident #5 required substantial/maximal assistance revealing helpers do more than half the effort. Helpers lift or hold trunk or limbs and provides more than half the effort for rolling left and right. Sitting to lying (the ability to move from sitting on side of bed to lying flat on the bed, lying on side of bed), Resident #5 was dependent, meaning helper does all the effort. Residents do none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident #5's care plan dated 08/03/2024 revealed: Focus: ADL Self-Care and/or mobility deficit. Needs assistance with ADL's Initiated on 09/23/2024.Interventions included: BED MOBILITY-Total ASSIST X 2 TRANSFERS-Total ASSIST with Hoyer X 2TOILETING-Total ASSIST X 2DRESSING-Total ASSIST X 2BATHING-Total ASSIST X 2 Review of Resident #5's Intervention/Task for July revealed one person assistance was provided for ADL-Bed Mobility on 07/26/2025 (day shift), 07/28/2025 (evening shift), 07/30/2025 (day shift), 07/31/2025 (evening shift), 08/01/2025 (day shift), 08/02/2025 (evening shift), 08/03/2025 (day shift and evening shift), 08/05/2025 (evening shift), 08/07/2025 day shift). A review of the physician order summary for Resident #5 revealed: Right hip Xray 2 views due to status post fall pain. Start Date 07/26/2025.Send to ER (emergency room) for further eval and treat. Start Date 07/27/2025. A review of Resident #5's right hip Xray, radiology report, dated 07/26/2025 revealed:Reason for Study: Acute Pain Due To TraumaFINDINGS: There is deformity of the femoral neck concerning for a fracture. There is joint space narrowing of the right hip with bony productive change. There is diffuse osteopenia.Conclusion: Deformity of the right femoral neck concerning for a fracture. A follow-up CT (computed tomography) scan of the hip is suggested. Review of Resident #5's progress notes revealed: -07/28/2025 at 7:47 p.m. Fall Risk Evaluation Fall Risk: History of falls (past 3 months): 1-2 falls in past 3 months. Level of consciousness / mental status: Alert (oriented x 3) OR comatose. Resident is chairbound / incontinent. Systolic blood pressure: No noted drop between lying and standing. Vision status: Adequate (with or without glasses). Predisposing disease: 1-2 present. Residents had a change in condition in the last 14 days. Recent hospitalization history in last 30 days: Yes. Notes: Post right hip surgery 7/27/25 Gait / balance: Requires use of assistive devices (i.e. cane, wheelchair, walker, furniture). Medication: Takes 3-4 these medications (or medication classes) currently and / or within last 7 days. Fall Risk Score: 15.0.-07/28/2025 6:05 p.m. Nursing Note Note Text: readmitted a [AGE] year-old female from [Acute Care Hospital] via stretcher accompanied by 2 Emergency Medical Services (EMS) staff.Surgical incision to right hip clean, dry with dressing intact, with PICO [a single-use, portable negative pressure wound therapy system designed to promote wound healing] dressing functioning well. Patient also has skin tear to right lower leg with sutures in place. Bruising noted to right knee/ right[sic] lower leg. Discoloration and flaking noted BIL [bilateral] feet.-07/27/2025 12:00 a.m. Nursing Note Late Entry:Note Text: Result of X ray[sic] right hip reported to ARNP [Advanced Practical Nurse Practitioner] with order received for resident to be sent to ER [Emergency Room] for further eval and treat. DON [Director of Nursing] notified. This writer called [Family Member] 2x [twice] left message, awaiting for call back. Facility protocol followed. Resident transported to ER via 911.-07/26/2025 07:38 a.m. Radiology Note Note Text: Patient complained of pain of 7 on right hip/pelvis area s/p [status post] fall last evening. Administered PRN [as needed] pain pill. Notified provider on call.received order for STAT (immediate) xray[sic] to right hip/pelvis area 2 views. [Mobile Radiology Company] services needed due to pt [patient] being bed bound.-07/26/2025 3:52 p.m. Nursing Note Note Text: Bariatric [bed] delivered to [room number], resident in new bed without difficulty. Resident[sic] says new bed is comfortable.-07/25/2025 4:56 p.m. Interdisciplinary (IDT) Note Late Entry:Note Text: Resident reviewed by IDT for s/p [status post] fall on 7/25. Resident found by the floor nurse lying on floor on her back next to bed. CNA reported she was providing incontinent care and stepped away to get a towel; during that time, resident rolled off the bed. Head-to-toe assessment completed; no visible injuries noted. Pt [patient] was complaining of left shoulder pain. Neuro checks initiated. NP [Nurse Practitioner] notified; new orders received for STAT [immediate] left shoulder x-ray and one-time dose of oxycodone for pain. Message left for [Family Member] return call regarding notification of family. Interventions: Wider bed ordered for resident. Staff re-educated on following Kardex instructions; emphasized requirement for two-person assist as documented. STAT x-ray of Left shoulder and one time dose of oxycodone was ordered.-7/25/2025 6:27 p.m. Nursing Note Note Text: Called to room by CNA. Observed resident lying on the floor on her back side next to bed. Resident states she rolled off of the side of the bed. Head to toe assessment completed. Complaints of left shoulder pain. No visible sign of injury. Neuro checks initiated. Returned to bed using [mechanical lift] with multiple staff present. [ARNP] notified. New order for STAT left shoulder xray[sic] and one time dose of oxycodone for pain. Message left for [Family Member] to return call to facility.-07/25/2025 7:15 p.m. Nursing Note Note Text: Spoke with [Employee of Bed Supplier]. Bariatric bed to be delivered 7/26 before 11:45am. Resident made aware. Review of Resident #5's Hospital Discharge Records dated 07/27/2025 revealed: Procedure History: Arthroplasty Hip Bipolar (a surgical procedure replaces the damaged femoral head with a prosthetic implant) (Right), (07/27/2025), Open Reduction Internal Fixation Hip (surgical procedure used to treat hip fractures by realigning the bone and securing it with internal hardware) (Right) (07/27/2025). During a phone interview on 08/06/2025 at 12:57 p.m., Staff A, CNA stated on 07/25/2025 she went to provide Resident #5 with care. She said, I rolled [Resident #5] onto her side in the bed, and I went to grab a towel from the dresser. While I was grabbing the towel [Resident #5] slipped off the bed. I usually take everything I need with me. She stated there was not a rail on the bed for the resident to hold onto. Staff A stated Resident #5 holds onto the top of the dresser for support, and It is difficult to roll her sometimes. She stated, I ran out and started screaming for the nurse. I grabbed her a pillow for her head while we were waiting for someone to come in the room. She stated Resident #5 said her hip was hurting after the fall. Staff A stated the nurse did an assessment and then they put Resident #5 back in bed. She said, I don't know if [Resident #5] went out to the hospital or not. I thought [Resident #5] was a one person assist. We look in the Kardex to tell you how many people a resident requires to provide care. She stated after the incident, the Director of Nursing (DON) did a one-on-one in-service. She said, It was something on falls being careful and being aware. During an interview on 08/06/2025 at 10:38 a.m., Staff B, Licensed Practical Nurse (LPN), stated on 07/25/2025 she did wound care in the morning and worked on the floor from 3:00 p.m.-11:00 p.m. She was called to Resident #5's room by Staff A, CNA, and Resident #5 was on the floor lying on her back between the two beds. Staff A, CNA told her she was in the middle of changing her when she walked to the dresser to grab towels and the resident fell. Staff B stated the aide told her, The weight of her body flipped her to the other side of the bed. [Staff A, CNA], was the only aide in the room. [Resident #5] was supposed to have two people assisting her. She did a head-to-toe assessment on Resident #5. Staff B stated, I did not move the right shoulder much because I know she has had long term pain in that shoulder. Her legs are big, and [Resident #5] cannot hold them up on her own. I lifted both of her legs, and she did not have any pain at that time. There was no redness, swelling or bruise at the time of the assessment. Resident #5 was only complaining of left shoulder pain. She stated she got orders for STAT (emergent) left shoulder Xray. She said Resident #5 never complained of hip pain on the shift. She stated she called the doctor and asked if the pain medication could be given early. She stated when she got back to work on Monday, she was told Resident #5 went out to the hospital for her hip. She stated at the time of the fall Resident #5 had a regular size standard bed. Staff B stated, We talked about getting her a bariatric bed a long time ago. Resident #5 was able to hold herself over by holding onto the nightstand next to the bed or the armoire on the other side. If she was in a bariatric bed she would not be able to reach the nightstand to hold herself up, so we did not get her the bariatric bed. She said Resident #5 does not use her right arm for anything anymore. She stated, The bed she had [at the time of the fall] did not have anything for her to hold onto. She said Resident #5 does not move; she can't reposition herself or anything. There was some room on each side of the bed, if she was a moveable person she would not be able to move much. Residents who need a bariatric bed just need to bring it up to the managers, and they would get them one. There really is not a system in place for determining when a resident needs a bariatric bed. The unit manager can call and request a bariatric bed if they feel a resident needs it. She said, If we need more room to turn the resident we would request for one. But usually, it is a customer service thing when a resident requests for it. During an interview on 08/06/2024 at 3:56 p.m., the Director of Nursing (DON) stated she did the reportable investigation for Resident #5's fall. On 07/25/2025 at 4:30 p.m. Staff A, CNA was providing incontinent care for Resident #5. Resident #5 was on her side in the bed. Staff A, CNA went to grab the towels off the dresser. Resident #5 legs began to slide down. Resident #5 told Staff A, CNA she was starting to slide and Staff A, CNA could not intercept her fast enough, resulting in Resident #5 falling to the floor. Resident#5 was assessed by the nurse and complained of left shoulder pain. They did an Xray of the left shoulder and it was negative for a fracture. The next day (07/26/2025), Resident #5 started complaining of right hip pain, they did an Xray, and it was positive for a hip fracture. The results came back close to midnight, and Resident #5 was sent to the hospital for further evaluation. Resident #5 was admitted to the hospital and underwent a right hip arthroplasty on 07/27/2025. The DON stated the resident returned back to the facility on [DATE]. During the investigation, she interviewed staff and other residents to see if there were any concerns with Staff A, CNA's care. No residents or other staff had concerns with Staff A, CNA's care. She provided education to all staff related to making sure they have all of their items in reach when providing care. If they need to grab something while providing care residents should be placed back on the bed. They ordered a wider bed for Resident #5, and it was delivered the next day (07/26/2025). They updated Resident #5's Kardex for her to be a two person assist with everything. The DON stated, There is not anything that is black or white to determine what type of assistance a resident needs while providing care. It can be determined by therapy; some people can do more than others. There are a lot of factors, there is not a guide. The DON stated Resident #5 had another event in October 2024. During this event Resident #5's legs were hanging over the side of the bed, they had to assist her down to the floor and then put her back in bed. She said, According to the 10/14/2024 interdisciplinary team (IDT) note it says Resident #5 is a two person assist with incontinence care. I thought this was referring to when Resident #5 was using the bathroom and holding onto the bar. She said bed mobility is how many people it takes to move people in bed. At the time her bed mobility was a one person assist, and her transfer status was two person assist. She stated, There was some confusion, because the two-person changing brief was not under the activities of daily living (ADL) part of the Kardex and her bed mobility in ADL's said Resident #5 was a one person assist. When the care plan was updated in October of 2024, it updated under a different part of the Kardex. She said Resident #5 needing to be a two-person assist for brief changing was only on the safety part of the Kardex. Staff A, CNA was following the ADL Kardex. Residents use different things to hold onto while care is being provided. They can use furniture, she said, Their chair would be up against their bed, or chairs that have handrails, or whatever is there for them to grab onto. If they have a scoop mattress they can hold onto that, it depends on the resident. We try to use trapezes; we try other interventions other than side rails. We don't like to utilize bed rails, she said, It is frowned upon to use them since the initiative for no bed rails. In our setting they don't want us to use the bed rails. If a resident uses bedrails, an evaluation is done for the adaptive rails, and we put them on. The CNA's document under tasks when they perform an activity for a resident. If the task is marked off as one person assist, then one person assists with that activity. We did not substantiate the allegation because everyone was under the impression she was a one person assist with the bed mobility. Review of the facility's policy, dated October 2014, revision date November 2018 revealed the following:PALM Program(Preventing Accidental Level Change Mishaps)Purposethe PALM program is designed to identify those residents who are at risk for repeated falls and serves to alert team members to provide interventions designed to reduce fall risk.ProcedureNew Admissions1. During the admission process, residents will be evaluated using the evaluation of risk for falls form.2. A therapy screen will be completed during the admission process, if no therapy is ordered on admission.3. Residents identified at risk for falls will have an interim plan of care developed to address identified risk factors.4. Residents who are identified as being at risk for falls and have fallen within the past 30 days or have had significant injury from a fall prior to admission may be placed in the PALM program.Current Residents1. following a fall, the resident will be reevaluated using the evaluation of risk for falls form. No, this evaluation will also be completed upon hospital return, quarterly and with significant change.2. The care plan will be updated following each fall with modification of interventions based on interdisciplinary team review and resident need.3. All residents experiencing a fall(s) will be reviewed at the next standards of care meeting following the fall(s).4. The interdisciplinary team will determine which residents are to be included in the PALM program. The program may include but is not limited to residents who are at risk for falls and have had one of the following: repeat falls within a 30 day periodProgram Overview1. once a resident has been selected by the interdisciplinary team to participate in the PALM program, a palm symbol will be placed in the following places as applicable: outside the residence room beside the residence name plate/door.2. The residents care plan will be updated to reflect participation in the PALM program.3. Team interventions which may apply to PALM program participants include the following suggested interventions:o Ambulation programo Family/resident educationo therapy processo bowel and bladder evaluation programo increase activities in the evening after dinner; scheduled individual activity, determine resident preferenceso pet therapyo exercise programo assist resident outdoors for fresh airo change nap or bedtimeo soothing music at bedtimeo Dim lights at night, provide quiet environmento lavender hand massageo pain management programo nonskid shoes, slipper socks; evaluate for proper footwearo medication review by pharmacy and or by physician/ARNP/[NAME] labs; chemical panel(s), urinalysiso orthostatic blood pressure checks, vital signso every 15 minute checks, 1 to 1 supervision or two to one supervisiono in view of staff when out of [NAME] encourage family visitso psychiatric consulto neurology consulto ophthalmology or audiology consulto keep glasses cleano heat brakes locked on wheelchair/[NAME] anti tipper device for wheelchairso automatic wheelchair brakeso Dycem chair [NAME] wheelchairs lock during transferso bad adjusted to accommodate resident height (hips at 90 degree angle when feet flat on floor)o specialty mattresso wheelchair cushions as appropriateo adequate lighting, Night Lightso remove clutter and barriers from floorso stop signso raised toilet seatso hipsterso low bed with mats, bed in lowest positiono evaluate resident ability to utilize bathroom assisted/unassisted according to their cognitive status or ability4. interventions to reduce risk of falls unique to each resident should be included in the residence care plan and on Kardex.5. Education regarding the PALM program will be provided to all team members upon hire annually and as needed. Facility immediate actions to remove the Immediate Jeopardy included: --The IDT team completed a root cause analysis 7/28/25 and medical record review for resident #5 to identify gaps in the level of supervision, ADL assistance and general safe practices to reduce resident injury. --The care plan specialist team/designee completed a resident review of ADL care plan/ Kardex interventions 8/6/25 and 8/7/25 to ensure there were no discrepancies in the number of staff support needed to complete task toileting/incontinence care or bed mobility. Those 13 residents identified had their care plan/Kardex corrected. The Kardex format was streamlined so all ADL support guidance is contained under the resident care tile to decrease staff error. --The Director of Education/designee provided education to nursing staff to (98.4% 62/63 of CNAs and 100% 29/29 Nurses) on pulling up the care plan/Kardex to identify the level of assistance and supervision required. The Director of Education/designee educated staff on general safety interventions identified based on the root cause analysis such as having required supplies gathered and within reach to provide care, utilize call bell when needed additional support, and to ensure resident is in a safe position prior to leaving the bedside, review care plan/Kardex prior to providing care to ensure level of assistance and support needed. This was initiated on 7/25/25 and is ongoing for new employees. Additionally, the one CNA left for education will return tomorrow and will be educated prior to working her shift. Completed 8/8/25. --The DON/designee on 8/8/25 conducted an observational audit of nursing staff providing ADL care at the bedside or completed an ADL documentation review of 15 (10 %) nursing staff providing resident ADL care to ensure appropriate support and safety measures were followed according to the resident's care plan or Kardex. Any identified concerns were corrected immediately with staff utilizing corrective education. Verification of the facility's removal plan was conducted by the survey team on 08/08/2025. On 08/08/2025 interviews with facility staff was conducted for 4 RN's, 9 CNA's, and 2 LPN's to verify education and training had been completed related to topics to include:-Reviewing Kardex before caring for Resident, Safety and Resident Care, prior to providing any care and document accordingly. All staff were able to voice understanding of the policies and processes required to provide competent care to residents. The staff interviewed have worked across all shifts. -A review of the sign in sheets was conducted to verify education and training was completed as outlined in the IJ removal plans. Based on verification of the facility's Immediate Jeopardy removal plan the immediate jeopardy was determined to be removed on 08/08/2025 and the non-compliance was reduced to a scope and severity of E.