**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 8) did not receive unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior and used to treat mental health disorders). The facility failed to: 1. Ensure Resident 8 w, not prescribed and administered Ativan (a prescription medicine often used to treat people living with anxiety [extreme worry]) 1 milligrams ([mg] a unit of weight measurement), every four hours as needed (PRN) for agitation (feelings of irritability, mental distress, or severe restlessness) and shortness of breath (SOB) for 14 day, without documented indication for use. 2. Ensure Resident 8 was not administered Ativan 1 mg every four hours for six days along with other psychotropic medications (Seroquel and Risperdal), causing Resident 8 to be over sedated. 3. Ensure Resident 8 was not prescribed and administered two antipsychotic (medication used to treat certain mental/mood disorders such as schizophrenia [a mental disorder characterized by abnormal thought processes and deregulated emotions], and bipolar disorder [a mental illness characterized by periods of elevated mood and periods of depression], medications simultaneously, Seroquel 50 mg for dementia (a progressive loss of memory) with psychotic (a person affected with psychosis [a severe mental disorder that causes a person to lose touch with reality and have disrupted thoughts and perceptions] features, manifested by visual hallucinations (false perceptions of things that seem real but are not) of seeing non-existent dead people, ordered on 6/14/2024 and Risperidone 1 mg for a mood disorder manifested by agitation, ordered on 6/20/2024. 4. Ensure Resident 8 was not prescribed antipsychotic medications Seroquel and Risperidone, that were not indicated for use for residents who displayed behaviors related to diagnoses of vascular dementia (a chronic condition that affects memory, thinking and behavior, caused by conditions that damage blood vessels and disrupts blood flow and oxygen supply to the brain) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest tasks). 5. Ensure Resident 8 was not prescribed Ativan 1 mg every four hours as needed for agitation, and Risperdal 1 mg two times daily for a mood disorder manifested by agitation as chemical restraints, as evidenced by interview that Resident 8 often tried to get out of bed unassisted, was at risk of falling and that was why she was given Ativan. 6. Ensure Resident 8 did not receive multiple psychotropic medications (Seroquel, Risperdal and Ativan) simultaneously causing the resident to fall four times from 6/15/2024 thru 7/13/2024. 7. Ensure the licensed nurses notified Resident 8's attending physician when Resident 8 had a change of condition (COC) and Risperdal was held due to drowsiness. 8. Ensure Resident 8's medication regimen, including monitoring and assessment of side effects/adverse reactions to psychotropic medications administered to Resident 8, was coordinated with the facility's nursing/medical staff and the Hospice team caring for Resident 8. 9. Ensure Resident 8's Responsible Party 1 (RP 1) was provided an informed consent by the Prescriber of Ativan, when Ativan was increased from 0.5 mg PRN for agitation, to 1 mg every four hours for agitation, and not by the Hospice case manager or the facility nurses. On 7/22/2024 at 6 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM), Assistant Director of Nursing (ADON) and the Director of Staff Development (DSD) due to the facility administering unnecessary anti-psychotic medications to Resident 1, causing her to be over sedated. On 7/24/2024, the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 7/24/2024 at 1:31 p.m., in the presence of the facility's ADM and DON. The facility's IJPR included the following immediate actions: 1. The Interdisciplinary ([IDT] a group of professionals from different disciplines who work together to achieve a common goal using their different perspectives and expertise) and the hospice agency reviewed Resident 8's medication regimen and care on 7/23/2024 at 10:00 a.m. 2. The DON and ADON in-serviced all licensed nursing staff on 7/22/2024 and 7/23/2024. Any licensed nursing staff currently on leave will receive an in-service prior to the start of their next shift. The in-services included the following: a. Recognition and documentation of Resident 8's COC. b. Implement interventions that call for non-pharmacological interventions versus the use of psychotropic medications that are not indicated for use with residents with dementia-related behaviors. c. Recognizing, monitoring, documenting, and reporting any COC's associated with adverse effects of medication administration. d. Recognizing when psychotropic medications are not indicated for use. e. Recognizing possible duplicate medication therapy and to follow up with nursing administration and/or the resident's physician for clarification. f. Who is responsible for the consent of psychotropic medications. Corrective Actions: 1. The IDT (consisting of the DON, Social Services Director (SSD), Director of Rehabilitation ([DOR] a person qualified to treat disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather by drugs or surgery, who plans, administers, and directs operation of the rehabilitation programs), Dietary Supervisor, Hospice Medical Director, Hospice DON, and Resident 8's family member (FM 1), reviewed Resident 8's medication regimen and care on 7/23/2024 and the residents medications were adjusted. The Seroquel was discontinued on 7/19/2024. The Ativan was changed to 1 mg two times daily PRN. Resident 8 will be seen and evaluated by the psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) on 7/24/2024. 2. The DON and ADM consulted with the Hospice physician on 7/23/2024 and 7/24/2024. Per the physician, in his clinical opinion (and as documented in his clinical note in the resident's chart), Risperdal is justified for the resident at the current dosage, and he has declined to discontinue or lower the dosage of Risperdal. Physician has documented his rationale in the resident's chart. Identification of other Residents: The DON, ADON, and RN Supervisor (RNS) reviewed residents with antipsychotic medications on 7/23/2024. Eleven additional residents with antipsychotic medications were reviewed and none of the residents were identified to have antipsychotic medications prescribed for Dementia or Alzheimer's Disease. Actions Taken to Prevent Reoccurrence: RN Clinical Resource in-serviced the DON and the ADM on 7/22/2024 regarding: a. Recognition and documentation of Resident 8's COC. b. Implement interventions that call for non-pharmacological interventions versus the use of psychotropic medications that are not indicated for use with residents with dementia-related behaviors. c. Recognizing, monitoring, documenting, and reporting any COC's associated with adverse effects of medication administration. d. Recognizing when psychotropic medications are not indicated for use. e. Recognizing possible duplicate medication therapy and to follow up with nursing administration and/or the resident's physician for clarification. f. Who is responsible for the consent of psychotropic medications. The DON and ADON conducted in-services with all licensed nursing staff on 7/22/2024 and 7/23/2024. Any licensed nursing staff currently on leave will receive an equivalent in-service prior to the start of their next shift. The in-services included the following: a. Recognition and documentation of Resident 8's COC. b. Implement interventions that call for non-pharmacological interventions versus the use of psychotropic medications that are not indicated for use with residents with dementia-related behaviors. c. Recognizing, monitoring, documenting, and reporting any COC's associated with adverse effects of medication administration. d. Recognizing when psychotropic medications are not indicated for use. e. Recognizing possible duplicate medication therapy and to follow up with nursing administration and/or the resident's physician for clarification. f. Who is responsible for the consent of psychotropic medications. The DON or designee will review residents with new orders for antipsychotic medications daily (Monday through Friday) to verify the orders are indicated for the residents' diagnoses and behaviors. Monitoring to Ensure Ongoing Compliance: a. The Medical Records Director (MRD) or designee will conduct a review of new orders daily (Monday through Friday) to ensure the informed consent has been obtained from a physician, orders are present for behavior monitoring, side effect monitoring, nonpharmacological interventions if appropriate, and the resident has a care plan in place. Any concerns will be relayed to the DON for follow up daily (Monday-Friday). The MRD was in serviced by the DON on 7/24/2024 regarding this process. b. The DON will report the progress of the monitoring to the Quality Assurance and Performance Improvement ([QAPI] a management approach whose goal is to create, implement, and maintain a program that focuses on systems of care, outcomes of care quality of life, and resident and staff satisfaction) Committee monthly for 6 months or until substantial compliance has been achieved. Completion Date: 7/24/2024 Findings: During a review of Resident 8's admission Record (Face sheet), the Face Sheet indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, vascular dementia with severe agitation, palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), anxiety, mood disorder, and a history of falls. During a review of Resident 8's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 6/21/2024, the MDS indicated Resident 8's cognitive skills for daily decision making were severely impaired and Resident 8 required a one-person substantial/maximal physical assist to complete her activities of daily living ([ADL]) such as dressing, bathing, hygiene, toileting, bed mobility [turning and repositioning] and transferring from chair/bed to chair. During a review of Resident 8's Physician's Order Summary Report (the Physician's Order Summary Report indicated Resident 8 was prescribed the following medications: 1. On 6/14/2024 - Seroquel 50 mg at bedtime for dementia with psychotic features manifested by visual hallucinations of seeing nonexistent dead people. 2. On 6/20/2024 - Risperdal 1 mg twice a day for a mood disorder, manifested by agitation. 3. On 6/14/2024 - Ativan 0.5 mg every four hours as needed (PRN) for agitation and shortness of breath (SOB) for 14 days. 4. On 7/11/2024 - Ativan 1 mg every four hours for agitation and SOB for 14 days. During a review of Resident 8's untitled Care Plan, dated 6/18/2024, the Care Plan (CP) indicated Resident 8 was on an anti-anxiety medication (Ativan). The Care Plan's goals indicated Resident 8 would be free from adverse reactions related to anti-anxiety medications and would have decreased episodes of anxiety. The Care Plan's intervention indicated to administer the anti-anxiety medication, monitor Resident 8 for side effects including drowsiness, lack of energy, clumsiness, dizziness, confusion/disorientation, monitor and record occurrence of target behaviors of agitation and SOB every shift, and provide Resident 8 with non-pharmacological interventions such as redirection, repositioning, offer snacks, assess pain, provide back rubs, provide a quiet environment to express feelings. During a review of Resident 8's untitled Care Plans dated 6/18/2024, the Care Plans indicated Resident 8 was taking anti-psychotic medications ([Risperidone, Seroquel]. The Care Plan's goals indicated Resident 8 would not have any reactions related to the anti-psychotic medication. The Care Plan's interventions indicated to monitor and document Resident 8's episodes of behavior, identify and document Resident 8's adverse reactions/side effects to the anti-psychotic medications, including drowsiness and provide and document non-pharmacological interventions such as redirection, repositioning, offer snacks, assess pain, provide back rubs and a quiet environment. During a review of Resident 8's Medication Administration Record (MAR) dated 6/2024 and 7/2024, the MAR indicated the following: 1. From 6/14/2024 thru 6/30/2024, 7/1/2024 thru 7/11/2024 and 7/17/2024, Resident 8 was administered Seroquel 50 mg at 9 p.m. The MAR from 6/14/2024 thru 7/17/2024 indicated Resident 8's dementia related psychotic features manifested by hallucinations of seeing non-existent dead people, were documented as zero occurrences, and drowsiness and hypotension documented as N (none) on each shift. (7 a.m. to 3 p.m., 3 p.m. to 11 p.m. and 11 a.m. to 7 a.m. shifts). 2. From 6/21/2024 through 6/30/2024, and from 7/1/2024 through 7/17/2024, Resident 8 was administered Risperidone 1 mg twice a day. The MAR dated from 6/21/2024 through 7/17/2024 indicated Resident 8's agitation related to a mood disorder manifested by agitation was documented as zero episodes and side effects related to the anti-psychotic medication including drowsiness and hypotension were documented as N (none) on each shift. 3. On 6/17/2024 at 4:19 p.m., 6/18/2024 at 8:26 p.m., 6/23/2024 at 2:37 a.m., 6/23/2024 at 9:30 a.m., 7/10/2024 at 5:59 p.m., and 7/11/2024 at 4:06 p.m., Ativan 0.5 mg was administered to Resident 8 every four hours for anxiety manifested by agitation and SOB. The MAR dated from 6/17/2024 through 7/17/2024 indicated zero documented occurrences of Resident 8's episodes of anxiety manifested by agitation and SOB and the side effects related to the anti-anxiety medication, including sedation, drowsiness, ataxia (clumsy movements), dizziness, falls and hypotension were documented as N (none) on each shift. 4. The MAR indicated, per Resident 8's Physician's Order, Resident 8 received Ativan 1 mg every four hours as follows: a. On 7/12/2024 at 12 a.m., 4 a.m., 8 a.m., and 8 p.m. b. On 7/13/2024 at 12 a.m., 4 p.m., and 8 p.m. c. On 7/14/2024 at 12 a.m., 4 a.m., 8 a.m., 12 p.m., 4 p.m., and 8 p.m. d. On 7/15/2024 at 12 a.m., 4 a.m., 8 a.m., 12 p.m., 4 p.m., and 8 p.m. e. On 7/16/2024 at 12 a.m., j4 a.m., 8 a.m., 12 p.m., and 8 p.m. d. On 7/17/2024 at 12 a.m., 4 a.m., and 8 a.m. During a review of Resident 8's Clinical Record, the Clinical Record indicated Resident 8 had four fall incidents from 6/15/2024 through 7/13/2024 during the period that Resident 8 was administered Seroquel, Risperdal, and Ativan as follows: 1. During a review of Resident 8's COC form dated 6/15/2024 and timed at 7:20 a.m., the COC form indicated Resident 8 had an unwitnessed fall and was found on the floor inside her room, face down with her head facing the door. During a review of Resident 8's Nursing Home to Hospital Transfer form dated 6/15/2024 and timed at 7:53 a.m., the Nursing Home to Hospital Transfer form indicated Resident 8 was transferred to a General Acute Care Hospital (GACH) on 6/15/2024 at 7:20 a.m. During a review of Resident 8's COC form dated 6/15/2024 and timed at 3:39 p.m., the COC form indicated Resident 8 was readmitted to the facility with a diagnosis of adult concussion (a mild traumatic brain injury that affects the brain function caused by an impact to the head or body). 2. During a review of Resident 8's COC form dated 6/16/2024 and timed at 8:17 a.m., the COC form indicated Resident 8 had a witnessed fall incident where she lowered herself down on the floor by the doorway of her room, was confused, unable to understand instructions, and unable to walk unassisted. 3. During a review of Resident 8's COC form dated 6/20/2024 and timed at 12:33 a.m., the COC form indicated Resident 8 had an unwitnessed fall, where she was found sitting on a floor mat beside her bed. 4. During a review of Resident 8's COC form dated 7/13/2023 and timed at 1:20 a.m., the COC form indicated Resident 8 had an unwitnessed fall and was found lying on the floor between her and her roommate's bed. The COC form indicated Resident 8 sustained a lump on the right area of the back of her head, complained of pain rated 9 to10 (on an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) to the back of her head and her right and left iliac (upper portion of the hip), and was more confused and sleepier than usual. During a review of Resident 8's Nursing Home to Hospital Transfer Form dated 7/13/2024 at 3:53 a.m., the Nursing Home to Hospital Transfer Form indicated Resident 8 was transferred to a GACH for evaluation and treatment due to a hematoma (an area of blood that collects blood outside of the blood vessels often caused by an injury or trauma) on the right upper area of the back of her head. During a review of Resident 8's COC form dated 7/18/2024 and timed at 6 p.m., the COC form indicated Resident 8 was drowsy with a blood pressure of 80/50 millimeters of mercury ([mmHg] blood pressure unit of measurement. The reference range for adult blood pressure 120/80 mmHg]), a decreased level of consciousness ([LOC] a person's awareness and understanding of what is happening in their surroundings), was sleepy and lethargic (a state of fatigue and low energy). During a telephone interview on 7/18/2024 at 4:30 p.m., RP 1 stated the hospice nurse informed him of Resident 8's increased agitation during the previous week (date unknown) and (RP 1) gave his consent to increase Resident 8's Ativan to 1 mg every four hours PRN for agitation. RP 1 stated he visited Resident 8 on 7/17/2024 at 2 p.m., and Resident 8 would not wake up, was snoring and had bouts of congestion and coughing. RP 1 stated Resident 8 attempted to wake up and say something to him (RP 1), but immediately went back to sleep. RP 1 stated he asked LVN 1 if there had been any changes in Resident 8's condition or medication and LVN 1 told him there were no changes. RP 1 stated he was worried that Resident 8 was overmedicated. During an observation 7/18/2024 at 6:12 p.m., with Certified Nursing Assistant (CNA 5), Resident 8 was observed in bed asleep with her mouth wide open, snoring and breathing slow and deep. Resident 8 was did not respond to repeated verbal and tactile (touching) stimuli (anything that causes a reaction or response) when CNA 5 called her name, asked her to open her eyes held and squeezed both of Resident 8's hands. During an interview on 7/18/2024 at 6:16 p.m., CNA 5 stated Resident 8 had been tired and was sleeping a lot since last week (date unknown) and it was hard for Resident 8 to open her eyes and stay awake in order to eat and drink. CNA 5 stated Resident 8 had never been drowsy like this before and despite being forgetful and/agitated at times, Resident 8 had always been able to follow directions and attend activities. CNA 5 stated RP 1 visited Resident 8 on 7/17/2024 at approximately 2 p.m., and he (RP 1) was concerned about Resident 8's drowsiness. CNA 5 stated RP 1 spoke to the charge nurse (LVN 1) about his concerns. During an interview on 7/18/2024 at 6:02 p.m., LVN 4 stated earlier that day (7/18/2024) during her rounds she observed Resident 8 was lethargic and decided not to give the resident Risperidone because she (LVN 4) was concerned that Resident 8 would not be able to swallow the medicine properly. During an interview on 7/19/2024 at 8:30 am., LVN 1 stated he called the Hospice Nurse (HN 1) to verify Resident 8's consent and the order for Ativan 1 mg, however, he did not document it in Resident 8's chart. LVN 1 stated he did not call Resident 8's physician nor did he create a COC when Resident 8 was observed drowsy and lethargic on 7/17/2024 because he was waiting on the HN 1 to initiate a COC. During a telephone interview on 7/19/2024 at 12:01 p.m., HN 1 stated she visited Resident 8 on 7/17/2024 at 9:30 a.m. and observed that Resident 8 was drowsy and unable to wake up despite shaking her up. HN 1 stated she was not informed that Resident 8 had a COC. HN 1 stated she was the one who informed RP 1 that Resident 8's Ativan dosage and administration time was being changed, and she did not know who was responsible to inform RP 1 to obtain an informed consent for new and/or changes to the psychotropic medications. During an interview on 7/19/2024 at 1:36 p.m., RNS 2 stated the licensed nursing staff should monitor the behavior of Residents who take psychotropic medications and the side effects/adverse reactions related to those medications. RNS 2 stated the Hospice Physician should contact the residents and/or their RP to inform them when psychotropic medications were prescribed and/or there are changes to the prescription. During a telephone interview on 7/19/2024 at 4:56 p.m., Resident 8's Hospice Physician stated he prescribed Ativan 1 mg every four hours to Resident 8 because of increased agitation; however, the facility staff must be diligent and monitor Resident 8's response to the medication and call him for any untoward changes in Resident 8's condition. The Hospice Physician stated Resident 8's agitation should be relieved to make her comfortable but not to the point of lethargy. During a telephone interview on 7/22/2024 at 12:58 p.m., LVN 8 stated she gave Resident 8 Ativan 1 mg as ordered (dates unknown), and stated she (LVN 8) was not sure what to assess Resident 8 for prior to administering the Ativan. During a telephone interview on 7/22/2024 at 2:05 p.m., LVN 7 stated he gave Resident 8 Ativan 1 mg as ordered (dates unknown), and did not assess Resident 8 for any side effects or adverse reactions. LVN 7 stated Resident 8 often tried to get out of bed unassisted and was at risk of falling and that was why she was given Ativan. During a telephone interview on 7/22/2024 at 2:52 p.m., LVN 6 stated Resident 8 was on several psychotropic medications and the hospice nurse would usually obtain the consent for the medications from the resident and/or the RP. LVN 6 stated it was the duty of each licensed nurse to verify the order with the physician and to ensure the medication's dose and or/frequency was not over the limit to prevent complications. During an interview on 7/22/2024 at 3:16 p.m., the Assistant Director of Nursing (ADON) stated Resident 8's Hospice Physician should obtain the consents for psychotropic medication from the residents and/or their RP before prescribing the medication and the licensed nurses should verify the order with the physician to ensure the consent was obtained from the resident and/or their RP before psychotropic medication is administered. During an interview and record review on 7/22/2024 at 4:43 p.m., the DON stated the consent for a psychotropic medication should be obtained by the physician prior to administering the medication. The DON stated monitoring should be conducted and documented to ensure accurate information was collected to determine if a gradual dose reduction ([GDR] tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose can be discontinued) of the Resident 8's psychotropic medications were appropriate and if Resident 8 had any side effects and/or adverse reactions associated with the medications. The DON stated the licensed nurses should inform the physician immediately if there is a COC so there is no delay in evaluation and treatment of the resident. The DON stated the care provided by the facility and the Hospice agency must be collaborative to ensure there is no delay in the delivery of care and services. During a review of the facility's Policy and Procedure (P/P) titled, Psychotropic Medications revised 12/2023, the P/P indicated it is the policy of the facility to: a. Ensure that residents are not given any psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. b. Ensure such medications should not be administered for the purpose of discipline or convenience and will be considered only after nonpharmacological interventions have been attempted and failed. c. Ensure efforts will be made by the licensed nurses to verify informed consents from the resident and their responsible party and must be documented in the resident's clinical record before carrying out the physician's orders. d. Ensure the licensed nurses shall review the classification of the drug, the appropriateness of the diagnosis and its indication, behavior monitored and related adverse side effects prior to verification of the admission and such behavior monitoring and/monitoring of adverse side effects shall be documented in the resident records/or physician orders. e. Ensure upon the change of condition or initiation of a new order for psychoactive medications, the facility will obtain consent prior to initiation of the new medication. During a review of the facility's (P/P) titled, Care and Treatment Psychotropic Drug Use revised 8/2017, the P/P indicated the psychotropic medication was prescribed to treat a specific diagnose condition, as documented in the chart: a. Should not be in excessive dose. b. Monitoring for adverse consequences and effectiveness of medications are in place and documented. c. Informed consent was obtained prior to medication use. During a review of the facility's P/P titled, Significant Change of Condition, Response revised 12/2023, the P/P indicated residents of the facility must receive quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing including during a change of condition. The P/P indicated the licensed nurses must perform and document an assessment of the resident and identify the need for additional interventions, considering implementation of existing orders or nursing interventions or through the resident's provider using the SBAR (Situation Background Assessment Recommendation) to obtain new orders or interventions and the licensed nurse shall use his/her clinical judgement to contact the physician based on the urgency of the situation and the resident's representative will be notified on the change of condition and any changes in the resident's medical or nursing care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents, who were assessed as a high risk for falls, had preventative measures implemented to prevent them from falls and injuries for three out of eight sampled residents (Residents 1, 3, and 4). The facility failed to: 1. Implement interventions including landing mats and bed alarm for Resident 1 as care planned Resident 1 had a history of falls on 10/24/2023 and 11/20/2024 and was assessed as a high fall risk. 2. Ensure Licensed Vocational Nurse (LVN 1) had knowledge of Resident 1's high risk for fall, how to access Resident 1' Care Plans, to implement interventions to safeguard Resident 1 from falls and injuries, and knowledge of facility's protocol for falls. 3. Implement bed in the lowest position for Resident 3, who had a history of seizures (brief episodes of involuntary movement which may include a part of the body or the entire body) as care planned. Resident 3 was assessed as a high fall risk. 4. Implement Resident 4's bed in the lowest position. Resident 4 was assessed as a high fall risk. 5. Ensure the facility has a protocol in place for facility staff to identify high fall risk residents and implement resident specific fall prevention measures for the residents who are identified as a high fall risk. 6. Ensure the licensed nurses (LNs) followed the facility's policy and procedure (P&P) titled, Fall Management System, by implementing individualized care plan interventions for residents who were identified as a high fall risk. 7. Ensure the licensed nurses discussed the residents who were at risk for falls at the daily huddle meetings and upon shift report and were responsible for relaying the information to the care team. 8. Ensure the licensed nurses were implementing resident centered Care Plan with interventions based on the resident's fall risk assessment. These failures resulted in: A. Resident 1 falling from the bed to the floor on 3/4/2024, vomiting (an act of throwing up the contents of the stomach through the mouth) and having an altered level of consciousness (a change in a person's state of awareness [ability to relate to self and the environment] and arousal [alertness]) on 3/5/2024. Resident 1 was transferred to a general acute care hospital (GACH) on 3/5/2024 and subsequently admitted to the Intensive Care Unit ([ICU] an area in the hospital which handles severe, potentially life-threatening cases) with diagnoses including with head trauma (any injury to the scalp, skull, or brain caused by injury), abrasion (a superficial rub or wearing off of the skin) to the right forehead, intracranial (within the skull) hemorrhage (bleeding) with thick subdural hematoma ([SDH] a collection of blood between the covering of the brain and the surface of the brain which develops after an injury to the head) over the right cerebral hemisphere (the part of the brain that controls muscle functions and also controls speech, thought, emotions, reading, writing, and learning) secondary to fall. Resident 1 required immediate endotracheal ([ET] placed within the trachea [windpipe]) intubation (a medical procedure in which a tube is placed into the windpipe through the mouth or nose to assist breathing), emergent right temporal (area of the brain located behind the ears) parietal (area of the brain at the top rear of the head) craniotomy (a medical procedure in which a piece of bone from the skull is removed to access the brain for surgical repair) and subdural hematoma evacuation (a surgical procedure which is done to remove a pooling of blood in the brain) with subdural drainage placement due to a high probability of clinically significant, life-threatening deterioration. While in ICU Resident 1 later required a tracheostomy (a surgically created hole in the windpipe which provides an alternative airway for breathing) due to a total dependence on ventilator (a machine used to help a person breathe when they can no longer breathe on their own) for breathing and gastrostomy tube ([GT] a tube which is inserted through the wall of the abdomen directly into the stomach which is used to give medications, fluid, and liquid food to a patient) for nutrition and medication administration. B. Residents 3's and Resident 4's care plans for fall with interventions to prevent falls and injuries were not being resident-centered and not implemented thus placing these residents at risk for injury resulting from a fall. On 3/19/2024 at 2:13 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation caused, or was likely to cause serious injury, harm, impairment, or death to a resident) related to the lack of a system in place to indicate what specific fall prevention measures nursing staff must utilize and implement for the residents who are identified as a high fall risk was called in the presence of the Administrator (ADM) and Assistant Director of Nursing (ADON). On 3/20/2024 at 3:53 p.m., the facility submitted an acceptable IJ removal plan ([IJRP] an intervention to immediately correct the deficient practices). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed on 3/20/2024 at 4:25 p.m., in the presence of the ADM, ADON and Registered Nurse Clinical Resource (RNCR) 1. The IJRP included the following: 1. Resident 1 was transferred to the hospital on 3/12/2024 and has not returned to the facility. 2. Resident 3 was re-evaluated by a licensed nurse on 3/19/2024 and identified to be at high risk for falls. On 3/20/2024, the IDT started reviewing and updating the care plan interventions based on Resident 3's individual risk factors. 3. Resident 4 was re-evaluated by a licensed nurse on 3/19/2024 and identified to be at high risk for falls. On 3/20/2024, the IDT started reviewing and updating care plan interventions based on Resident 4's individual risk factors. 4. On 3/19/2024, the facility IDT implemented a Falling Star Program to communicate high fall risk residents to the facility staff. 5. The Director of Staff Development (DSD), ADON, and RNCR 1 initiated licensed nurses in-services (staff education sessions) regarding the evaluation of residents' fall risk upon admission, readmission, with every fall and as needed. 6. The DSD, ADON, and RNCR 1 initiated all Certified Nursing Assistants (CNAs) in-services regarding the Falling Star Program. 7. The DSD, ADON, and RNCR 1 initiated in-services with all facility staff regarding the updated Fall Management Policy, the Falling Star Program for high risk for fall residents, and the Special Needs List. 8. On 3/19/2024 and 3/20/2024, the ADON, the Minimum Data Set ([MDS] a standardized assessment and care planning tool) Nurse ([MDSN] long-term nurses specializing in assessing the needs of long-term care residents), the Unit Manager (UM), RNCR 1, and the Infection Prevention Nurse (IP) re-evaluated all residents (84 total) for their fall risk and documented this in the Licensed Nurse-Fall Risk Evaluation. These were reviewed by RNCR 1. 32 residents were identified to be at high risk for falls and were added to the Falling Star Program. Their fall risk interventions were added to the Special Needs List for staff reference and this list will be updated daily, Monday through Friday, by the DSD. The Special Needs List will include residents' individual fall interventions and will be available in the nursing stations for reference. 9. On 3/19/2024, the DSD, ADON, RNCR 1 and Therapy Program Manager reviewed and updated the Special Needs List to include all current residents, their fall risk, and fall interventions. This list will be updated daily Monday through Friday by the DSD. The Special Needs List will include residents' individual fall interventions and will be available in the nursing stations for reference. 10. Person centered CPs developed interventions were added to the CPs specific to resident's identified as high fall risk. 11. The Fall Committee (including ADON, Director of Rehabilitation [DOR], DSD, Maintenance Director, Social Services, Activities, and CNA Designee) will review all high-risk residents in the Falling Star Program weekly to ensure their interventions are resident-centered and appropriate. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including epilepsy (a disorder of the brain characterized by repeat seizures, lack of coordination (not able to move different parts of the body together with intention), need for assistance with personal care, unspecified dementia (the impaired ability to remember, think, or make decisions which interfere with doing everyday activities), and hemiplegia (total or partial loss of the ability to move one side of the body) affecting the left nondominant (part of the body which is not used as much) side. During a review of Resident 1's History and Physical (H&P), dated 1/16/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1's cognitive (a person's ability to think, learn, remember, use judgement, and make decisions skills for daily living) skills for daily decision making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff for eating, personal hygiene, toileting, bathing, upper and lower body dressing and rolling left to right in bed. During a review of Resident 1's Fall Risk Evaluation, dated 6/17/2023, the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk. During a review of Resident 1's untitled Care Plan, initiated on 6/17/2023, the Care Plan indicated Resident 1 was identified to be at risk for falls related to left sided weakness, unsteady gait (manner of walking) /balance, generalized muscle weakness, and hypertension (high blood pressure). The Care Plan goal indicated Resident 1 would be free of falls through review date of 3/8/2024. The Care Plan interventions for Resident 1 included to have landing mats (high-impact foam pads which are placed adjacent to the bed on the floor to help reduce the impact of falls and help prevent injury from potential falls) at bedside. During a review of Resident 1's Fall Risk Evaluation dated 10/24/2023 and timed at 9:52 p.m., the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk after sustaining a fall from the bed to the floor on 10/24/2023. During a review of Resident 1's Fall Risk Evaluation dated 11/20/2023, the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk after sustaining a second fall from the bed to the floor on 11/20/2023. During a review of Resident 1's untitled Care Plan dated 11/22/2023, the Care Plan indicated Resident 1 utilizes bed and wheelchair alarm to alert staff and resident when he gets up unassisted. The Care Plan goal indicated Resident 1 will remain free of complications related to alarm use through review date of 3/8/2024. The Care Plan interventions included to apply a sensor pad (a weight sensitive alarm device) as ordered. During a review of Resident 1's quarterly Fall Risk Evaluation dated 12/14/2023, the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk. During a review of Resident 1's readmission Note dated 1/19/2024 and timed at 10:30 p.m., the readmission Note indicated Resident 1 was readmitted from a GACH where he had been transferred to on 1/17/2024 due to syncope (fainting or passing out) during hemodialysis (a mechanical procedure to remove waste products and excess fluid from the blood when the kidneys [a pair of organs which remove waste and extra water from the blood and keep chemicals balanced in the body] stop working). During a review of Resident 1's readmission Fall Risk Evaluation dated 1/13/2024, the Fall Risk Evaluation indicated Resident 1 was assessed as a high fall risk. During a review of Resident 1's Change of Condition ([COC] a document indicating a deterioration or improvement in a resident's physical or behavioral health which may require a modification in the resident's treatment) dated 3/4/2024 and timed at 8:09 p.m., the COC indicated Resident 1 had an unwitnessed fall from the bed to the floor. The COC indicated Resident 1 sustained redness to the right side of his forehead. The COC indicated to initiate neurological check (identifying and assessing the functions of the vital portions of the central nervous system [transmits signals between the brain and the rest of the body which controls the ability to move, breathe, think, and see] functioning) for 72 hours. During a review of Resident 1's COC dated 3/5/2024 and timed at 2:34 a.m., the COC indicated Resident 1 was vomiting and had ALOC. The COC indicated Resident 1 was awake and alert but unable to maintain eye contact or verbalize his needs. During a review of Resident 1's Incident Report (a documentation tool used by emergency medical responders ([EMRs] provide immediate lifesaving care to critical patients who are not in the hospital) to record patient data when arriving on the scene) dated 3/5/2024, the Incident Report indicated Emergency Medical Services ([EMS] a system which provides emergency medical care) were called to the SNF. The Incident Report indicated Resident 1's level of consciousness (being awake and aware of surroundings) was an 11 based on the Glasgow Coma Scale ([GCS] clinical scale used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients which is scored between 3 and 15, with 3 being the worst and 15 the best). The Incident Report indicated Resident 1 was found with an abrasion to the right temple area. On 3/5/2024 Resident 1 was subsequently transported to a GACH due to ALOC and traumatic injury (physical injuries of sudden onset and severity which require immediate medical attention) During a review of Resident 1's GACH admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the GACH on 3/5/2024 under trauma services (a hospital equipped and staffed to provide care for patients suffering from major traumatic injuries such as falls, motor vehicle collisions, or gunshot wounds). During a review of Resident 1's GACH Trauma/Resuscitation Flowsheet dated 3/5/2024 and timed at 3:31 a.m., the Trauma/Resuscitation Flowsheet indicated Resident 1 had an abrasion and a hematoma to the right forehead. During a review of Resident 1's Physician's Emergency Documentation dated 3/5/2024 and timed at 3:42 a.m., the Physician's Emergency Documentation indicated Resident 1 was brought in by EMS from SNF after an unwitnessed fall with evidence of head trauma and activated as a trauma alert. The Physician's Emergency Documentation indicated Resident 1 normally had a GCS of 13 and presented to the GACH with a GCS of 11. The Physician's Emergency Documentation indicated Resident 1 presented in critical condition, with concern for acute decompensation (failure of an organ) and possible cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing and consciousness). During a review of Resident 1's Computed Tomography ([CT] a procedure which uses a computer linked to an x-ray an imaging study which takes pictures of bones and soft tissue] machine to make a series of detailed pictures of areas inside the body) scan dated 3/5/2024 and timed at 4:04 a.m., the CT scan indicated Resident 1 had a 1.7 centimeter ([cm] a measure unit of length) thick acute subdural hematoma over the right cerebral hemisphere and a 1.1 cm midline shift (when the natural centerline of the brain is pushed to the to the right or left following traumatic brain injury associated with a hematoma) from right to left. During a review of Resident 1's GACH Neurosurgery Operative and Procedural Report dated 3/5/2024 and timed at 8 a.m., the Neurosurgery Operative and Procedural Report indicated Resident 1 underwent a right sided frontotemporal (the areas behind the forehead and behind the ears) craniotomy for evacuation of acute subdural hematoma and resection (surgery to remove tissue or part or all of an organ) of membranes (layer which protect the brain), and externalized drain placement (tube which drains excess fluid or blood from the brain and stops the fluid building up). The Neurosurgery Operative and Procedural Report indicated Resident 1 was then transferred to the ICU post-operatively. During a review of Resident 1's GACH Operative and Procedure Report dated 3/13/2024 and timed at 1:16 p.m., the Operative and Procedure Report indicated Resident 1 underwent a GT insertion due to oropharyngeal (the middle part of the throat behind the mouth) dysphagia (difficulty swallowing) and tracheostomy due to acute respiratory failure (not enough oxygen in the body to sustain life) requiring long term mechanical ventilation. During an interview on 3/14/2024 at 4:37 p.m., Registered Nurse (RN 1) stated on 3/4/2024, the Licensed Vocational Nurse (LVN 1) informed her of Resident 1's fall from the bed to the floor. RN 1 stated when she went to assess Resident 1 after the fall, there were no landing mats noted on the floor. RN 1 stated because of Resident 1's high risk for fall and history of previous falls, there should have been landing mats on the floor. During an interview on 3/14/2024 at 5:34 p.m., LVN 1 stated she was assigned to Resident 1 on 3/4/2024. LVN 1 stated at around 8 p.m., she was informed by Certified Nurse Assistant (CNA) 1of Resident 1's fall from the bed to the floor. LVN 1 stated upon arrival to Resident 1's room, she found Resident 1 on the floor. LVN 1 stated Resident 1 was on the bare floor and there were no landing pads underneath him, nor were there any or bed alarm. LVN 1 stated she was not aware of Resident 1's Care Plan and interventions which included bed alarm, and landing mats. LVN 1 stated it was her second day working on the unit and was not aware on how to access residents' Care Plans. LVN 1 stated she was not aware that Resident 1 was a high risk for falls because the outgoing nurse did not report it to her during shift report, and it was not mentioned during the huddle at the beginning of the shift. LVN 1 stated she was not aware of what interventions should be implemented for residents who are a high fall risk. LVN 1 stated she should have looked at Resident 1's Care Plan prior to assuming care of Resident 1 since she was not familiar with the resident. LVN 1 stated the purpose of a Care Plan is to prevent accidents and incidents from occurring or reoccurring. LVN 1 stated she does not know what the facility's protocol for falls and fall prevention. During an interview on 3/14/2024 at 6:22 p.m., CNA 1 stated on 3/4/2024 at around 8 p.m., she was walking by Resident 1's room and saw Resident 1 laying on the bare floor. CNA 1 stated she did not see any landing mats underneath Resident 1, nor did she hear a bed alarm going off. During an interview on 3/15/2024 at 11:45 a.m., Resident 1's Responsible Party (RP 1) stated on 3/4/2024 at approximately 8:52 p.m., she received a call from the SNF indicating Resident 1 had an unwitnessed fall from the bed to the floor. RP 1 stated in the early morning of 3/5/2024 she received a second call from the SNF indicating Resident 1 vomited and had ALOC which required the resident's transfer to the GACH. RP 1 stated this was Resident 1's third fall since 10/2023. RP 1 stated after Resident 1's second fall in 11/2023 she requested a bed alarm, landing mats, two siderails up, and bed bolsters (air filled raised pads placed at the edge of the bed to prevent residents from rolling out of the bed) implemented in Resident 1's care. RP 1 stated in 2/2024, when (Family Member) FM 2 went to visit Resident 1 in the facility, he noticed there was no landing mats, no bed alarm, nor siderails. RP 1 stated she brought this to the facility's attention, but her requested interventions were never implemented. During an interview on 3/16/2024 at 3:16 p.m., CNA 2 stated on 3/4/2024 she was assigned to Resident 1 but did not witness the fall. CNA 2 stated she was not aware that Resident 1 was a high fall risk or what interventions to implement if a resident is a high fall risk. CNA 2 stated Resident 1 did not have landing mats or a bed alarm when she cared for him on 3/4/2024. During an interview on 3/13/2024 at 2:11 p.m., the ADON stated the facility does not currently have a program in place to prevent falls. The ADON stated the facility does not use special identifiers in the resident's room to identify those residents who are a high risk for falls. The ADON stated the facility has a Special Needs binder located at each nursing station which identifies the residents who are a high fall risk with interventions to prevent the residents from falls. The ADON stated the licensed nurses are responsible for knowing the resident's fall risk assessment and Care Plan interventions while caring for the resident. The ADON stated the licensed nurses should discuss the residents who are at risk for falls at the daily huddle meetings and upon shift report and are responsible for relaying the information to the care team. The ADON stated the licensed nurses are responsible for implementing resident's centered Care Plan with interventions based on the fall risk assessment. During an interview on 3/13/2024 at 3:36 p.m., CNA 4 stated she does not know how to identify residents who are assessed at high risk for falls other than asking the licensed nurses. CNA 4 stated residents who are a high fall risk are not mentioned during the huddle meetings. During an interview on 3/18/2024 at 3:38 p.m., LVN 2 stated the MDSN reviews and updates the care plans as needed. LVN 2 stated she can input information on the CPs if the resident has a change of condition but does not have time to review each resident's individual CP prior to caring for the resident because of all the other tasks she must complete throughout her shift. LVN 2 stated the purpose of a CP is to help the care team provide care for each resident individually and help prevent incidents and accidents from occurring and reoccurring. LVN 2 stated if we do not review the CPs then we (licensed nurses) do not know what interventions need to be implemented for each resident and communicated to the care team. LVN 2 stated she was not aware of the facility's fall protocol. B. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including history of seizures, hemiplegia and hemiparesis affecting right dominant side, lack of coordination, and muscle weakness. During a review of Resident 3's H&P, dated 2/29/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was sometimes understood and sometimes was able to understand others. The MDS indicated Resident 3 had severe impairment in cognitive skills for daily decision making. The MDS indicated Resident 3 was totally dependent on staff for toileting, showering, lower body dressing, sitting to lying, lying to sitting on the side of the bed, chair/bed to chair transfer, and toilet transfer. The MDS indicated Resident 3 required substantial/maximal assistance from staff for oral hygiene, upper body dressing, personal hygiene, and rolling left to right in bed. The MDS indicated Resident 3 had bilateral (both sides) upper body impairment and lower extremity impairment on one side. During a review of Resident 3's readmission Note dated 1/25/2024 and timed at 11:59 p.m., the readmission Note indicated Resident 3 was readmitted to the SNF from a GACH (where he had been transferred to on 1/20/2024 due to seizures.) During a review of Resident 3's readmission Fall Risk Evaluation, dated 1/25/2024, the Fall Risk Evaluation indicated Resident 3 was assessed as a high fall risk. During a review of Resident 3's untitled Care Plan, dated 3/1/2024, the Care Plan indicated Resident 3 had a risk for falls related to generalized muscle weakness, unsteady gait/balance, and seizure disorder. The Care Plan goal indicated Resident 3 would be free from falls through the target date of 4/25/2024. The Care Plan interventions included bed in lowest position. During a concurrent observation and interview on 3/18/2024 at 4:09 p.m., with CNA 5, in Resident 3's room, Resident 3 was observed lying in bed. CNA 5 stated the only way she identifies the residents at high fall risk if the residents' beds are low. CNA 5 stated Resident 3 was not a fall risk because the bed was not at the lowest position. During a review of Nursing Station 1's Special Needs Binder on 3/18/2024, Resident 3 was not found on the Special Needs List as a high risk for falls. C. During a review of Resident 4's Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis affecting right dominant side, aphasia (inability to communicate with others), functional quadriplegia (complete immobility due to severe physical disability or frailty), vascular (affecting blood vessels) dementia, muscle weakness, and abnormal posture. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was sometimes understood and was sometimes able to understand others. The MDS indicated Resident 4's cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 4 had functional impairment in one upper extremity and had bilateral functional impairment in both lower extremities. The MDS indicated Resident 4 was totally dependent on staff for toileting, bathing, lower body dressing, sit to lying, sit to stand and chair/bed to chair transfers. The MDS indicated Resident 4 required substantial/maximum assistance from staff for rolling left to right in bed, upper body dressing, personal hygiene, and required supervision from staff for eating. The MDS indicated Resident 4 was incontinent of urine and stool. The MDS indicated Resident 4 used a wheelchair for mobility. During a review of Resident 4's untitled Care Plan dated 5/3/2023, the Care Plan indicated Resident 4 was at risk for falls related to functional quadriplegia, dementia, and incontinence. The Care Plan goal indicated Resident 4 would be free from falls though the review date of 3/7/2024. The CPs interventions included bed in lowest position and follow facility fall protocol (no specific person-centered fall interventions were documented on the Care Plan.) During a review of Resident 4's quarterly Fall Risk Evaluations dated 10/6/2023, and 1/18/2024 the Fall Risk Evaluations indicated Resident 4 was assessed as a high fall risk. During a concurrent observation and interview with CNA 5 on 3/18/2024 at 3:09 p.m., in Resident 4's room, Resident 4 was observed lying in bed watching TV. Resident 4's bed was observed to be not in lowest position. CNA 5 stated Resident 4's bed was not in the lowest position. CNA 5 stated Resident 4 did not require landing mats because she was not a high fall risk (CNA 5 was not aware Resident 4 was a high fall risk). During a review of Nursing Station 1's Special Needs List on 3/18/2024, the Special Needs List indicated Resident 4's special needs (fall precaution interventions) included bed at the lowest position for safety and bilateral landing pads on the side of the bed for safety while Resident 4 was in bed. During an interview on 3/19/2024 at 11:06 a.m., LVN 3 stated the only way she knows to check if a resident is a high fall risk is by checking the Special Needs Binder at each nursing station. LVN 3 stated if a resident is not listed on the Special Needs Binder, then they must not be a high risk for falls. LVN 3 stated she does not know what interventions are to be put in place for a resident based on the level of the fall risk (low, medium, high). LVN 3 stated she was not aware of the facility's fall protocol. During an interview on 3/19/2024 at 12:33 p.m., the DSD stated the licensed nurses should verbally communicate with each other about the residents who are a fall risk and what interventions should be implemented, during the change of shift and during the huddle. The DSD stated the licensed nurses can also refer to the Special Needs Binder at each nursing station to help them identify which level of fall risk each resident is and what interventions are required. The DSD stated the facility staff is responsible for updating the Special Needs Binder as needed. During an interview on 3/19/2024 at 1:36 p.m., the ADON stated there is a systemic problem regarding communication between the care team about the residents who are a high risk for falls, what Care Plan interventions are to be implemented based on their needs and implementing their Care Plan interventions for each resident. The ADON stated we educate the staff on how to identify those residents who are a high fall risk and what Care Plan interventions need to be implemented based on their needs, but it is up to the staff to follow through and apply the interventions to the residents. During a review of the facility's LVN Job Description dated 12/17/2021, the LVN Job Description indicated essential duties of the LVN include examining the resident and his/her records and charts, implementing, and maintaining established policies and procedures, and assist in the development of preliminary and comprehensive assessments of the nursing needs of each resident are performed in furtherance of the resident care planning policy. During a review of the facility's ADON Job Description dated 12/17/2021, the ADON Job Description indicated the essential duties of the ADON include assisting in the development of preliminary and comprehensive assessments of the nursing needs of each resident are performed in furtherance of the resident care planning policy. During a review of the facility's P&P titled, Fall Management System, revised 12/2023, the P&P indicated it is the policy of this facility to provide an environment that remains as free from accident hazards as possible. The P&P indicated it is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The P&P indicated residents with high risk factors identified on the Fall Risk Evaluation will have an individualized Care Plan developed that includes measurable objectives and timeframes. The P&P indicated the Care Plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk. During a review of the facility's P&P titled, Comprehensive Person-Centered Care Planning, revised 12/2023, the P&P indicated it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered (to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives) Care Plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.