**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be provided to attain or maintain the residents' highest practicable physical, mental, and psychosocial needs, for 1 of 4 residents (Resident #1) reviewed for care plans in that: The facility failed to ensure an individualized care plan to address Resident #1's level of assistance that was required for ADLs by a 1 or 2 person assist. The CNA made the determination to provide perineal care by herself, resulting in Resident #1 to fall and was discharged to the hospital on [DATE]. An Immediate Jeopardy was identified on 08/22/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 12:20 p.m. While the Immediate Jeopardy was removed on 08/23/2025 at 3:30 p.m. The facility remained out of compliance at a scope of isolation and a severity of not actual harm with potential for more than the minimal harm that was not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures. This failure could place residents at risk of injuries and their individual medical, physical and psychosocial needs not being met. The findings were: Record review of Resident#1 electronic admission record dated 08/21/2025, revealed a [AGE] year-old female with an admission date of 12/11/2022 and an original admission date of 04/09/2021. Resident #1's pertinent diagnosis included Dementia, Cerebral Vascular Accident (stroke) with right sided weakness, epilepsy (seizures), Heart Failure, and Atrial Fibrillation (irregular heartbeat). Record review of Resident #1's comprehensive MDS dated [DATE], revealed a BIMS score of 02, indicating severe cognitive impairment. Resident #1 was noted in section GG- Functional Abilities coded as a 03 (Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for self-care tasks and transfers. Resident #1 was noted to be bowel and bladder always incontinent. Record review of Resident #1's comprehensive care plan dated 05/22/2025, revealed Resident#1 had an ADL self-care performance deficit related to CVA with hemiplegia, Dementia. Interventions: BED MOBILITY: The resident requires (extensive assistance) by (1-2) staff to turn and reposition in bed daily and as necessary. Care needs may vary. TOILET USE: The resident requires extensive assistance by 1-2 staff for toileting. Care needs may vary. Record review of Resident #1's narrative of the incident dated 08/20/2025, revealed the resident was receiving perineal care from CNA A. As CNA A turned to dispose of the soiled brief in the trash can at bedside, the resident rolled over onto the floor mat at bedside. Charge nurse was immediately notified and performed a head-to-toe assessment prior to bed transfer. Resident #1 was initially able to communicate and stated she had right sided shoulder pain. Family and NP were informed. Neuro checks were initiated, and a change of condition with AMS was noted approximately 20 minutes into the neuro checks, 911 call was activated and resident was transferred to hospital.In an interview on 08/21/2025 at 11:06 a.m., CNA A stated that she was the one who determined if the resident would be a one or two person assist. She stated that she would determine this by seeing if the resident was cooperative and followed commands, prior to starting the task. If they were, then she would proceed with doing the task on her own. If they do not want to cooperate and assist, then she would get another staff member to assist. She stated that the Kardex (summary of a patients care plan and needs during their shift) had Resident #1 as a 1-2 person assist. CNA A stated that she normally does Resident #1's perineal care on her own.In an interview on 08/21/2025 at 11:43 a.m., CNA C stated that she was familiar with Resident #1's care and that she would normally do perineal care on her own. She stated that she looked in the computer Kardex to see if the resident would be a one person or two person assist. If the resident was a 1-2 person assist, then she determined if she could do it on her own or if she would need assistance. She would determine this after she talked to the resident and informed them of the task. If the resident was cooperative then she would continue to do the task on her own. If she saw that they were not, then she would get another person to assist. In an interview on 08/21/2025 at 12:30 p.m., LVN B stated that Resident #1 was a 1-2 person assist depended on the task. She stated Resident #1 was a one person assist the day of the incident, 08/20/2025, because she was cooperative. LVN B stated that the CNAs that provided the care would determine if the patient cooperated. The CNAs were more hands-on with them. Then they would report to her that they were transferred well. In an interview on 08/22/2025 at 2:25 p.m., CNA G stated that she worked at the facility for about ten months. She stated that she was familiar with Resident #1's care. She stated that Resident #1 would assist with moving her around in the bed, she followed commands. CNA G stated that she would know if a resident was a one or two person assist by looking in the computer, the Kardex. She stated that if showed 1-2 person assist, then she would determine if the resident was going to be a one or two person by seeing if the resident had been cooperative and followed commands. If not cooperative and were sleepy, then she would get someone to assist. She stated it depended on the state that the resident was in, but she would make that decision if she would need the extra help. She would document afterwards when she had time, if the task was done with a one or two person assist.In an interview on 08/25/2025 at 1:56 p.m., RN D stated that she and the MDS nurse were responsible for completing the care plans. She stated that when a resident was admitted , she performed a head-to-toe assessment. They gather all that information, and she communicated this with the CNAs. She would then talk to MDS and formulated everything on the care plan. RN D stated that it was important for the care plans to be person centered for each resident for their safety and the safety of the staff. She stated that they could have something general for everybody. The staff or resident can hurt themselves if it was supposed to be a 2 person and was done by a 1 person. She stated that it was important for the care plan to be individualized with their specific needs for safety and to prevent accidents. In an interview on 08/22/2025 at 10:39 a.m., MDS E, stated that she coded Resident #1 as 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort under the Functional Abilities was because the patient could be 1 or 2 person assist. She stated the patients in the morning could be extensive and, in the evening, they could be total assist. It all depended on what they needed at that moment. The CNA and the charge nurse would be the ones who determined the level of assistance. MDS E stated that changes in condition were communicated every day in the IDT morning meeting. She stated that they were responsible for care planning. In a follow up interview on 08/25/2025 at 2:20 p.m., MDS E, stated that person centered care plan meant it was an individualized care plan with their specific needs based on the patient's diagnoses, their functions, limitations, goals, and their preferences. It focused on them as a whole. MDS E stated that the process for care planning was if it was an admission, the nurse would go assess the patient. The initial baseline care plan would be started. She stated once that was closed, it imported to the system. In the morning meetings, they go over our patients and make any changes to the care plan that were needed. She stated she would then have 14 days to complete the comprehensive. If any changes were made in their 24-hour reports, they reviewed them in the morning meetings. MDS E stated that it was important for the care plans to be person centered for each resident because nobody was the same, everybody has different limitations. She stated, What can work for someone, does not work for others; they all have different preferences. The negative outcome of the care plan not being individualized with their specific needs and being a 1 -2 assist would be that incidents can happen. The care of the patient can be at risk and the safety of both the patient and staff. In an interview on 08/21/2025 at 2:44 p.m., the DON stated that the MDS nurses formulated the care plan, but it was a team collaboration. She stated the therapist, charge nurses, ADON, and she were all involved. It was a holistic approach from the staff if a resident would be a one or two person; it takes a team. She stated the 1-2 person assist depended on the time of the day. In the morning, Resident #1 does well, she followed commands. There were other moments that she might need two person assist, this would be when Resident #1 was more tired or fatigued towards the end of the day. The CNAs would not begin care on their own if they knew she needed a two person assist. In a follow up interview on 08/25/2025 at 2:35 p.m., the DON stated the charge nurse was responsible for starting the care plan. She stated that a head to touch assessment was done upon admission. This was considered a mini care plan. She stated the nurse and MDS nurse can update and change interventions. The DON stated that it was important for the care plans to be person centered for each resident because every patient was different. She stated every care plan needed to be specific to that patient's needs. The DON stated the negative outcome of not having an individualized care plan would be that the patient or the staff could get hurt. Record review of facility's policy for Comprehensive Care Plans date implemented 10/24/2022 revealed: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Policy Explanation and Compliance Guidelines: 3.The comprehensive care plan will describe, at a minimum, the following:f. Resident specific interventions that reflect the residents needs and preferences and align with the residents cultural identify, as identified.8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. An Immediate Jeopardy was identified on 08/22/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 12:20 p.m. The Immediate Jeopardy template was provided to administrator. The following Plan of Removal was accepted on 08/23/2025 at 10:50 a.m.: PLAN OF REMOVALDate: 08/22/2025Issue:F 656 Comprehensive Patient Centered Care Plan The facility failed to develop and implement a comprehensive specific person-centered care plan for each resident to ensure adequate staff is provided to meet the needs of residents that require increased supervision.Actions Taken:For those Identified: Resident #1 was discharged from the facility and admitted to the hospital on [DATE].To Identify Other Residents: On 8/22/25, the MDS Nurses completed 100% review of residents to assess level of supervision required. Based on the assessment the Plan of Care was updated as needed to reflect the level supervision required. The level of ADL assistance is clarified to one (1) or two (2) person assist. The updated level of ADL assistance is reflected in the Point of Care nurse aide task list.The Interdisciplinary Team (IDT) i.e. MDS nurse, Director of Nursing, Director of Rehab, Social Services, Activities, Dietary will determine the initial level of ADL assistance based on admission Assessments. The IDT will no less than quarterly assess and update the level of ADL assistance required and update the Plan of Care, Kardex and Point of Care nurse aide tasks. The charge nurse will continuously evaluate the resident's status to determine whether the current level of assistance remains appropriate.The charge nurse will review the 24h report during the change of shift to identify any changes in conditions were identified for any resident. The nurse will review the level of assistance required and determine if this remains appropriate. If the charge nurse determines that a higher level of assistance is required, the nurse will arrange for additional support to meet the resident's need and communicate this change to the nurse aide. If a permanent change in level of assistance is identified this will be reflected in the Point of Care nurse aide task listing.The nurse will report any changes in level of assistance during the Clinical Morning MeetingMonday-Friday with the Interdisciplinary Team present. The IDT will further assess to determine if the change in level of assistance is permanent. lf this is determined in the positive the Plan of Care, Kardex and tasks will be updated to reflect the change.Education / System Change:Effective immediately on 8/22/25, the Administrator/ DON and/ or designee began reeducation to 100% of direct care staff on the following:o Abuse, Neglect & Exploitationo Fall Preventiono Safe Handling of Residentso Perineal Careo Turning and Repositioningo Process for Level of Assistance Required Effective immediately on 8/22/25, the Administrator/ DON and/ or designee beganreeducation to 100% of non- direct staff on the following: Abuse, Neglect & Exploitation The completion date of education of direct care staff will be 8/22/25, in person or via telephone. Those that were not scheduled on 8/22/2025 will have the education completed prior to accepting assignment for their next scheduled work. Any direct care staff not re­ educated in person or via phone today (8/22/2025), will be removed from providing care until education is provided. Verification of 100% of direct care staff education will be verified by the Director of Nursing/ designee. On 8/22/25, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and the Regional Clinical Specialist to review the IJ Template and the Plan for Removal. Monitoring: Beginning 8/22/25, and going forward, the Director of Nursing/designee will review the 24 Hour Report to identify residents who may have had a change in condition that may require increased level of supervision in facility Clinical Morning Meeting, attended Monday-Friday. The Director of Nursing/designee will ensure that the residents' Plan of Care and Kardex is updated to reflect the change in level of supervision and the Point of Care nurse aide task list is updated. The DON/designee will conduct daily observations for all shifts for 5 days, then 5 days on random shifts to ensure the level of ADL assist is being followed as care planned. DON/designee will complete weekend rotations on random shifts to ensure the level of ADL assist is be followed as care planned. Administrator and DON will monitor compliance with the facility process implemented. The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months. Trends will be presented and discussed in the monthly QAPI meeting for three months. Monitoring: Started on 08/23/2025 at 11:00 a.m. and included: Record review of an In-Service with subject of Fall Prevention, initiated date 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Safe Resident Handling/Transfers, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Turning and Repositioning, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Perineal Care, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of ADLs, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Abuse, Neglect, and Exploitation, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of the Process for Level of Assistance Required dated 08/23/2025 revealed, The staff providing direct care to residents must be aware of the level of assistance required by the resident. The nurse will assess the patient's current condition and overall needs and provide direction to the nurse aide regarding the appropriate level of supervision require to ensure safe and effective care. The nurse will continuously evaluate the patient's status to determine whether the current level of assistance remains suitable. If the patient exhibits signs of agitation, fatigue, or any indication of a change in conditions (note: this is not an exhaustive list), the nurse will promptly inform the nurse aide. If it is determined by the nurse that a higher level of assistance is necessary, the nurse will arrange for additional support to meet the patient needs and communicate this change to the nurse aide accordingly. The aide will refer to the Kardex daily, or as needed, and follow any special instructions provided by the nurse to confirm the appropriate level of care for tasks such as Activities of Daily Living (ADLs). If a permanent change in the patients required level of assistance is identified, the Plan of Care will be updated accordingly, and the changes will be reflected in the Kardex. At no time will the nurse aide unilaterally determine the level of assistance required by the resident. The nurse will have the sole responsibility to assess and determine the level of assistance required by the resident. Record Review of the QAPI meeting was held on 08/22/2025 QAPI documentation reviewed. During interviews on 08/23/2025 at 11:29 a.m. - 08/23/2025 at 2:09 p.m., 8 CNAs indicated they were all knowledgeable of the expectation that at no time would they determine the level of assistance required by the resident. They stated that the nurses would have the sole responsibility to assess and determine the level of assistance required by the resident. The CNAs stated that the level of assistance would be reflected in the residents Kardex. They were to refer to the Kardex daily, or as needed, and if they had any questions then they would ask the nurse to confirm the appropriate level of care for tasks such as ADLs. During interviews on 08/23/2025 at 1:26 p.m. - 08/23/2025 at 2:44 p.m., 5 LVNs and 1 RN indicated they were aware of the expectations to review the 24-hour report during the change of shift and identify any changes in conditions the residents might have. They would review the level of assistance required and determine if this remains appropriate. If they determine that a higher level of assistance was required, they will arrange for additional support to meet the residents needs and communicate the change to the nurse aides. If the change were permanent in the level of assistance, then it would be reflected in the point of care nurse aide task listing. They would report any changes in level of assistance during the clinical morning meeting with the IDT team present. They were knowledgeable of the process for the determination of level of assistance required and having reeducation of the following policies and procedure- Abuse, neglect, and exploitation, Falls, Safe Handling of residents, Turning and reposition, and Perineal care. In an interview on 08/23/2025 at 3:00 p.m., MDS F stated that they completed 100% reviews of the residents to assess level of supervision required. She stated that the Plan of Care was updated to reflect the level of supervision required, based on the assessment. MDS F stated that there were about 75% of care plans that had 1-2 person assist for the level of ADL assistance and were clarified to reflect either one or two person assist. She stated the updated level of ADL assistance was reflected in the Point of Care nurse aide task list.On 08/23/25 at 12:33 an Observation of peri care revealed CNAs reviewed the cardex before providing the care to verify the level of assistance required by the resident. On 08/23/25 from 1:26 p.m., to 1:42 p.m., two observations were done for two LVNs reviewing care plans to make sure the care plans were updated to reflect a one or two person assist. Record review of six care plans and 6 cardex were reviewed to verify that the information was the same in both records.The Administrator was informed that the Immediate Jeopardy was removed on 8/23/2025 at 3:30 p.m., however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was provided with adequate supervision and assistance while provided incontinent care on 08/20/25. Resident#1 suffered a fall that resulted in a subdural hematoma (a collection of blood that forms on the surface of the brain, between the brain and its outermost protective covering). Resident#1 was discharged to hospital on [DATE] and passed away on 08/21/25. The facility did not have consistent procedures for floor staff to establish level of need for residents requiring 1-2 person assist for ADLs. An Immediate Jeopardy was identified on 08/22/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:37 p.m. While the Immediate Jeopardy was removed on 08/23/2025 at 3:30 p.m. The facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that was not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury, harm, or death. Findings included: Record review of Resident#1 electronic admission record dated 08/21/2025, revealed a [AGE] year-old female with an admission date of 12/11/2022 and an original admission date of 04/09/2021. Resident #1's pertinent diagnosis included Dementia, Cerebral Vascular Accident (stroke) with right sided weakness, epilepsy (seizures), Heart Failure, and Atrial Fibrillation (irregular heartbeat). Record review of Resident #1's Comprehensive MDS dated [DATE], revealed a BIMS score of 02, indicating severe cognitive impairment. Resident #1 was noted in section GG- Functional Abilities coded as a 03 (Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for self-care tasks and transfers. Resident #1 was noted to be bowel and bladder always incontinent. Record review of Resident #1's comprehensive care plan dated 05/22/2025, revealed Resident#1 had an ADL self-care performance deficit related to CVA with hemiplegia, Dementia. Interventions: BED MOBILITY: The resident requires (extensive assistance) by (1-2) staff to turn and reposition in bed daily and as necessary. Care needs may vary. TOILET USE: The resident requires extensive assistance by 1-2 staff for toileting. Care needs may vary. Record review of Resident #1' s Order Summary Report revealed Apixaban (anticoagulant) tablet 2.5 mg for A Fib and Keppra (anticonvulsant) tablet 500 mg for Seizures. Record review of Resident #1's narrative of the incident dated 08/20/2025, revealed the resident was receiving perineal care from CNA A. As CNA A turned to dispose of the soiled brief in the trash can at bedside, the resident rolled over onto the floor mat at bedside. Charge nurse was immediately notified and performed a head-to-toe assessment prior to bed transfer. Resident #1 was initially able to communicate and stated she had right sided shoulder pain. Family and NP were informed. Neuro checks were initiated, and a change of condition with AMS was noted approximately 20 minutes into the neuro checks, 911 call was activated and resident was transferred to hospital. Record review of Resident #1's Final report from the Hospital revealed Resident #1 suffered a subdural hematoma (a collection of blood that forms on the surface of the brain, between the brain and its outermost protective covering) secondary to anticoagulant therapy and recent fall with head injury. In an interview on 08/21/2025 at 11:06am, CNA A stated the incident happened around 10:45ish but not before 11am. She stated she went in and notified Resident #1 that she would be doing perineal care. She then proceeded to clean her. She turned her on the right side. She then removed the dirty brief and as she turned halfway to throw it away in the trash can that was beside her, Resident#1 did a quick movement and fell. She was not able to grab her because it happened so quickly. She notified charge nurse immediately. In an interview on 08/21/2025 at 12:30pm LVN B stated that she was called by CNA A to go to Resident #1's room. Resident #1 was awake, alert, and responsive. No visible injuries noted. She stated Resident #1 answered yes when asked if rolled off the bed. Resident#1 was immediately assessed for injuries, no visible injuries were noted. LVN B stated Resident #1 complained of pain to the right-side right shoulder, no swelling or redness noted to affected area. Neuro checks initiated. She stated the NP and RP were notified. LVN B stated Resident #1 was a 1-2 person assist depended on the task. She stated Resident #1 was a one person assist the day of the incident, 08/20/2025. LVN B stated that the CNAs that provided the care would determine if the patient cooperated. The CNAs were more hands-on with them. Then they would report to her if they were transferred well. In an interview on 08/21/2025 at 2:44 p.m., the DON stated she was at the facility at the time of the incident. She stated she was informed about the incident right away. She stated she did her own head to toe assessment. The DON stated Resident #1 was initially responding, then she had a decline. She stated everything happened fast, within minutes. The DON stated that she was familiar with her care and the staff were as well. She stated Resident #1 had been there for a while. The CNA had worked with her for a long time. The DON stated that because Resident #1 was doing so well yesterday morning, 08/20/2025, that was why CNA A provided care alone at that moment. In a follow up interview on 08/22/2025 at 10:44 a.m., the DON stated that the charge nurse did daily rounds first thing at the beginning of their shifts. She stated the charge nurse would determine if the resident would be a one or two person assist and verbally communicated this with the CNAs. Record review of the facility's policy dated 02/19/2025 titled Turning and Repositioning revealed: Policy Explanation and Compliance Guidelines:2. Turning and repositioning is a primary responsibility of nursing assistants. However, all nursing staff are expected to assist with turning and repositioning. 3. Turning and positioning includes using both side lying and back positions, alternating from the right, back, and left side.5. Use the appropriate number of staff to perform the tasks safely. Record review of the facility's policy dated 02/19/2025 titled Safe Resident Handling/Transfers Policy revealed: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess ach residents' individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Record review of the facility's policy dated 08/15/2022 titled Fall Prevention Program Policy revealed: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. An Immediate Jeopardy was identified on 08/22/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:37 p.m. The Immediate Jeopardy template was provided to administrator. The following Plan of Removal was accepted on 08/23/2025 at 10:50 a.m.: PLAN OF REMOVALDate: 08/22/2025Issue: F689: Free of Accident Hazards/Supervision/Devices: 483.25(d)(2)The facility failed to develop and implement processes and procedures to ensure adequate staff is provided to meet the needs of residents that require increased supervision, and that staff provide this supervision were trained and familiar with the resident's supervision needs.Actions Taken:For those Identified: Resident #1 was discharged from the facility and admitted to the hospital on [DATE].To Identify Other Residents: On 8/22/25, the MDS Nurses completed 100% review of residents to assess level of supervision required. Based on the assessment the Plan of Care was updated as needed to reflect the level supervision required. The level of ADL assistance is clarified to one (1) or two (2) person assist. The updated level of ADL assistance is reflected in the Point of Care nurse aide task list.The Interdisciplinary Team (IDT) i.e. MDS nurse, Director of Nursing, Director of Rehab, Social Services, Activities, Dietary will determine the initial level of ADL assistance based on admission Assessments. The IDT will no less than quarterly assess and update the level of ADL assistance required and update the Plan of Care, Kardex and Point of Care nurse aide tasks. The charge nurse will continuously evaluate the resident's status to determine whether the current level of assistance remains appropriate.The charge nurse will review the 24h report during the change of shift to identify any changes in conditions were identified for any resident. The nurse will review the level of assistance required and determine if this remains appropriate. If the charge nurse determines that a higher level of assistance is required, the nurse will arrange for additional support to meet the resident's need and communicate this change to the nurse aide. If a permanent change in level of assistance is identified this will be reflected in the Point of Care nurse aide task listing.The nurse will report any changes in level of assistance during the Clinical Morning Meeting. Monday-Friday with the Interdisciplinary Team present. The IDT will further assess to determine if the change in level of assistance is permanent. lf this is determined in the positive the Plan of Care, Kardex and tasks will be updated to reflect the change.Education / System Change: Effective immediately on 8/22/25, the Administrator/ DON and/ or designee began reeducation to 100% of direct care staff on the following:o Abuse, Neglect & Exploitationo Fall Preventiono Safe Handling of Residentso Perinea! Careo Turning and Repositioningo Process for Level of Assistance Required Effective immediately on 8/22/25, the Administrator/ DON and/ or designee beganreeducation to 100% of non- direct staff on the following: Abuse, Neglect & Exploitation The completion date of education of direct care staff will be 8/22/25, in person or via telephone. Those that were not scheduled on 8/22/2025 will have the education completed prior to accepting assignment for their next scheduled work. Any direct care staff not re­ educated in person or via phone today (8/22/2025), will be removed from providing care until education is provided. Verification of 100% of direct care staff education will be verified by the Director of Nursing/ designee. On 8/22/25, an Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and the Regional Clinical Specialist to review the IJ Template and the Plan for Removal. Monitoring: Beginning 8/22/25, and going forward, the Director of Nursing/designee will review the 24 Hour Report to identify residents who may have had a change in condition that may require increased level of supervision in facility Clinical Morning Meeting, attended Monday-Friday. The Director of Nursing/designee will ensure that the residents' Plan of Care and Kardex is updated to reflect the change in level of supervision and the Point of Care nurse aide task list is updated. The DON/designee will conduct daily observations for all shifts for 5 days, then 5 days on random shifts to ensure the level of ADL assist is being followed as care planned. DON/designee will complete weekend rotations on random shifts to ensure the level of ADL assist is be followed as care planned. Administrator and DON will monitor compliance with the facility process implemented. The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months. Trends will be presented and discussed in the monthly QAPI meeting for three months. Monitoring: Started on 08/23/2025 at 11:00 a.m. and included: Record review of an In-Service with subject of Turning and Repositioning, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Safe Resident Handling/Transfers, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Fall Prevention, initiated date 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Perineal Care, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of ADLs, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of an In-Service with subject of Abuse, Neglect, and Exploitation, dated 08/22/2025, indicated that working staff signed the in-service record on 08/22/2025 and 08/23/2025. Record review of the Process for Level of Assistance Required dated 08/23/2025 revealed, The staff providing direct care to residents must be aware of the level of assistance required by the resident. The nurse will assess the patient's current condition and overall needs and provide direction to the nurse aide regarding the appropriate level of supervision require to ensure safe and effective care. The nurse will continuously evaluate the patient's status to determine whether the current level of assistance remains suitable. If the patient exhibits signs of agitation, fatigue, or any indication of a change in conditions (note: this is not an exhaustive list), the nurse will promptly inform the nurse aide. If it is determined by the nurse that a higher level of assistance is necessary, the nurse will arrange for additional support to meet the patient needs and communicate this change to the nurse aide accordingly. The aide will refer to the Kardex daily, or as needed, and follow any special instructions provided by the nurse to confirm the appropriate level of care for tasks such as Activities of Daily Living (ADLs). If a permanent change in the patients required level of assistance is identified, the Plan of Care will be updated accordingly, and the changes will be reflected in the Kardex. At no time will the nurse aide unilaterally determine the level of assistance required by the resident. The nurse will have the sole responsibility to assess and determine the level of assistance required by the resident. Record Review of the QAPI meeting was held on 08/22/2025 QAPI documentation reviewed. During interviews on 08/23/2025 at 11:29 a.m. - 08/23/2025 at 2:09 p.m., 8 CNAs were all knowledgeable of the of the expectation that at no time would they determine the level of assistance required by the resident. They stated that the nurses will have the sole responsibility to assess and determine the level of assistance required by the resident. The CNAs stated that the level of assistance would be reflected in the residents Kardex. They were to refer to the Kardex daily, or as needed, and if they had any questions then they would ask the nurse to confirm the appropriate level of care for tasks such as ADLs. During interviews on 08/23/2025 at 1:26 p.m. - 08/23/2025 at 2:44 p.m., 5 LVNs and 1 RN were aware of the expectations to review the 24-hour report during the change of shift and identify any changes in conditions the residents might have. They will review the level of assistance required and determine if this remains appropriate. If they determine that a higher level of assistance was required, they would arrange for additional support to meet the residents needs and communicate the change to the nurse aides. If the change were permanent in the level of assistance, then it would be reflected in the point of care nurse aide task listing. They would report any changes in level of assistance during the clinical morning meeting with the IDT team present. They were knowledgeable of the process for the determination of level of assistance required and having reeducation of the following policies and procedure- Abuse, neglect, and exploitation, Falls, Safe Handling of residents, Turning and reposition, and Perineal care. In an interview on 08/23/2025 at 3:00 p.m., MDS F stated that they completed 100% reviews of the residents to assess level of supervision required. She stated that the Plan of Care was updated to reflect the level of supervision required, based on the assessment. MDS F stated that there were about 75% of care plans that had 1-2 person assist for the level of ADL assistance and were clarified to reflect either a one or two person assist. She stated the updated level of ADL assistance was reflected in the Point of Care nurse aide task list. On 08/23/25 at 12:33 an Observation of peri care revealed CNAs reviewed the cardex before providing the care to verify the level of assistance required by the resident. On 08/23/25 from 1:26 p.m., to 1:42 p.m., two observations were done for two LVNs reviewing care plans to make sure the care plans were updated to reflect a one or two person assist. Record review of six care plans and 6 cardex were reviewed to verify that the information was the same in both records.The Administrator was informed that the Immediate Jeopardy was removed on 8/23/2025 at 3:30 p.m., however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system.