Based on record review, surveillance video review and interviews, the facility failed to protect the resident's right to be free from physical, verbal abuse and psychosocial harm by a staff member for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. The actual harm occurred for Resident #1, who was cognitively impaired, on 02/13/2025 at 8:32 a.m. when S6 CNA (Certified Nurse Assistant) was observed on surveillance video verbally and physically abusing Resident #1 while providing care. Physical abuse occurred when S6 CNA pulled down on Resident #1's left contracted leg, forcefully snatched Resident #1's right arm from the right side rail and pushed Resident #1's right arm towards him, then snatched the diaper off Resident #1. Verbal abuse occurred when S6 CNA cursed at Resident #1 saying, God d-mn it and D-mn. While S6 CNA provided incontinent care, S6 CNA stated, I can't do this anymore, I refuse to do this ever again, you trying to hurt me. It can be determined a reasonable person would not expect that they would be harmed in his own home or a health care facility and would experience psychosocial harm - dehumanization and humiliation as a result of the verbal and physical abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/31/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's Abuse/Neglect Policy with a revision date of 03/20/2025 revealed in part: Purpose: The purpose of the Abuse/neglect policy is to comply with the seven-step approach to abuse and neglect detection and prevention: 1. Screening 2. Training 3. Prevention 4. Identification 5. Investigation 6. Protection 7. Reporting and Response Policy: It is the policy of the facility that each resident will be free from abuse. This facility will not condone any form of resident abuse. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident(s). Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect, and misappropriation of property. Physical abuse includes hitting, slapping, pinching, biting, and kicking. It also includes controlling behavior through corporal punishment. Alleged violation - is the terminology used when a verbal allegation of resident abuse, neglect, or misappropriation of resident property has been made either by a resident, family member, visitor or employee. An alleged violation may also be triggered by an observation of an injury of unknown origin (i.e., bruise or skin tear) that the resident or staff member cannot explain. Mistreatment means inappropriate treatment or exploitation of a resident. Review of Resident #1's room surveillance video with audio was viewed on Resident #1's sister cellphone with Resident #1's sister present. The surveillance video clip started on 02/13/2025 at 8:32 a.m. with a duration of about 5 minutes and revealed the following: S6 CNA could be seen pulling down on Resident #1's left contracted leg and Resident #1 could be heard saying, That hurt me. Two voices, male and female, could be heard saying, God d-mn it, God d-mn it and S6 CNA stated, D-mn. Then S6 CNA forcefully snatched Resident #1's right arm from the right side rail and pushed Resident #1's right arm towards him. S7 CNA was holding him over and Resident #1 could be heard saying, You are not going to pull me out, you are not going to pull me out. S6 CNA said, I'm not and snatched diaper off of Resident #1. While S6 CNA provided incontinent care she said, I can't do this anymore. Resident #1 stated, I'm sorry if I hurt your feelings, I'm sorry if I hurt your feelings, I'm sorry if I hurt your feelings. S6 CNA then stated, I refuse to do this ever again, you trying to hurt me. Review of Resident #1's medical record revealed the following diagnoses but not limited to neurological conditions, hemiplegia following cerebral infraction affecting left non-dominant side, non-Alzheimer's dementia, anxiety disorder, bipolar disorder, schizophrenia, metabolic encephalopathy, muscle wasting and atrophy, to the left shoulder, right lower leg, and left thigh, age related cognitive decline, insomnia, and adjustment disorder with anxiety. Review of Resident #1's Quarterly and State Optional MDS (Minimum Data Set) assessment date 01/08/2025 revealed a BIMS (Brief Interview of Mental Status) of 99; indicating resident was unable to complete the interview. Further review revealed Resident #1 required extensive assistance with two person physical assist for bed mobility, transfer and was always incontinent of urine and bowel. Review of Resident #1's March 2025 Physician Orders revealed: 08/09/2024: Turning and repositioning program: Turn and reposition every 2 hours and as needed. 01/16/2025: incontinence care: Check for incontinence at least every two hours. Cleanse Peri area/buttocks with remedy essentials cleanse, Pat dry, apply Remedy prevent silicone cream as a preventative maintenance. Review of Resident #1's Care Plan revealed in part, Resident #1 had impaired physical mobility, had a self-care deficit, and was resistive to care related anxiety - with interventions to use draw sheet only - per family request for turning and repositioning. During an interview on 04/01/2025 at 2:35 p.m., Resident #1's sister reported the surveillance video on 02/13/2025 at 8:32 a.m. revealed S6 CNA manhandled Resident #1 while providing care and she would call that abuse. During a telephone interview on 04/02/2025 at 11:00 a.m., S6 CNA reported she was not Resident #1's primary CNA and she assisted other CNAs with ADL (activities of daily living) care as he was a two person assist with everything except feeding. S6 CNA reported in the video she was assisting S7 CNA with morning care. S6 CNA reported trying to loosen Resident #1 fingers off the rail. S6 CNA reported the video was edited and did not show when he grabbed her hand and she tried to loosen his grip. During a telephone interview on 04/01/2025 at 2:30 p.m., S7 CNA reported Resident #1 was a two person assist with all ADLs, but was able to feed self. S7 CNA reported she received in-service/training on identifying rough handling, yelling, and cursing during patient care was considered abuse and S6 CNA should have been reported immediately to the Administrator. During an interview on 04/02/2025 at 4:40 p.m., S1 Administrator reported on 03/14/2025 Resident #1's sister made an allegation of abuse of her brother (Resident #1) that occurred on 02/13/2025 during morning care and she had a video. S1 Administrator reported an investigation was started for alleged abuse on 03/14/2025. S1Administrator requested the video from Resident #1's sister and on 03/15/2025 about noon (around lunch) Resident #1's s sister provided the video to S3 DON (Director of Nursing). S1 Administrator reported on 03/15/2025 he watched the video from 02/13/2025 of S6 CNA and S7 CNA with Resident #1 and it revealed S6 CNA was rough with Resident #1 while providing care and abuse was substantiated. S1 Administrator reported S6 CNA was suspended on 03/14/2025 and was terminated on 03/17/2025. During an interview on 04/03/2025 at 10:30 a.m., S1 Administrator reported care and monitoring for Resident #1 are reviewed daily in the facility's quality assurance meeting. On 04/03/2025 at 11:00 a.m., S2 Assistant Administrator presented the facility's QA (Quality Assurance) daily meetings from 02/14/2025 through 03/31/2025. Review of facility's QA meeting note revealed Resident #1's care concerns, grievances and issues with nursing and incident on 02/13/2025. During the survey, in-service records and QA monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. Beginning on 03/14/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 03/21/2025: Incident investigation report started on 03/14/2025. Review of Resident #1's incident investigation report folder and corroborated with S9 Corporate Nurse revealed: On 03/14/2025 at 12:10 p.m., Resident #1's sister made an allegation that Resident #1 was abused during care, incident investigation report started within two hours of an allegation of abuse. On 03/14/2025: S6 CNA was suspended from facility and residents on Hall A were assessed and interviewed by administrative nursing team members for injuries. S6 CNA had not provided care for Resident #1 since 02/13/2025. On 03/14/2025: S3 DON notified physician of the allegation of abuse. In-services on 03/14/2025 on Abuse and Neglect-define abuse, verbal abuse, report, baseline staff interviews were initiated regarding abuse and neglect. On 03/17/2025: the Police were notified and police report initiated. On 03/17/2025: S6 CNA was terminated, S7 CNA reviewed video of care on 02/13/2025 and reeducated on abuse. On 03/18/2025: Inservice on removing residents' hands off the assist handles - you cannot pry (forcefully remove) the residents' hands off assist handles. Do not bend fingers back. Do not grab the arm. On 03/20/2025: Revision to Abuse policy #5 Investigation and Protection when there is a witnessed or alleged abuse event. On 03/21/2025: In-service on reporting abuse/investigation and protection/employee interview and workplace violence. On 03/21/2025: Baseline employee questionnaire was implemented regarding the changes to the policy/procedure of resident protection. Plan of action and/or return demonstration by S3 DON revealed after reviewing the video with S7 CNA, retraining on abuse was provided on 03/17/2025. S3 DON and S7 CNA discussed grabbing residents hand off the assist handle was considered physical abuse and if S6 CNA was the person cursing in the video that was considered verbal abuse. This should be reported immediately. S7 CNA verbalized understanding and signed on 03/18/2025. Post Event Sustained Monitoring-alleged/inappropriate physical encounter 03/15/2025 through 03/27/2025. QAPI (Quality Assurance and Performance Improvement) monitoring Staff/resident Interview Post event sustained monitoring-alleged/inappropriate physical encounter from 02/24/2025 through 03/27/2025-3x week for 6 weeks in an effort to sustain facility compliance related to alleged/inappropriate physical abuse encounters at the facility, monthly thereafter. Negative findings will be addressed by facility administration immediately with plan of action in place. Effectiveness of this QAPI will be discussed weekly in QA minutes for 6 weeks as well. Monitoring: Employee interview: protection of the resident with new guidelines 03/21/2025 through 03/27/2025. Date facility asserts the likelihood for serious harm to any resident no longer exists: 03/21/2025.

Based on record review, surveillance video review, and interviews, the facility failed to protect the resident's right to be free from physical abuse and psychosocial harm by staff for 1 (#3) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for Resident #3, who was cognitively impaired, on 07/04/2024 at approximately 7:33 p.m. when S7 Sunshine Aide was observed on surveillance video physically abusing Resident #3. S7 Sunshine Aide was observed hitting Resident #3 on her hands and forearm with a hard plastic kitchenware cup. Because this type of inappropriate, unwanted physical abuse would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in Resident #3's position would have experienced severe psychosocial harm-dehumanization, and humiliation- as a result of the physical abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility's Abuse/Neglect policy statement (revision date 12/11/2018) revealed in part: This facility will not condone any form of resident abuse or neglect. Each resident residing on the facility has the right to be free from verbal, sexual, mental, and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean and humiliate a resident (s). Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultant or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. 1. Abuse- the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 6. Physical Abuse - includes hitting, slapping, pinching, and kicking. Additionally, it includes acts of corporal punishment to control behavior. Review of Resident #3's medical record revealed an admission date of 10/29/2020 with medical diagnoses including, but not limited to Medical Diagnoses: generalized osteoarthritis unspecified diastolic (congestive) heart failure, type 2 DM (Diabetes Mellitus), vascular dementia with behavioral disturbances, chronic pain, long term insulin use, schizoaffective disorder/bipolar type, muscle wasting and atrophy multiple sites, right shoulder/ left shoulder, right lower leg, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit, visual hallucinations, restlessness and agitation, schizophrenia. Review of Resident #3's Quarterly MDS (Minimum Data Set) dated 05/29/2024 revealed a BIMS (Brief Interview for Mental Status) of 5 out of 15 indicating severely impaired cognition. Further review of Resident #3's Quarterly MDS revealed no functional limitation in range of motion to upper or lower extremity. Review of Resident #3's Comprehensive Care Plan revealed: Behavior: verbally aggressive toward staff and other residents with interventions to talk calm voice when behavior is disruptive, remove from public area when behavior is disruptive and unacceptable, reinforce unacceptability of verbal abuse, monitor for target behaviors, do not argue with resident, discuss options for appropriate channeling of anger Thought process impaired: Impaired cognition related to diagnosis of dementia with behavioral disturbances. Resident has a history of visual hallucinations. Resident has a history of sun downing in evening times with interventions to administer medications as ordered, anticipate needs, approach in a calm manner, ask simple direct questions, call light within reach, calmly talk with resident and offer reassurance prior to care. Review of Resident #3's July 2024 Physician Orders revealed: 10/18/2021: Namenda 10 mg tablet. Give one tab by mouth twice daily. 10/30/2020: Monitor for behaviors and side effects -is on psychotropic medications Review of facility's incident investigation report revealed an altercation on 07/04/2024 with Resident #3 and S7 Sunshine Aide. Resident #3 in her wheelchair went up to the coffee cart, grabbed two empty coffee cups and threw them at S7 Sunshine Aide when she came out of a room. This occurred when they were approximately 3-4 feet apart. S7 Sunshine Aide reacted, she stated to protect herself. S7 Sunshine Aide said she was trying to knock the other cup out of her hand. They were both swinging their arms in front of them, and S7 Sunshine Aide appeared to make contact with Resident #3's arm 2-3 times. Review of the date and time stamped surveillance video with S1 Administrator revealed on 07/04/2024: 7:33:04: Coffee cart on the hall with hard plastic kitchenware cups on top of the cart. 7:33:08: Resident #3 exited her room in her wheel chair and continued toward the cart with cups and silverware. 7:33:26-30: Resident #3 continued down the hall way, picked up 1 cup with her left hand and 2 cups with her right hand off the coffee cart. 7:33:34: S5 RN (Registered Nurse) came out of another resident room and attempted to redirect Resident #3 to put the cups back on the coffee cart. Attempt was unsuccessful as Resident #3 was moving her mouth appearing to be talking and did not return the cups to the cart. The video did not have sound. 7:33:39: S7 Sunshine Aide exited another room across the hall with a cup in her right hand and walked around the cart to Resident #3. Resident #3 had cups in both her right and left hands with her right hand raised. S7 Sunshine Aide had a cup in her right hand with her right hand raised. 7:33:43: As S7 Sunshine Aide walked closer to Resident #3, Resident #3 begin to swing her right hand holding 2 cups and S7 Sunshine Aide moved to dodge the swing of Resident #3. S7 Sunshine Aide was also swinging at Resident #3 with a cup in her right hand. Both S7 Sunshine Aide and Resident #3 continued to swing at each other as cups fell from Resident #3 hands. S7 Sunshine Aide still had cups in her right hand and made contact with Resident #3's hands and forearm. 7:33:48: S7 Sunshine Aide pushed the other cups on the cart and walked away from Resident #3. Resident #3 attempted to pick up silverware and cups that were on the floor as the video ended. Review of S5 RN (Registered Nurse), nursing note dated 07/09/2024 at 5:59 p.m. (late entry): Resident #3 in wheelchair in hall when she saw S7 Sunshine Aide picking up silverware. Resident #3 rolled over to her cart and picked up silverware and started to throw them at S7 Sunshine Aide; but dropped some. S7 Sunshine Aide picked them up. Resident #3 was cursing and making threats and attempted to throw silverware at S7 Sunshine Aide. S7 Sunshine Aide came out of room with arms raised in order to guard her face. Resident #3 continued to yell at S7 Sunshine Aide as S7 Sunshine Aide was working in another resident room. Writer attempted to calm res down when S7 Sunshine Aide stepped close and begin to attempt to hit resident. Addendum nursing note by S5 RN dated 07/11/2024 at 1:46 p.m. revealed a late entry for 07/04/2024 when the above incident occurred. S8 Physician was notified and attempted to notify responsible party and S7 Sunshine Aide was sent home. A body audit was completed with another nurse and no injuries found. During an interview on 07/23/2024 at 4:21 p.m. S5 RN reported she was in another resident's room on the night of 07/04/2024. Resident #3 was throwing a cup of silverware and S7 Sunshine Aide got upset. S5 RN reported Resident #3 and S7 Sunshine Aide were separated and S7 Sunshine Aide was told to clock out and go home. Resident #3 was assessed with no injuries. During an interview on 07/23/2024 at 4:45 p.m. S6 CNA (Certified Nurse Assistant) reported she did not see the beginning. S6 CNA reported she was in the breakroom when she heard lots of noise and commotion. S6 CNA reported she walked to the end of the hall and witnessed S7 Sunshine Aide swinging at Resident #3 who was in the hallway, in her wheel chair. Resident #3 and S7 Sunshine were swinging at each other. S6 CNA reported S7 Sunshine Aide did hit Resident #3 on the arm. S6 CNA reported she also heard Resident #3 say you hit me. During an interview on 7/23/2024 at 3:50 p.m. S4 Assistant Administrator reported the administrator was out of town when the incident occurred on 07/04/2024. S4 Assistant Administrator reported she started the facility's incident investigation report after being notified on 07/04/2024 around 8:15 p.m. by S2 DON (Director of Nursing) of an altercation and S4 Assistant Administrator needed to come to the facility to view the surveillance video. S4 Assistant Administrator reported she then watched the surveillance video and the footage showed S7 Sunshine Aide did hit Resident #3's arm. S4 Assistant Administrator reported the authorities were notified, Resident #3's responsible party was also notified. S4 Assistant Administrator reported Resident #3 was interviewed. S4 Assistant Administrator reported during the interview with Resident #3, Resident #3 stated the girl hit my arm. S4 Assistant Administrator reported when she arrived to the facility S7 Sunshine Aide had already left and did not answer telephone calls. During an interview on 07/24/2024 at 10:00 a.m. Resident #3 reported staff was nice to her. Resident #3 denied being scared or fearful at the facility. Resident #3 was unable to recall S7 Sunshine Aide. During an interview on 07/25/2024 at 10:00 a.m. S3 ADON (Assistant Director of Nursing) reported on 07/05/2024 S7 Sunshine Aide came straight to the S3ADON's office after clocking in. S3 ADON reported asking S7 Sunshine Aide to provide details of the incident but S7 Sunshine Aide was not able to explain what happened. S3 ADON reported she informed S7 Sunshine Aide that the S1 Administrator and S4 Assistant Administrator would also like to speak to her and walked S7 Sunshine to the front foyer to wait on the S1 Administrator and S4 Assistant Administrator. S3 ADON reported S7 Sunshine Aide left the facility and they have not been able to make contact with her. S3 ADON reported Resident #3 was being seen by a behavioral health nurse practitioner and was care planned for aggressive behaviors. S3 ADON reported at times Resident #3 is not easily redirected and staff should walk away. Attempted telephone interview with S7 Sunshine Aide on 07/25/2024 at 1:00 p.m. telephone call went to voicemail. During an interview on 07/25/2024 at 2:30 p.m. S9 NP (Nurse Practitioner) reported Resident #3 had aggressive behaviors and received a report of an incident on 07/04/2024. Resident #3 was assessed on 07/05/2024 and S9 NP ordered lab, urine and changed her medications. S9 NPs Assessment found no injuries and Resident#3 had not been withdrawn or appeared fearful since incident. S9 NP reported the behavioral health nurse practitioner would have followed up with Resident #3's medications. Attempted telephone interview with S10 Behavioral Health NP on 07/25/2024 at 4:00 p.m Office staff reported S10 Behavioral Health NP was not in the office, message left with office staff. Multiple observations during survey revealed Resident #3 ate lunch in dining room with other residents. Observations during survey revealed Resident #3 was talkative with other residents and staff. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice. Review of facility's Performance Improvement Plan revealed the following with a completion date of 7/11/2024: Topic: Abuse/ Neglect Areas identified as needing improvement: knowing de-escalation tactics and dealing with burnout Plan implementation: 1. Abuse-Neglect monitoring was started on 07/05/2024 and in-service (Abuse and Neglect) with all staff 2. 07/05/2024 census was pulled, care plan nurse ask residents the attached questions. All staff were given test regarding abuse and neglect. 3. 07/10/2024 De-escalation training was done by all staff Implemented changes will be monitored by ADON and DON for 6 weeks beginning 07/04/2024. Plan will be evaluated for effectiveness by review of incidents and review of monitoring. Review of typed facility's incident investigation report time line by S3 ADON dated 07/11/2024 revealed in part, 07/05/2024 S9 NP made rounds and increased Seroquel to 50 mg in the a.m. and 100 mg in the p.m. as well as adding Vistaril 25 mg every evening. New order to collect a urinalysis with culture and sensitivity. S10 Behavioral Health NP notified of resident behavior and medication change. Resident #3's care plan updated to notify staff to only remove dishes etc. from room while Resident #3 is out of the room. Updated the aggression to the care plan to include: (resident becomes angry and physically aggressive with staff when staff attempts to assist or redirect). Resident #3 hoards silverware including coffee cups and utensils in her room. Added to wall care sign in room. 07/05/2024: In-service initiated on abuse-which includes both physical and mental abuse, in-service initiated on burn-out, de-escalation-report abusive patient as soon as it is noted to happen to supervisor or nurse. Communication in-service staff to be in close proximity with communicating patient care. Testing completed for all staff on abuse and neglect. Resident interviews completed to ensure all resident feel safe and have no concerns. 07/08/2024: Abuse and Neglect-Grievance monitor added as a QA (Quality Assurance) tool for administrative staff to complete with all residents and to for six weeks and then weekly which includes a questionnaire for reside to ensure they feel safe and have no other concerns. 07/10/2024: De-escalation in-service with completed by S11 RN, __________ local behavioral hospital with de-escalation testing for all staff. 07/11/2024: Resident #3 does not recall the incident; she has continued her daily activities as usual. Resident #3 remains very social and has a good quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4, #5) residents reviewed for accidents received adequate supervision to prevent accidents/falls. The deficient practice resulted in harm for Resident #1 on 08/08/2023 when the resident fell from bed after S4 CNA (Certified Nursing Assistant) left Resident #1's room during peri care to seek assistance of a second CNA. Resident #1 required two person assistance for bed mobility. On 08/08/2023 S4 CNA was providing peri care, Resident #1 was positioned to her right side with her foot hanging off the bed and S4 CNA realized she could not reposition Resident #1 alone. S4 CNA left Resident #1's room to obtain assistance and when S4 CNA returned, Resident #1 was on the floor with left leg bent at the knee. Resident #1 was transported and admitted to a local hospital on [DATE] with diagnosis of fracture of left femur. Findings: Review of hospital physician progress notes revealed in part: Resident #1 was admitted to hospital on [DATE] with diagnosis of fracture of left femur and orthopedics consulted. On 08/09/2023 Resident #1 had a left open reduction internal fixation (ORIF) performed. Resident #1 was discharged back to nursing home on [DATE] with immobilizer to left lower extremity. Review of Resident #1's medical record revealed an admission date of 01/20/2012 and reentry date of 08/14/2023 with diagnoses including, but not limited to, Left Femur Fracture, HIV (Human Immunodeficiency Virus), Latent Syphilis, Multifocal Leukoencephalopathy, Obesity, and Generalized Weakness. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Further review of the MDS dated [DATE] revealed Resident #1's functional status was total dependence requiring two person physical assist with bed mobility. Review of Resident #1's Care Plan revealed, in part, the following: Activities of daily living (ADL) deficits and included approach of two person assistance with all ADLs with start date of 01/27/2023. Review of facility's Incident Report dated 08/08/2023 for Resident #1 revealed in part, S4 CNA was providing peri care for Resident #1, S4 CNA stepped out to seek help, when S4 CNA returned resident was found on floor. Review of documentation of S4 CNA statement for Resident #1's 08/08/2023 fall revealed: On 08/08/2023 S4 CNA was changing Resident #1 in the bed and Resident #1 was turned to her right side with foot was hanging off of the bed. (Resident #1 was still in the bed) S4 CNA went to get another CNA for help and when S4 CNA went back in the room Resident #1 was out of the bed. Review of documentation of S5 CNA statement for Resident #1's 08/08/2023 fall revealed: S5 CNA went to Resident #1's room to assist with her care. S5 CNA noticed Resident #1 was lying on the floor by the refrigerator and Resident #1's knee was bent. Review of documentation of S3 LPN (Licensed Practical Nurse), MDS (Minimum Data Set) Nurse statement for Resident #1's 08/08/2023 fall revealed: After being summoned to Resident #1's room, S3 LPN, MDS Nurse entered room and observed resident lying on floor in supine position with left leg bent at knee back toward resident's head. Resident #1 stated she was lying on the bed positioned on her side, she moved her leg and slid off the bed. S3 LPN, MDS Nurse questioned S4 CNA assigned to resident and S4 CNA stated she was performing peri care, needed help, stepped outside in hallway to get help, returned to room to find resident on floor. Review of documentation of S2 DON (Director of Nursing) statement for Resident #1's 08/08/2023 fall revealed in part: S4 CNA provided one person ADL care per Resident #1's Care Communication sheet. During an interview on 08/30/2023 at 3:05 p.m. S7 Therapy Director reported Resident #1 was receiving occupational therapy prior to her hospitalization on 08/08/2023. S7 Therapy Director reported she has noticed a decline in Resident #1 over the past couple of years related to progression of Resident #1's Neuro Syphilis and the lesions on Resident #1's brain. S7 Therapy Director confirmed the MDS assessment dated [DATE] reporting resident required assist of two persons with ADLs was an accurate assessment of the assistance Resident #1 required. During an interview on 08/31/2023 at 8:02 a.m. S6 LPN reported Resident #1 required two person assist with ADLs, but on the day of the incident when Resident #1 broke her leg, there was only one CNA helping her. During an interview on 08/31/2023 at 10:35 a.m. Resident #1 confirmed earlier this month when she fell out of bed and broke her leg there was only one CNA in the room helping her and the CNA left the room to get assistance leaving Resident #1 positioned to her right side. Resident #1 also reported she was transported to the hospital and had surgery on her left leg the next day. During an interview on 08/31/2023 at 10:45 a.m. S3 LPN, MDS Nurse reported each resident has a Care Communication sheet hanging in their room which informs staff of the amount of assistance required by the resident. S3 LPN, MDS Nurse reported the Care Communication sheet is based on each Resident's care plan. S3 LPN, MDS Nurse further reported she knows Resident #1's Care Communication sheet stated resident required assistance of one person with ADLs prior to Resident #1 falling and breaking her leg because she was the person who filled the sheet out. During an interview on 08/31/2023 at 11:05 a.m. S2 DON confirmed the resident's care plan and Care Communication sheet should match. S2 DON acknowledged Resident #1's care plan revealed Resident #1 was a 2 person assist with ADLs and the Care Communication Sheet indicated Resident #1 was a 1 person assist for everything except transfers. During an interview on 08/31/2023 at 11:30 a.m. S1 Corporate Nurse reviewed Resident #1's care plan and confirmed Resident #1 was care planned for two person assist with all ADLs since 01/27/2023.