Based on record review and staff interviews, the facility failed to protect residents' right to be free from neglect by failing to ensure staff consistently provide safe nursing care to prevent avoidable accidents and serious physical harm for 1 (Resident #1) of 3 dependent residents reviewed.Resident #1 had a history of cerebral infarction (stroke) with resultant hemiplegia (paralysis) of his right dominant side and was dependent on the assistance of 2 staff for bed mobility.On 6/19/25 the Certified Nurse Assistant (CNA) chose to not follow safety precautions of 2 staff assistance listed on the care plan to provide incontinent care, causing Resident #1 to fall out of bed.Resident #1 sustained a serious head injury from the avoidable fall, requiring an emergency transfer to an acute care hospital for evaluation and treatment.Resident #1 was diagnosed with a subarachnoid and subdural hematoma (collection of blood between the skull, brain membrane and brain surface). The facility failure to prevent the neglect resulted in serious injury to Resident #1 and created a likelihood of further incidents of neglect for all 15 residents care planned for the assistance of 2 staff for bed mobility.This failure resulted in the determination of Immediate Jeopardy.The findings included:Cross reference to F689.Review of the facility's policy titled Abuse, Neglect and Exploitation last revised 11/16/23 noted, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent . neglect .The policy noted the facility will implement policies and procedure to prevent and prohibit all types of neglect that achieves the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to neglect.Review of the facility's incidents investigations revealed on 6/19/25 the facility initiated a neglect investigation related to Resident #1 falling out of bed while receiving care.Review of the facility provided investigation revealed:On 6/19/25 at 11:15 a.m., Resident #1 had a witnessed fall from his bed while receiving care from his assigned Certified Nursing Assistant (CNA). A bump was noted on the resident's right forehead. The physician issued an order to transfer Resident #1 to the local Emergency Department (ED) for evaluation.CNA Staff A provided a statement that on 6/19/25 she changed Resident #1's incontinent brief. The resident had a bowel movement. She turned Resident #1 to his left side to wipe him. While attempting to change the resident, she was holding him with one hand and reaching for wipes with the other. The resident slipped from her hold.Registered Nurse (RN) Staff B provided a statement that on 6/19/25 she was called into Resident #1's room and saw him on the floor. She noted the bed was in a higher position. Resident #1 was on his right side with a hematoma to his right temple. Resident #1 was assessed and 911 was called. RN Staff B stated she applied ice to the resident's head and waited with him until 911 arrived.Licensed Practical Nurse (LPN) Staff C assessed Resident #1 after the fall. A bump was noted to the resident's right forehead. The physician was notified and gave an order to transfer the resident to the ED for further evaluation.The Director of Nursing (DON) interviewed CNA Staff A about the resident's fall from the bed. CNA Staff A performed a reenactment with the DON present. CNA Staff A said that she was providing incontinent care, she reached for wipes that were placed at the resident's knees, and he rolled out of bed onto the floor.The DON asked CNA Staff A if there was anyone else in the room to help her. CNA Staff A stated, No, we usually do two people, but everyone is busy, so I did it myself.The DON asked CNA Staff A if she was aware that the resident was care planned for 2 staff assistance with toileting and bed mobility needs. CNA Staff A stated, Yes, we usually use two, but we are busy, and I needed to clean him up, so I did it myself.The DON asked CNA Staff A if she checks the Kardex (provides essential information for care) first when she comes to work and starts her assignment. CNA Staff A replied, No, I can't do that there is no time.The DON asked CNA Staff A how she knew how to take care of Resident #1. CNA Staff A responded, I know from the last time I worked.The DON asked CNA Staff A if she knew how to find the Kardex and she stated, Yes. The DON and CNA Staff A walked to the kiosk and CNA Staff A was able to locate the Kardex.The investigation noted 9 licensed nurses and 8 CNAs who were present and working on 6/19/25 at the time of the fall were interviewed. All 17 staff interviewed said that they were not asked to assist with Resident #1's care.On 6/25/25, the hospital provided the facility with a diagnosis of traumatic subarachnoid hemorrhage and subdural hematoma.On 6/25/25, the facility verified the allegation of neglect and noted CNA Staff A demonstrated her decision to act independently of the guidance provided by the facility's education and practices when she chose to not review and follow the Kardex prior to providing care to Resident #1. The resident's Kardex was available, up to date, and accurate at the time of the resident's fall.On 7/7/25, review of the clinical record revealed Resident #1 had a re-admission date of 1/26/25. Diagnoses included Cerebral Infarction with resultant hemiplegia affecting the resident's right dominant side.Review of the discharge Minimum Data Set (MDS) Assessment with a target date of 6/19/25 noted Resident #1 was dependent on staff for rolling left and right, personal hygiene, and toileting.Review of the care plan created on 5/10/25 revealed Resident #1 had Activities of Daily Living self-care performance deficit. The interventions included Dependent Assist of 2 for toileting, and Dependent Assist of 2 with bed mobility (repositioning self in bed).Review of the Kardex revealed Resident #1 required dependent assistance by 2 staff to turn and reposition in bed as necessary.Review of the progress notes revealed:On 6/19/25 at 12:41 p.m., a nursing progress note read, Resident fell off the bed while the CNA was attempting to change him at 11:20 AM. A large bump was observed on the resident's right side head . Resident was sent to emergency room for further evaluation.On 6/19/25 at 4:39 p.m., a nursing progress note documented a follow up call was placed to the local hospital. Resident #1 was being transferred to another hospital for further treatment.On 7/7/25 at 9:38 a.m., in an interview, the Administrator said Resident #1's daughter informed the facility Resident #1 passed away on June 30th. The Administrator said they investigated and confirmed neglect. She said CNA Staff a did not follow Resident #1's care plan for 2 staff assistance for bed mobility which resulted in the resident's fall and injury requiring the resident's transfer to a higher level of care.On 7/7/25 at 11:47:a.m., in an interview the Assistant Director of Nursing (ADON) said after the incident, she interviewed the nursing staff who worked on 6/19/25 and were present when Resident #1 fell out of bed. She said all staff interviewed said CNA Staff A did not ask for their assistance to provide incontinent care to the resident.On 7/7/25 at 2:18 p.m., in a telephone interview, CNA Staff A said on 6/19/25 Resident #1 had soiled himself and asked her to clean him. Staff A said she was working her hall alone. Another CNA was split with another hall. She said at the time of the incident she was alone on the hall. The nurse was busy with another patient. CNA Staff A said she raised the bed, rolled the resident on his side. She held Resident #1 with her hand and leaned to grab supplies. CNA Staff A said Resident #1 was a big man with a big belly and the bed was not big. She said Resident #1 hung over the side and rolled off the other side of the bed. She ran to get the nurse. CNA Staff A said she knew Resident #1 required 2 person assistance and they usually use 2 staff. In that situation she said she was alone and cleaned him alone. CNA Staff A said she couldn't leave someone sitting in a bowel movement.On 7/8/25 at 3:30 p.m., in an interview the Administrator said CNA Staff A had been educated multiple times before the incident on bed mobility and on the Kardex. He said CNA Staff A acted independently when she made the decision to move Resident #1 on her own. She did not seek help from anyone.On 7/9/25 at 11:00 a.m., in an interview LPN Staff H said on 6/19/25 she was at the nurses station when CNA Staff A came to tell her Resident #1 was on the floor. She went to the room. She found Resident #1 lying on his right side on the floor. He had a hematoma to the right side of his head. She called for emergency services. LPN Staff H said 2 CNAs were assigned to the hall at that time but one was split with another hall. LPN Staff H said she felt the hall required 2 CNAs dedicated just to that hallway. On 7/10/25, the survey team verified the facility's immediate actions to remove the Immediate Jeopardy effective 6/25/25. The survey team verified the facility's corrective actions to correct the noncompliance on 7/3/25, prior to the survey visit.The immediate and corrective actions implemented by the facility included:On 7/10/25 the survey team verified through review of the documentation and interview with the Administrator that on 6/19/25 CNA Staff A who failed to follow correct procedure for use of resident Kardex and care plan was immediately suspended.On 7/10/25 the survey team verified through review of audits and interview with the Administrator that the DON completed a house-wide audit of care plans/Kardex for accuracy with bed mobility tasks.On 7/10/25 the survey team verified through record review and interview with the Administrator that on 6/19/25 the facility initiated a Performance Improvement Plan (PIP) as a working document, open to edits and revisions. There was documentation the Medical Director reviewed the PIP.On 7/10/25 the survey team verified through review of the personnel file for CNA Staff A that on 4/25/25 CNA Staff A received education on proper positioning of residents in bed, customer service, Kardex and Plan of Care. On 5/6/25 CNA Staff A completed a self-study electronic education on fall prevention, CNA safely moving residents, lifting and transfers.On 7/10/25 the survey team verified through interview with the Administrator, review of sign-in sheet, and record review that on 6/20/25 an Ad Hoc (unplanned) Quality Assurance and Performance Improvement (QAPI) meeting was held with the interdisciplinary team. Participants included the Administrator, the Director of Nursing, the Staff Development Coordinator, Unit Managers, the Social Services Director, the Therapy Director and the Medical Director. The Performance Improvement Plan was reviewed and updated as appropriate.On 7/10/25 the survey team verified through record review that on 6/20/25 the facility completed a care plan review for bed mobility level of care.On 7/10/25 the survey team verified through review of sign-in sheets, content of education and interview with 3 licensed nurses and CNAs that on 6/19/25 through 6/25/25 current staff including contracted and agency staff educated in person, telephonically, or electronically prior to working their next shift: Licensed Nurses were educated on Incidents and Accidents/Supervision, Abuse, Neglect and Exploitation, and using the Kardex to ensure residents with two person assist needs for bed mobility are identified and two staff are providing care with return demonstration. Certified Nursing Assistants were educated on Incidents and Accidents/Supervision, Abuse, Neglect, Exploitation and using the Kardex to ensure residents with two person assist needs for bed mobility are identified and two staff are providing care with return demonstration. Non-clinical Staff: Non-clinical staff were educated on Abuse, Neglect, Exploitation, Incidents and Accidents/Supervision.115 of 115 current staff, 35 of 35 current contracted staff, 15 agency licensed nurses and CNAs received the education.On 7/10/25 the survey team verified through record review and interview with the Administrator that on 6/24/25 an Ad Hoc meeting was held with the interdisciplinary team (Administrator, DON, and Medical Director). The meeting included the planning of Quality Review Audits to review compliance with use of the Kardex, High Fall Risk residents, visualization of staff implementation of compliance with the Kardex and care plan interventions.On 7/10/25 the survey team verified through record review, and interview with the Administrator that on 6/27/25 the facility held a monthly Quality Assurance meeting. The Administrator, DON and Medical Director attended the meeting. The survey team verified the areas discussed included the Performance Improvement Plan in place that resulted in the Ad Hoc QAPI meeting on 6/19/25. Ongoing audits were in place. Current audits reviews were active and ongoing. The staff education was completed on 6/25/25.On 7/10/25 the survey team verified that on 7/3/25 the facility held a QAPI meeting with the Administrator, the DON, and the Medical Director to review the current status of the quality review audits completed. As of 7/3/25 audits have been completed on the following:Accidents and Incidents: Staff verbalize fall risk residents on their assignment and 1 fall intervention for fall residents. On 6/25/25 7 staff audits completed, on 6/26/25 10 staff audits completed, and on 7/3/25 10 staff audits completed.Kardex use: Staff able to verbalize how to access resident care information, provide return demonstration on accessing the Kardex, and verbalize what to do in the event they need assistance providing care to a resident as evidenced by reading the Kardex. On 6/21/25, 6/23/25, 6/24/25, and 6/30/25, 10 staff completed the audit. On 6/26/25 5 staff members One staff member was provided hand over hand direction and demonstration on using the Kardex.Accidents and Incidents: Observation of high fall risk residents for fall interventions in their room, wheelchair, or on their person. On 6/26/25 10 residents audits completed, on 6/28/25, 7 residents audits completed, on 6/30/25 59 residents audits completed, and on 7/2/25 5 residents audits completed.On 7/10/25 the survey team verified 7 of 15 residents care planned for assistance of 2 have been reviewed in the audits.On 7/10/25 during interviews, 2 residents, who require assistance of 2 staff said there are always 2 staff members to provide care.On 7/10/25 the survey team verified through record review and staff interviews that the department head team members are completing staff members audits on abuse, neglect and exploitation randomly during walking rounds as assigned. As of 7/10/25, the audits were ongoing.

Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure effective processes were in place to protect 1 (Resident #1) of 3 residents reviewed from avoidable fall and fall related major injury.Resident #1 had a history of cerebral infarction (stroke) with resultant hemiplegia (paralysis) of his right dominant side and was dependent on the assistance of 2 staff for bed mobility.On 6/19/25 the Certified Nurse Assistant (CNA) chose to not follow safety precautions of 2 staff assistance listed on the care plan to provide incontinent care, causing Resident #1 to fall out of bed.Resident #1 sustained a serious head injury from the avoidable fall, requiring an emergency transfer to an acute care hospital for evaluation and treatment.Resident #1 was diagnosed with a subarachnoid and subdural hematoma (collection of blood between the skull, brain membrane and brain surface). The facility failure to ensure residents safety during care resulted in serious injury to Resident #1 and created a likelihood of serious harm, serious injury or death from avoidable falls for all 15 residents care planned for the assistance of 2 staff during care and resulted in the determination of Immediate Jeopardy (IJ).The findings included:Cross reference to F600. Review of the facility's policy titled, Accidents and Supervision with a date reviewed/Revised of 10/18/2022 revealed, Each resident will receive adequate supervision and assistive devices to prevent accidents . Implementation of interventions. Using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes: . Ensuring that the interventions are put into action .Resident-directed approaches may include: Implementing specific interventions as part of the plan of care. Supervising staff and residents . Monitoring and Modification . Ensuring that interventions are implemented correctly and consistently .Review of the clinical record for Resident #1 revealed a re-admission date of 1/25/25. Diagnoses included Cerebral infarction with resultant hemiplegia affecting the resident's right dominant side.Review of the discharge Minimum Data Set (MDS) Assessment with a target date of 6/19/25 noted Resident #1 was dependent on staff for rolling left and right, personal hygiene, and toileting.Review of the care plan created on 5/10/25 revealed Resident #1 had Activities of Daily Living self-care performance deficit. The interventions included Dependent Assist of 2 for toileting, and Dependent Assist of 2 with bed mobility (repositioning self in bed).Review of the Kardex revealed Resident #1 required dependent assistance by 2 staff to turn and reposition in bed as necessary.Review of the progress notes revealed:On 6/19/25 at 12:41 p.m., a nursing progress note read, Resident fell off the bed while the CNA was attempting to change him at 11:20 AM. A large bump was observed on the resident's right side head . Resident was sent to emergency room for further evaluation.Review of the facility provided fall investigation for Resident #1revealed:On 6/19/25 at 11:15 a.m., Resident #1 had a witnessed fall from his bed while receiving care from his assigned Certified Nursing Assistant (CNA) Staff A. A bump was noted on the resident's right forehead. The physician issued an order to transfer Resident #1 to the local Emergency Department (ED) for evaluation.CNA Staff A provided a statement that on 6/19/25 she changed Resident #1's incontinent brief. The resident had a bowel movement. She turned Resident #1 to his left side wipe him. While attempting to change the resident, she was holding him with one hand and reaching for wipes with the other. The resident slipped from her hold.Registered Nurse (RN) Staff B provided a statement that on 6/19/25 she was called into Resident #1's room and saw him on the floor. She noted the bed was in a higher position. Resident #1 was on his right side with a hematoma to his right temple.The Director of Nursing (DON) interviewed CNA Staff A about Resident #1's fall from the bed. CNA Staff A said that she was providing incontinent care, she reached for wipes that were placed at the resident's knees, and Resident #1 rolled out of bed onto the floor.The DON asked CNA Staff A if there was anyone else in the room to help her. CNA Staff A stated, No, we usually do two people, but everyone is busy, so I did it myself.The DON asked CNA Staff A if she was aware that the resident was care planned for 2 staff assistance with toileting and bed mobility needs. CNA Staff A stated, Yes, we usually use two, but we are busy, and I needed to clean him up, so I did it myself.The investigation noted 9 licensed nurses and 8 CNAs who were present and working on 6/19/25 at the time of the fall were interviewed. All 17 staff interviewed said that they were not asked to assist with Resident #1's care.On 6/25/25, the hospital provided the facility with a diagnosis of traumatic subarachnoid hemorrhage and subdural hematoma.On 6/25/25, the facility's investigation noted that CNA Staff A demonstrated her decision to act independently of the guidance provided by the facility's education and practices when she chose to not review and follow the Kardex prior to providing care to Resident #1. The resident's Kardex was available, up to date, and accurate at the time of the resident's fall.On 7/7/25 at 9:38 a.m., in an interview, the Administrator said CNA Staff a did not follow Resident #1's care plan for 2 staff assistance for bed mobility which resulted in the resident's fall and injury requiring the resident's transfer to a higher level of care.On 7/7/25 at 11:47:a.m., the Assistant Director of Nursing (ADON) was interviewed about facility processes to ensure that individualized interventions listed in Resident #1's care plan are consistently and correctly implemented.The ADON said after the incident, she interviewed all 17 nursing staff who worked on 6/19/25 and were present when Resident #1 fell out of bed. All 17 nursing staff said CNA Staff A did not ask for their assistance to provide incontinent care to the resident.On 7/7/25 at 12:07 p.m., in an interview the Administrator said, they always look at the breakdown of assignments. They make sure there is always someone they can ask for help. He said for example if there are 3 staff assigned, they all have a separate assignment, no floater. On weekend they have a weekend supervisor. The supervisor is not assigned to a cart and can assist as needed. During the day, they have the DON, ADON, Unit Managers and MDS nurses who can assist with care.On 7/7/25 at 2:02 p.m., in an interview CNA Staff C was asked how she knew how much assistance a resident required. She said she would find out in the Kardex. CNA Staff C said, Sometimes I work so many days, I just know and I don't need to look. But if I need the information, I can always look. When asked if there were enough staff to take care of the residents, CNA Staff A said, I cannot give that answer, I am sorry.On 7/7/25 at 2:10 p.m., in an interview CNA Staff D she worked for an agency and has worked at the facility 10 times. When asked if there was enough staff to take care of the residents, CNA Staff D said, Yes for today but no for other days. When asked how she knew how much assistance the residents needed, she said, I get a paper, I walk and look in the room. If I see a sling I know they need 2 staff. If they are heavier, or exhibit behaviors I know I will need more help. There is no paperwork that tells me. When asked if she knew about the Kardex, CNA Staff D said, Yes, I know the Kardex from prior use of [the facility's electronic documentation system]. However, when is there any time to check it? It would tell me the care plan but it is never accurate.On 7/7/25 at 2:18 p.m., in a telephone interview, CNA Staff A verified she did not follow the safety precautions listed on Resident #1's Kardex and changed the resident alone. She said on 6/19/25 Resident #1 had soiled himself and asked her to clean him. Staff A said she was working her hall alone. Another CNA was split with another hall. She said at the time of the incident she was alone on the hall. The nurse was busy with another patient. CNA Staff A said she raised the bed, rolled the resident on his side. She held Resident #1 with her hand and leaned to grab supplies. CNA Staff A said Resident #1 was a big man with a big belly and the bed was not big. She said Resident #1 hung over the side and rolled off the other side of the bed.On 7/9/25 at 10:51 a.m., the Unit Manager, Licensed Practical Nurse (LPN) Staff B was interviewed about supervising staff to ensure residents' care plan interventions are implemented correctly and consistently. Unit Manager Staff B said she made rounds every hour; she checks with staff and helps if needed. She said on 6/19/25 CNA Staff A should have checked with any other nursing staff. There was another CNA and a licensed nurse on the hall that day. She said that a lot of times the nurses are at the nurse's station doing paperwork.On 7/9/25 at 11:00 a.m., in an interview LPN Staff H said on 6/19/25 she was at the nurse's station when CNA Staff A called her and said Resident #1 was on the floor. CNA Staff A did not ask her for help. She said there were 2 CNAs assigned to that hall but one CNA was split with the other hallway. LPN Staff H said there used to be 2 CNAs dedicated to the hall were Resident #1 resided. She said the hallway needed 2 CNAs and they should not split halls.On 7/10/25, the survey team verified the immediate actions implemented by the facility to remove the Immediate Jeopardy, effective 6/25/25. The survey team verified the corrective actions implemented by the facility to correct the noncompliance, effective 7/3/25, prior to survey visit. The immediate and corrective actions implemented by the facility included:On 7/10/25, the survey team verified through review of documentation and interview with the Administrator that on 6/19/25 CNA Staff A was immediately suspended.On 7/10/25, the survey team verified through review of the audits provided that on 6/19/25 the DON completed a house-wide audit of care plans/Kardex for accuracy with bed mobility tasks.On 7/10/25 the survey team verified through record review that on 6/19/25 a Performance Improvement Plan (PIP) was initiated as a working document, open to edits and revisions. The survey team verified the Medical Director reviewed the PIP.On 7/10/25, the survey team verified through record review that on 6/20/25 CNA Staff A's personnel file was reviewed. It included education dated 4/25/25 and signed by the CNA on proper positioning of residents in bed, customer service, Kardex, and Plan of Care. On 5/6/25 CNA Staff A completed a self-study electronic education on fall preventions, CNA safely moving residents, lifting and transfers.On 7/10/25 the survey team verified through record review and interview with the Administrator that on 6/20/25 an Ad Hoc (unplanned) QAPI (Quality Assurance and Performance Improvement) meeting was held with the interdisciplinary team (IDT). The Performance Improvement Plan was reviewed and updates as appropriate. The Administrator, the DON, the Staff Development Coordinator, Unit Managers, The Social Service Director, the Therapy Director and the Medical Director attended the meeting.On 7/10/25, the survey team verified through record review that on 6/20/25 the facility completed care plan reviews of bed mobility level of care.On 7/10/25, the survey team verified through review of the education provided and the sign-in sheets that on 6/19/25 thru 6/25/25 current staff including contracted and agency staff were educated in person, telephonically, or electronically prior to working their next shift.Licensed Nurses were educated on Incidents and Accidents/Supervision, Abuse, Neglect and Exploitation, and using the Kardex to ensure residents with two person assist needs for bed mobility are identified and two staff are providing care with return demonstration. Certified Nursing Assistants were educated on Incidents and Accidents/Supervision, Abuse, Neglect, Exploitation and using the Kardex to ensure residents with two person assist needs for bed mobility are identified and two staff are providing care with return demonstration. Non-clinical staff were educated on Abuse, Neglect, Exploitation, Incidents and Accidents/Supervision.115 of 115 total Staff received the education. 35 of 35 current contracted staff received the education. 15 Agency Licensed Nurses/CNAs received the education.The survey team verified through review of documentation provided that any agency nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.On 7/10/25, the survey team verified through record review and interview with the Administrator that on 6/24/25 the facility held an Ad Hoc QAPI meeting with the IDT. The meeting included planning the planning of Quality Review Audits to review compliance with use of the Kardex, high fall risk residents, visualization of staff implementation of compliance with the Kardex and care plan interventions.On 7/10/25, the survey team verified through record review that on 6/27/25 the facility held their monthly Quality Assurance meeting. The Administrator, Director of Nursing, and Medical Director attended the meeting. The subject areas included the Performance Improvement Plan in place that resulted in the Ad Hoc QAPI on 6/19/25 was ongoing with audits in place. Current audits reviews were active and ongoing. The education was completed on 6/25/25.On 7/10/25, the survey team verified through record review and interview with the Administrator that on 7/3/25 the facility held a QAPI meeting with the Administrator, the Director of Nursing, and the Medical Director to review current status of Quality Review Audits completed by the facility.As of 7/3/25 audits have been completed on the following:Accidents and Incidents: Staff verbalize fall risk residents on assignment and 1 fall intervention for fall residents. On 6/25/25 7 staff audits were completed, on 6/26/25, and 7/3/25, 10 staff audits were completed.Compliance with Kardex and care plan interventions. This audit included visualizing during resident care the Kardex was followed. On 6/26/25 and 7/3/25, 15 staff audits were completed.Kardex use: Staff able to verbalize how to access resident care information, provide return demonstration on accessing the Kardex, and verbalize what to do in the event they need assistance providing care to a resident as evidenced by reading the Kardex. On 6/21/25, 6/23/25, 6/24/25, and 6/30/25, 10 staff audits were completed. On 6/26/25, 5 staff audits were completed.Accidents and Incidents: Observation of high fall risk residents to ensure fall interventions are in place in the residents' room, wheelchair, or on their person. 6/26/25 10 residents audits were completed. On 6/28/25, 7 residents audits were completed. On 6/30/25, 59 residents audits were completed, and on 7/2/25 5 residents audits were completed.During the above audits 7 of 15 residents care planned for assistance of 2 staff were audited.On 7/10/25 during interviews, 2 residents who were care planned for assistance of 2 staff said 2 staff members always provide care.On 7/10/25, the survey team verified through review of the documentation that the audits were being completed beyond 7/3/25.