**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure licensed nurses provided neurological assessments after an unwitnessed fall and failed to ensure licensed nurses notified a physician of changes in condition post-fall per professional standards of practice for post fall monitoring for 1 of 8 residents reviewed for falls, of a total sample of 13 residents, (#4). On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found her notified assigned Registered Nurse (RN) H. Assigned night shift RN H documented in the medical record a brief Event Note that resident #4 was assessed as having no injuries, no change in range of motion and was to have continued monitoring. There was no documentation in the medical record of neurological assessments having been initiated or performed, nor of the physician or family being notified after the fall. The next day, at the end of her night shift on [DATE] at 7:55 AM, RN F documented resident #4's CNA had stated she was not herself, had a headache and was alert, but confused. RN F did not document any notification to the physician regarding a change in condition, nor did she document any neurological assessments or other post fall monitoring of resident #4. Later that day, [DATE] at 6:29 PM, assigned Licensed Practical Nurse (LPN) G documented in the medical record that resident #4 was pronounced deceased at around 6:00 PM after she was notified the resident did not look well by the CNA. LPN G did not document any post fall monitoring or neurological assessments of resident #4, nor did she document notification of a change in condition to the physician or the family until after resident #4 was pronounced deceased . The facility's failure to initiate and document a post fall assessment including neurological checks after an unwitnessed fall and the facility's failure to notify the physician of resident #4's change in condition in a timely manner, resulted in Immediate Jeopardy. There was likelihood resident #4 experienced anxiety and distress in the hours before her death. This failure resulted in Immediate Jeopardy starting on [DATE] and as of the exit date of [DATE], the Immediate Jeopardy was ongoing. Findings: Cross reference to F600, F607, F689, F726, F835 and F842 Review of the Lippincott's Neurologic assessment, long-term care dated [DATE] and referenced by the facility Policy and Procedure revealed, A neurological assessment is an indispensable tool for quickly evaluating a resident's neurological status, and supplements the routine vital signs as those alone rarely indicate neurologic compromise. The document indicated a focused neurologic assessment is necessary if a resident may have sustained a head injury after a fall, or if they receive an anti-coagulant which increased the risk of bleeding. The document described the need for the nurse to immediately notify the physician if a previously stable resident suddenly developed a change in neurologic status or vital signs as this change may be one of the earliest indicators of increasing pressure inside the head due to bleeding. Resident #4 was an [AGE] year-old, admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, type 2 diabetes mellitus, chronic kidney disease, chronic lung disease, and heart failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had clear speech, was usually understood and usually understood others, but had impaired vision. The MDS indicated resident #4 had a Brief Interview for Mental Status score of 14 out of 15 which indicated she was cognitively intact, and had no behaviors towards others or herself during the lookback period. The MDS assessment section G showed resident #4 needed extensive physical assistance from one staff for bed mobility and was totally dependent on at least two staff for transfers from surface to surface. Resident #4 did not walk during the lookback period but was able to eat with set up and supervision assistance. The assessment indicated resident #4 had no falls since the prior assessment, nor any skin impairments. Review of the Order Summary Report dated [DATE] revealed resident #4 had physician orders to not be hospitalized dated [DATE] and do not resuscitate (DNR) dated [DATE]. She also had physician orders for 2 liters per minute of oxygen via nasal cannula, and for 81 milligrams of Aspirin daily related to heart disease. Aspirin is a type of medication called a blood thinner often used to prevent heart attacks and strokes by preventing a type of blood cell called platelets from clumping together to form a clot. The most common side effect of this medication is bleeding, so you should go to the hospital or call your doctor if you fell and might have hit your head, because you may have bleeding internally that you can't see (retrieved on [DATE] from the National Institutes of Health, Medline Plus website at www.medlineplus.gov). Resident #4 had a care plan for risk for falls initiated [DATE] related to impaired mobility, psychotropic and diabetic medications, history of falls, and use of anti-thrombotic medications which can put a resident at risk for bleeding. Interventions included frequent checks on resident during the day, observe for signs or symptoms of unstable blood sugar, and report to the physician any side effects associated with medication use. A care plan for actual fall with no injury was initiated on [DATE] related to poor balance and unsteady gait with intervention for frequent checks. None of the interventions mentioned any post fall monitoring or post fall care. An additional care plan for risk for abnormal bruising, bleeding or hemorrhage related to antithrombotic medication use initiated on [DATE] noted goal was for the resident to be free of abnormal bleeding. Interventions included staff to observe for sudden changes in mental status and/or vital signs and to report to the physician any signs or symptoms. The care plan did not include any interventions related to falls in regard to the antithrombotic medication. Review of an event note dated [DATE] revealed resident #4 was found on the floor next to her bed. The nurse documented assessments were performed including a neurological assessment which was at baseline. Resident #4 complained of pain to her legs and had an abrasion and raised area to the right lower leg. The nurse documented the Advanced Practice Registered Nurse (APRN) was notified, and gave order to do a chest x-ray immediately. She noted the resident's son was apprised of the situation and neurological checks were continued. Review of the medical record revealed a Neurological Check form dated [DATE] completed for 72 hours. Vital signs, papillary response, hand and leg strength were documented over 3 days. Review of another event note dated [DATE] at 12:15 AM, revealed Registered Nurse (RN) H documented resident #4 was observed sitting on the floor close to her bed. RN H described no injury was noted, and there was no change in range of motion, but she would continue to monitor the resident. There was no documentation in the medical record by RN H of any post-fall assessments of resident #4. RN H did not document vital signs at that time, nor was there any documentation that she notified the physician or the family of resident #4. No record of neurological assessments was found in the medical record after resident #4's fall on [DATE]. The next morning, [DATE] RN F documented a progress note at 7:55 AM, which revealed the CNA notified her resident #4, Was not looking her usual self, she complained of a headache and was alert, but confused. RN F documented she offered resident #4 pain medications which she refused. RN F documented that resident #4 took all her ordered medications, had no signs or symptoms of low or high blood sugar, and was in bed with her call light within reach. The medical record did not contain any documentation of neurological assessments being performed or of notification to the physician or resident representative due to resident #4's change in condition. Review of the Progress Notes revealed an Administration Note dated [DATE] at 10:50 AM by LPN G. LPN G documented, C/O (complained of) chest pain. NP (Nurse Practitioner) aware. No interventions were documented regarding the complaint of chest pain, or for any orders given by the provider. The next progress note later that day on [DATE] at 6:29 PM, by LPN G documented she was told at the beginning of her shift by the off going nurse (RN F), that resident #4 was not well. LPN G detailed in her note that at 9:45 AM, the resident complained of not feeling well. She described resident #4's vital signs being taken, with a blood pressure of 111/43 (mmHg) and a heart rate of 45 beats per minute but did not detail at what time these were taken. She documented she notified the Advanced Practice Registered Nurse (APRN), and that she was unable to reach resident #4's son but did not note the time this was done. LPN G did not document any orders given, any post fall neurological assessments, or any interventions attempted on resident #4. Finally she wrote in the same note at 5:58 PM the CNA notified her the resident was not looking well, and on arrival into resident #4's room she noticed her lips were pale, so she notified the APRN and the Unit Manager (UM). She documented resident #4 was pronounced dead by the APRN a few minutes later at approximately 6:00 PM, and her son was notified shortly afterward. No documentation was found in the medical record from the physician or the APRN concerning resident #4's declining condition, chest pain or vital signs nor any interventions or orders placed by the doctor concerning this decline. In a telephone interview on [DATE] at 3:28 PM, RN F stated she recalled being resident #4's nurse the night before she died on [DATE]. She stated she didn't know the resident well as she did not work regularly on that unit. She explained that when the CNA notified her that resident #4 did not look herself that night shift, she assumed she might be having trouble with her blood sugar. RN F stated she did not know resident #4 had fallen the night before and had therefore not done any neurological assessments. She explained no one told her in shift report that resident #4 had an unwitnessed fall that morning. RN F stated she was worried about resident #4 during her shift and did not want to leave that morning without the next shift knowing her concerns regarding resident #4's blood sugar. She admitted to being unaware resident #4 had fallen until the conversation with the surveyor. RN F stated if she had known resident #4 had fallen, she would have done neurological assessments as per protocol and she would have called the physician about her change in condition to see if they wanted to send her to the hospital. She said neurological assessments were done for 72 hours, usually on paper when there was an unwitnessed fall and the information passed on to the next shift. She explained if staff were aware of resident #4's fall, her change in mental status would have been identified during the neurological assessments. In a telephone interview on [DATE] at 4:13 PM, resident #4's son was adamant he was not told his mother had fallen the day before she died. He explained he had visited his mother the day before she died, and she was her normal self. She was fine and in good spirits he recalled. Resident #4's son stated the next day someone called him from a personal phone, not the facility number and because he was busy at work he let it go to voicemail. He said later he got a call in the early evening that his mother had passed. He explained his mother had kidney failure and was told by her doctor she needed dialysis so they decided not to resuscitate and not to hospitalize as they did not want to put her through dialysis. Resident #4's son said he would have wanted his mother to get treatment for any injuries due to a fall or something like that, just not for her chronic diseases. He said he was not informed she had fallen the day before she died. In a telephone interview on [DATE] at 12:45 PM, the assigned night shift CNA D recalled resident #4 as a feisty lady who she knew well. She stated she helped the nurse assist resident #4 back to bed after she had fallen on the morning of [DATE] and she seemed okay. CNA D described the end of her shift that morning around 7:00AM, resident #4 asked her for a hug when she was leaving which she thought was unusual. She stated she was surprised when she learned resident #4 had died later that day. In a telephone interview on [DATE] at 3:51 PM, LPN G stated she worked day shift on [DATE] and remembered resident #4's death in the facility. LPN G recalled earlier in the day, resident #4 had begged her to not to leave her alone, because she didn't want to be by herself, which was not her normal behavior. LPN G stated a CNA notified her of resident #4's condition that afternoon and when she went to her room she was not able to obtain vital signs. She notified the UM and the APRN, who arrived a short while later and pronounced her dead. She stated she did not find out that resident #4 had fallen on [DATE] until after her death on [DATE]. LPN G said she thought she was told in report that morning that resident #4 was actively dying but said she did not call her physician and stated she was not able to reach her son until the end of the day to notify them. When asked if there were any interventions in place, she explained resident #4 was a Do Not Resuscitate and Do Not Hospitalize so she did not think any interventions were called for. She recalled taking resident #4's vital signs and notifying the APRN who was at the facility that day but did not document any orders or interventions that were in place from the provider. She stated she could not recall if they were doing anything for resident #4. LPN G stated she recalled the APRN coming to look at resident #4 at some point after notifying her of resident #4's vital signs and even though they could not reach resident #4's son, she could not recall if they provided any interventions for resident #4's condition. In a telephone interview on [DATE] at 4:06 PM, the APRN who worked under resident #4's primary physician stated she recalled resident #4's passing. The APRN recalled she saw resident #4 earlier in the day as she made her rounds but did not remember the nurse notifying her of anything abnormal. The APRN stated no one had told her resident #4 had fallen the day before, so when the nurse called later in the day to tell her resident #4 was not doing well, she figured it was due to her chronic kidney condition and did not order any interventions other than try to reach out to her son and make the UM aware of what was going on. The provider stated had she known resident #4 had an unwitnessed fall the day before, she would have given the family the option to send her to the hospital for her change in condition. She stated the nurses should have notified her or the physician on duty that she had fallen, and she in turn would have contacted the doctor of her concerns that day. In a telephone interview with RN H on [DATE] at 9:24 AM, she recalled she worked the night shift on [DATE] when she was notified by the CNA in the early morning of [DATE] that resident #4 was found on the floor by her bed. RN H remembered she did not find any injuries on resident #4 after her fall, but her blood pressure was unusually high. She stated resident #4 refused the staff to take her vital signs after that, but she could not recall notifying the physician or documenting the refusal. RN H stated nurses were supposed to do neurological assessments on all residents who fell for 72 hours, both on paper and in the computer but could not say why no neurological assessments were documented in resident #4's medical record. RN H did not explain why there was no documentation in the medical record of contacting the physician or the family about resident #4's fall. In an interview on [DATE] at 11:45 AM, the A wing UM Manager stated neurological assessments should be documented on paper by the nurse for 72 hours after a fall. She said the neurological assessment was done to check in case there was bleeding in the brain after a fall. The A wing UM said the nurse would immediately notify the physician if a resident complained of a headache or had confusion like resident #4 did after a fall. She indicated the nurse should assess the resident who fell, start the neurological assessments, notify the physician and the family and document in the medical record. The A wing UM stated an order for Do Not Hospitalize did not mean that a resident would not get care for an acute injury such as from a fall. The A wing UM recalled on the day resident #4 died, by the time she found out she wasn't feeling well, the APRN was here at the end of the shift around 6:00 PM. She said she was surprised to hear she had died, and neither she nor the APRN were aware at the time that resident #4 had a fall the previous day. She recalled the APRN looked shocked when she saw resident #4 in her bed, moments before her death, breathing shallowly and said she had tried to call the son, but he had not picked up. The 200 UM indicated she thought the APRN just assumed it was part of her disease process, because no one had told her she may have hit her head when she fell. On [DATE] at 3:06 PM, agency LPN A stated she did not get any education or direction on what the facility expected her to do after a resident fell. She stated the process at some facilities was to contact the physician and the Director of Nursing (DON), but she was not sure what this facility expected her to do or what their policies included. In interviews on [DATE] at 3:39 PM and [DATE] at 11:08 AM, the DON stated her expectation was nurses would document a note that explained what happened, what interventions were done, the outcome of their assessments as well as notification of the physician and the family after a fall. She said after an unwitnessed fall, aggressive neurological assessments should be implemented and acknowledged resident #4 displayed signs and symptoms of a brain bleed in the time before she died that facility nurses should have recognized. The DON explained a DNR or Do Not Hospitalize did not mean you would not provide care to a resident if they were acutely ill. She said it was a significant concern that nurses did not recognize the signs of a brain bleed and contact the physician and family to provide further orders for care. The DON confirmed neurological assessments should have been done after resident #4's unwitnessed fall on [DATE] and acknowledged they had no documentation that nurses performed those assessments nor was there documentation that they notified the physician of resident #4's change in condition. She confirmed there was no note from the physician or APRN nor documentation from the nurse that resident #4 was assessed by a provider prior to her death on [DATE]. Review of the policy, Changes in Resident's Condition or Status with review date [DATE] revealed the facility would notify the physician and resident's representative of changes in the resident's condition or status. The facility must immediately consult with the resident's physician and notify the resident representative when there is an accident which results in injury and has the potential to require physician intervention or if there is a significant change in the resident's health such as a deterioration or clinical complication. Review of the undated facility Fall management, long-term care procedures noted falls in long term care facilities are a major cause of injury and death. The document described procedures for staff to take pre and post fall of a resident including to determine if the resident suffered any head trauma which would require further diagnostic evaluation to rule out a brain bleed. Further direction included staff to look at the medical history to determine whether the resident is at risk for a bleed to the brain due to medications such as anti-coagulants if so to monitor accordingly. Also, for nurses to monitor neurologic status per facility practice and to notify the physician if they noted any changes from baseline. Review of the Neurological Assessment policy dated [DATE] revealed the neurological assessment should be initiated in the electronic medical record when indicated such as head injury, post fall or neurological decompensation. The procedure included the nurse to immediately notify the physician of any pertinent changes in the resident's neurological status and any interventions taken should be noted in the nurses' notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure licensed and agency nurses were knowledgeable and competent in initiating and performing neurological assessments after an unwitnessed fall, and in notifying the physician and oncoming staff of a resident's fall and changes in condition for 1 of 8 residents reviewed for falls of a total sample of 13 residents, (#4). On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found resident #4 notified assigned Registered Nurse (RN) H of resident #4's fall. Assigned night shift RN H documented in the medical record a brief Event Note that resident #4 was assessed as having no injury, no change in range of motion and for continued monitoring, although there was no documentation that specified what monitoring was to be continued. There was no documentation in the medical record of neurological assessments having been initiated or performed, nor of the physician or family being contacted after the fall. The next day on [DATE] at 7:55 AM, RN F documented she was alerted by the CNA that resident #4 was not herself, had a headache and was alert, but confused. RN F also did not document any notification to the physician regarding a change in condition, nor did she document any neurological assessments or other post fall monitoring of resident #4. Later that day, [DATE] at 6:29 PM, assigned Licensed Practical Nurse (LPN) G documented in the medical record that resident #4 was pronounced deceased at approximately 6:00 PM after she was notified by a CNA the resident did not look well. LPN G had not documented any post fall monitoring or neurological assessments of resident #4, nor did she document notification of a change in condition to the physician or the family prior to resident #4's death. The facility's failure to ensure licensed nurses demonstrated competency in post fall care including neurological checks after an unwitnessed fall per recognized standards of practice, as well as competency to recognize, notify and document a change in condition in a timely manner resulted in Immediate Jeopardy. While resident #4's blood pressure increased, her pulse slowed until it ceased, there was likelihood she experienced severe anxiety and distress before her death. Findings: Cross reference to F684, F600, F607, F689, F835 and F842 Resident #4 was an [AGE] year-old, admitted to the facility on [DATE] for long term care. Her diagnoses included chronic lung disease, kidney disease, type 2 diabetes, heart failure, Parkinson's disease, and dementia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had clear speech, but impaired vision. The MDS indicated resident #4 had a Brief Interview for Mental Status score of 14 out of 15 that indicated she was cognitively intact. She had no behaviors towards herself or others during the lookback period and had no falls since the previous assessment. Review of the Order Summary Report dated [DATE] revealed resident #4 had physician orders to not be hospitalized dated [DATE] and not to be resuscitated dated [DATE]. She also had physician orders for 2 liters per minute of oxygen via nasal cannula, and for 81 milligrams of Aspirin daily related to heart disease. Aspirin is a type of medication called a blood thinner often used to prevent heart attacks and strokes by preventing a type of blood cell called platelets from clumping together to form a clot. The most common side effect of blood thinners is bleeding. To stay safe while taking a blood thinner, you should call your doctor and/or go to the hospital immediately if you fall or hit your head, even if you are not bleeding because you may have bleeding on the inside of your skull you cannot see (retrieved on [DATE] the National Institutes of Health, Medline Plus website from www.medlineplus.gov). An event note dated [DATE] at 12:15 AM, by assigned night shift RN H documented resident #4 was observed sitting on the floor close to her bed. RN H described that no injury was noted, and there was no change in resident's range of motion, but she would continue to monitor. There was no documentation in the medical record by RN H of pain assessments, neurological assessments or any other assessments of resident #4 post fall. RN H did not document notification of the physician and their response nor did she document notification of the family of resident #4. No record of neurological checks/assessments was found in the medical record pertaining to resident #4's fall on [DATE]. The next day, [DATE] at 7:55 AM, assigned night shift RN F documented resident #4 was alert and confused. RN F detailed that the CNA notified her resident #4, Was not looking her usual self, and complained of a headache. RN F documented she offered resident #4 pain medications which she refused. RN F detailed that resident #4 took all of her ordered medications, and had no signs or symptoms of low or high blood sugar, and was in bed with her call light within reach. RN F did not document neurological assessments being performed post unwitnessed fall, nor did she document any notification to the physician due to a change in condition post fall for resident #4 after she was notified by the CNA of resident #4's condition. Later that same day, on [DATE] at 6:29 PM, LPN G documented she was told at the beginning of her shift by the off going nurse (RN F), that resident #4 was not well, but did not specify what not well meant. LPN G continued in her note that at 9:45 AM, the resident complained of not feeling well. LPN G described resident #4's vital signs being taken, with a blood pressure of 111/43 and a heart rate of 45, but she did not give what time the vital signs were taken. She documented she notified the Advanced Practice Registered Nurse (APRN), but that she was unable to reach resident #4's son, and again did not specify when this occurred as she did not document this until after the fact in a late entry. LPN G did not document any orders given by the provider, any post fall neurological assessments, or any interventions attempted on resident #4 until she wrote in the same note at 5:58 PM the CNA again notified her the resident was not looking well. LPN G then wrote that on arrival into resident #4's room, she noticed her lips were pale, so she notified the APRN and the Unit Manager (UM). She continued that resident #4 was pronounced dead by the APRN a few minutes later at approximately 6:00 PM, and her son was notified shortly afterward. No documentation was found in the medical record from the physician or the APRN nor the nurse concerning resident #4's declining condition and vital signs nor any interventions or orders placed by the doctor concerning this decline. A telephone interview with the APRN on [DATE] at 4:06 PM, revealed although she had seen resident #4 during her rounds in the facility on [DATE], she was not notified by assigned LPN G or other nursing staff that resident #4 had anything abnormal going on. She recalled later in the day, the nurse called to tell her resident #4 was not doing well, so she went to see her and reached out to her son and the UM to let them know what was going on. She stated no one told her resident #4 had fallen the previous morning. She explained if she had known resident #4 had an unwitnessed fall the day preceding the decline, she would have called the family to send her to the hospital. She would've given them that option she said. In an interview on [DATE] at 11:45 AM, the UM stated she did not know, nor had been notified resident #4 had fallen the previous morning before she was notified of her decline around 6:00 PM. She could not say why resident #4 had not had neurological assessments documented after her fall on [DATE]. She explained if a resident had an unwitnessed fall the nurse was supposed to initiate neurological assessments for 72 hours and document on paper, but said some nurses were not doing what they were supposed to do. The UM confirmed the APRN was also not aware resident #4 had an unwitnessed fall the day before and was unaware her condition may not be part of her disease process; therefore, no interventions were ordered. On [DATE] at 3:06 PM, agency LPN A stated she did not get any education or direction on what the facility expected her to do after a resident fell. She stated some facilities expected a call to the physician and the Director of Nursing (DON) after a fall. She explained she was not sure what this facility expected her to do or what their policies included, where to find the information, nor what documentation they expected. In a telephone interview on [DATE] at 3:28 PM, night shift RN F confirmed she was assigned resident #4 on [DATE] from 11:00 PM to 7:00 AM. She stated she did not receive report that resident #4 had an unwitnessed fall that morning, nor was she told that neurological assessments were being performed. She explained she would have received the neurological assessment form to document they were being done as they were usually done for 3 days after a fall. RN F stated had she been doing neurological assessments on resident #4 per fall protocols and standard of care, she would have immediately notified the physician when resident #4 complained of a headache and was not acting herself during her shift for further orders, but since they were not being done she did not recognize the change in resident #4's mental status as something she needed to notify the physician. In an interview on [DATE] at 3:17 PM, the Staff Development Coordinator (SDC) stated nursing staff had two days of general orientation in which they addressed policies and all mandated topics online. The third day consisted of modules online that included topics like head-to-toe assessment, but was unsure whether documentation requirements, change in condition and post fall care was included in the education. The SDC described that newly hired nurses were then precepted by an experienced nurse and had a competency packet they completed together. The SDC was asked to describe the company's procedures and protocols for post fall care, but she was unsure whether there was a specific facility protocol or procedure for post fall care and was only able to give her own nursing knowledge about what interventions should be done. The SDC was unsure whether there was any specific education completed by nurses on post-fall care but said there was a section in the head to toe assessment module for neurologic assessments. The SDC provided RN H's education history, which included introduction to documentation for nurses and neurological assessment within the head-to-toe assessment module, but her file did not include any education on recognizing and notifying the physician of changes in condition nor of any post fall care or procedures. Review of the 2023 Staff Education Calendar revealed no topics covered for change in condition, falls or post fall care in the yearly education subject matter. In interviews on [DATE] at approximately 1:30 PM, and [DATE] at 11:08 AM, the DON and Assistant Director of Nursing (ADON) confirmed the Risk Management Incident Reports were not part of a resident's medical record. The DON explained nurses were expected to document a Nurse's Note and the UM and ADON were supposed to follow up to ensure the note was completed after a fall. She detailed the contents of the Nurse's note should include what happened, any interventions any injuries, the outcome of the assessment and notification to the physician and family. The DON and ADON confirmed RN H did not document in the medical record that the physician or family were notified, nor that neurological assessments including vital signs were performed. They stated in her witness statement RN H wrote resident #4 refused medications, blood sugar checks and vital signs, but did not mention or document if she had notified the physician of the refusals per protocol. The DON and ADON were asked to provide the facility's protocol/procedure for post-fall care, including any education given to nurses for post-fall care protocol, but could not say whether there were written procedures or education for the nursing staff. On [DATE] the DON was asked again to provide completed education for RN H on change in condition, falls or post-fall interventions. At 3:52 PM, the DON stated she was unable to find any education for RN H for these topics. In a telephone interview on [DATE] at 9:24 AM, night shift RN H stated she was assigned to resident #4 the night she fell on [DATE]. She recalled resident #4 did not appear to have any injuries and although she knew neurological assessments were to be done for 72 hours after a fall, she could not explain why she had not documented them after resident #4's unwitnessed fall that night. RN H did not explain why there was no documentation that she notified the physician and family in the medical record. RN H explained that resident #4 had refused further vital signs and checks after the initial set but could not explain why she had not notified the physician of resident #4's refusals nor why she did not document any of resident #4's refusals per protocol. RN H did not know of a specific facility procedure or protocol they were to follow after a resident fell at that time, but she said she received education on post fall procedures including neurological assessments yesterday, [DATE] when she came to work. Review of the Neurological Assessment policy and procedure with review date of [DATE], revealed a neurological assessment should be initiated in the electronic medical record by physician's order or when indicated after a fall. The procedure described the nurse initiating the check list and completing it as indicated, then signing each entry. The procedure included direction for the nurse to document and report any pertinent changes in the resident's neurological status immediately to the physician along with any resulting interventions taken as a result of the assessment. The document specified the Neurological check list should remain a permanent part of the resident's medical record. The Changes in Resident's Condition or Status policy with review date of [DATE] revealed the facility would notify the resident, primary physician and resident representative of changes in the resident's condition or status. The policy read the facility must immediately consult with the resident's physician when there was an accident involving the resident which resulted in injury and had the potential to need physician intervention or a deterioration in health in either life threatening conditions or clinical complications. The Fall Management, long-term care procedure undated, revealed nursing care procedures post fall included assessment for injuries, pain, level of consciousness, limb strength, range of motion and neurological status. The document directed nursing staff to monitor neurologic status per facility procedures and to notify the physician if there were any changes from baseline. The document also described nurses to evaluate residents who were on anticoagulant medications and monitor accordingly because the risk for bleeding in the brain was higher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the medical record was complete and accurate and included post fall reporting, notifying and monitoring for 1 of 8 residents reviewed for falls, of a total sample of 13 residents (#4). On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found her notified assigned Registered Nurse (RN) H. Assigned night shift RN H documented in the medical record a brief Event Note that resident #4 was assessed as having no injuries, no change in range of motion and was to have continued monitoring. There was no documentation in the medical record of neurological assessments having been initiated or performed, nor of the physician or family being notified after the fall. The next day, at the end of her night shift on [DATE] at 7:55 AM, RN F documented resident #4's CNA had stated she was not herself, had a headache and was alert, but confused. RN F did not document any notification to the physician regarding a change in condition, nor did she document any neurological assessments or other post fall monitoring of resident #4. Later that day, [DATE] at 6:29 PM, assigned Licensed Practical Nurse (LPN) G documented in the medical record that resident #4 was pronounced deceased at around 6:00 PM after she was notified the resident did not look well by the CNA. LPN G did not document any post fall monitoring or neurological assessments of resident #4, nor did she document notification of a change in condition to the physician or the family until after resident #4 was pronounced deceased . The facility's failure to initiate a post fall assessment including neurological checks after an unwitnessed fall as well as the facility's failure to document and notify the oncoming staff of the resident's fall and failure to notify the physician of resident #4's change in condition in a timely manner, resulted in Immediate Jeopardy. The Immediate Jeopardy was ongoing as of the exit date of [DATE]. Cross reference to F600, F726, and F684 Findings: Resident #4 was an [AGE] year-old, admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, type 2 diabetes mellitus, chronic kidney disease, chronic lung disease, and heart failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had clear speech, was usually understood and usually understood others, but had impaired vision. The MDS indicated resident #4 had a Brief Interview for Mental Status score of 14 out of 15 that indicated she was cognitively intact. The assessment indicated resident #4 had no falls since the prior assessment, nor any skin impairments. Review of the Order Summary Report dated [DATE] revealed resident #4 had physician orders to not be hospitalized dated [DATE] and Do Not Resuscitate (DNR) dated [DATE]. Resident #4 had a care plan for a risk for falls initiated [DATE] related to impaired mobility, psychotropic and diabetic medications, history of falls, and use of anti-thrombotic medications which can put a resident at risk for bleeding. Interventions included frequent checks on resident during the day, observe for signs or symptoms of unstable blood sugar, and report to the physician any side effects associated with medication use. There was also a care plan for an actual fall with no injury initiated on [DATE] related to poor balance and unsteady gait. Interventions again included frequent checks. None of the interventions mentioned any post fall monitoring or post fall care. Review of the Lippincott's Neurologic assessment, long-term care dated [DATE] and referenced by the facility Policy and Procedure revealed, A neurological assessment is an indispensable tool for quickly evaluating a resident's neurological status, and supplements the routine vital signs as those alone rarely indicate neurologic compromise. The document indicated a focused neurologic assessment is necessary if a resident may have sustained a head injury after a fall, or if they receive an anti-coagulant which increased the risk of bleeding. The document described the need for the nurse to immediately notify the physician if a previously stable resident suddenly developed a change in neurologic status or vital signs as this change may be one of the earliest indicators of increasing pressure inside the head due to bleeding. Review of an event note dated [DATE] at 12:15 AM, revealed Registered Nurse, (RN) H documented resident #4 was observed sitting on the floor close to her bed. RN H described that no injury was noted, and there was no change in range of motion, but she would continue to monitor the resident. There was no documentation in the medical record by RN H of any post- fall assessments of resident #4. RN H did not document vital signs at that time, nor was there any documentation that she notified the physician or the family of resident #4. No record of neurological assessments was found in the medical record after resident #4's fall on [DATE]. The next morning, [DATE], RN F documented a progress note at 7:55 AM, which revealed the CNA notified her resident #4, Was not looking her usual self, she complained of a headache and was alert, but confused. RN F documented she offered resident #4 pain medications which she refused. RN F documented that resident #4 took all her ordered medications, had no signs or symptoms of low or high blood sugar, and was in bed with her call light within reach. The medical record did not contain any documentation of neurological assessments being performed or of notification to the physician or resident representative due to resident #4's change in condition. Review of the Progress Notes revealed an Administration Note dated [DATE] at 10:50 AM by LPN G. LPN G documented, C/O (complaints of) chest pain. NP (Nurse Practitioner) aware. No interventions were documented regarding the complaint of chest pain, or for any orders given by the provider. The next note was later that day, [DATE] at 6:29 PM, LPN G documented she was told at the beginning of her shift by the off going nurse (RN F), that resident #4 was not well. LPN G detailed in her note that at 9:45 AM, the resident complained of not feeling well. She described resident #4's vital signs being taken, with a blood pressure of 111/43 and a heart rate of 45 but did not detail at what time these were taken. She documented she notified the Advanced Practice Registered Nurse (APRN), but that she was unable to reach resident #4's son, but again did not give a time as to when this happened. LPN G did not document any orders given, any post fall neurological assessments, or any interventions attempted on resident #4. Finally she wrote in the same note at 5:58 PM the CNA notified her the resident was not looking well, and on arrival into resident #4's room she noticed her lips were pale, so she notified the APRN and the Unit Manager (UM). She documented resident #4 was pronounced dead by the APRN a few minutes later at approximately 6:00 PM, and her son was notified shortly afterward. No documentation was found in the medical record from the physician or the APRN concerning resident #4's declining condition, chest pain or vital signs nor any interventions or orders placed by the doctor concerning this decline. In a telephone interview on [DATE] at 3:28 PM, RN F stated she recalled being resident #4's nurse the night before she died on [DATE]. She stated she did not know the resident well as she was not regularly assigned to the unit so when the CNA notified her resident #4 did not look herself that night shift, she assumed she might be having trouble with her blood sugar. She explained she had not done any neurological assessments as she was unaware of the fall. She explained no one told her in shift report that resident #4 had an unwitnessed fall that morning. RN F stated she was worried about resident #4 during her shift and didn't want to leave that morning without the next shift knowing her concerns regarding resident #4's blood sugar. She admitted to being unaware resident #4 had fallen until the conversation with the surveyor. RN F stated if she had known resident #4 had fallen, she would have done neurological assessments per protocol and she would have called the physician about her change in condition to see if they wanted to send her to the hospital. She said neurological assessments were done for 72 hours, usually on paper when there is an unwitnessed fall and you would pass it on to the next shift so if resident #4 had fallen the day before she should still be having them when she had her change in mental status. In a telephone interview on [DATE] at 4:13 PM, resident #4's son was adamant he was not told his mother had fallen the day before she died. He explained he had visited his mother the day before she died, and she was acting her normal self. She was fine and in good spirits he recalled. Resident #4's son stated the next day someone called him from a personal phone, not the facility number and because he was busy at work he let it go to voicemail. He said later he got a call in the early evening that his mother had passed. He explained his mother had kidney failure and was told by her doctor she needed dialysis so she was made a do not resuscitate and do not hospitalize because the family had decided they would not put her through dialysis. Resident #4's son said he would have wanted his mother to get treatment for any injuries due to a fall or something like that, just not for her chronic diseases. He said no one from the facility mentioned she had fallen the day before she died to him. In a telephone interview on [DATE] at 3:51 PM, LPN G stated she worked day shift on [DATE] and remembered resident #4's death in the facility. LPN G recalled earlier in the day, resident #4 had begged her to not to leave her alone, because she didn't want to be by herself, which was not her normal behavior. LPN G stated a CNA notified her of resident #4's condition that afternoon and when she went to her room she was not able to get vital signs. She notified the UM and the APRN, who arrived a short while later and pronounced her dead. She stated she did not find out that resident #4 had fallen on [DATE] until after her death on [DATE]. LPN G said she thought she was told in report that morning that resident #4 was actively dying but said she did not call her physician and stated she was not able to reach her son until the end of the day to notify them. She recalled taking resident #4's vital signs and notifying the nurse practitioner who was at the facility that day but did not document any orders or interventions that were in place from the provider. She stated she could not recall if they were doing anything for resident #4. In a telephone interview on [DATE] at 4:06 PM, the APRN who worked under resident #4's primary physician stated she recalled resident #4's passing. The APRN recounted that she saw resident #4 earlier in the day as she made her rounds but did not remember the nurse notifying her of anything abnormal. The APRN stated no one had told her resident #4 had fallen the day before, so when the nurse called later in the day to tell her resident #4 was not doing well, she figured it was due to her chronic kidney condition and did not make any interventions other than try to reach out to her son and make the UM aware of what was going on. The provider stated had she known resident #4 had an unwitnessed fall the day before, she would've given the family the option to send her to the hospital for her change in condition. The advanced practice nurse stated the nurses should have notified her or the physician on duty that she had fallen, and she in turn would've contacted the doctor of her concerns that day. In a telephone interview with RN H on [DATE] at 9:24 AM, she recalled she worked the night shift on [DATE] when she was notified by the CNA in the early morning of [DATE] that resident #4 was found on the floor by her bed. RN H remembered she did not find any injuries on resident #4 after her fall, but her blood pressure was unusually high. She stated resident #4 refused the staff to take her vital signs after that, but she could not recall notifying the physician or documenting the refusal. RN H stated nurses were supposed to do neurological assessments on all residents who fall for 72 hours, both on paper and in the computer but could not say why no neurological assessments were documented in resident #4's medical record. RN H was also unable to say why there was no documentation in the medical record of contacting the physician or the family about resident #4's fall. In an interview on [DATE] at 11:45 AM, the A wing UM Manager stated neurological assessments should be documented on paper by the nurse for 72 hours after a fall. She said the neurological assessment is done to check in case there was bleeding in the brain after a fall. The A wing UM said you would immediately notify the physician if someone getting neurological checks complained of a headache or had confusion like resident #4 did. She indicated the nurse should assess the resident who fell, start the neurological assessments, notify the physician and the family and document it all in the medical record. The A wing UM explained some nurses aren't doing what they are supposed to be doing. The A wing UM recalled on the day resident #4 died, by the time she found out she wasn't feeling well the APRN was here at the end of the shift around 6:00 PM. She said she was surprised to hear she had died, and neither she nor the APRN realized that resident #4 had a fall the previous day at that time. She recalled the APRN looked shocked when she saw resident #4 in her bed, moments before her death, breathing shallowly and said she had tried to call the son, but he had not picked up. The 200 UM indicated she thought the APRN just assumed it was part of her disease process, because no one had notified or reported the resident may have hit her head. On [DATE] at 3:06 PM, agency LPN A stated she did not get any education or direction on what the facility expected her to do after a resident fell. She stated some facilities want you to call the physician and the Director of Nursing, but she was not sure what this facility expected her to do or what their policies included. In interviews on [DATE] at 3:39 PM and [DATE] at 11:08 AM, the Director of Nursing (DON) stated her expectation was nurses would document a note that explained what happened, what interventions were done, the outcome of their assessments as well as notification of the physician and the family after a fall. She said after an unwitnessed fall you would want to do aggressive neurological assessments and acknowledged resident #4 displayed signs and symptoms of a brain bleed in the time before she died that facility nurses should have recognized. The DON explained a DNR or Do Not Hospitalize did not mean you would not provide care to a resident if they were acutely ill. She said it was a significant concern that nurses did not recognize the signs of a brain bleed and contact the physician and family to provide further orders for care. The DON confirmed neurological assessments should have been done after resident #4's unwitnessed fall on [DATE] and acknowledged they had no documentation that nurses performed those assessments nor was there documentation that they notified the physician of resident #4's change in condition. She confirmed there was no note from the physician or APRN nor documentation from the nurse that resident #4 was assessed by a provider prior to her death on [DATE], but after her fall. Review of the policy, Changes in Resident's Condition or Status with review date [DATE] revealed the facility would notify the physician and resident's representative of changes in the resident's condition or status. The facility must immediately consult with the resident's physician and notify the resident representative when there is an accident which results in injury and has the potential to require physician intervention or if there is a significant change in the resident's health such as a deterioration or clinical complication. Review of the undated facility Fall management, long-term care procedures, falls in long term care facilities are a major cause of injury and death. The document describes procedures for staff to take pre and post fall of a resident including to determine if the resident suffered any head trauma which would require further diagnostic evaluation to rule out a brain bleed. Further direction includes staff to look at the medical history to determine whether the resident is at risk for a bleed to the brain due to medications such as anti-coagulants if so to monitor accordingly. Also, for nurses to monitor neurologic status per facility practice and to notify the physician if you note any changes from baseline. Review of the Neurological Assessment policy dated [DATE] revealed the neurological assessment should be initiated in the electronic medical record when indicated such as head injury, post fall or neurological decompensation. The procedure included the nurse to immediately notify the physician of any pertinent changes in the resident's neurological status and any interventions taken should be noted in the nurses' notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by their failure to provide post fall neurologic assessment and monitoring, failure to immediately notify the physician of changes in condition post fall, (#4); failure to implement fall management protocols to ensure residents received necessary care, equipment, and services to prevent falls and avoid major injuries; and failure to maintain processes that supported effective interdisciplinary team (IDT) functions to meet the safety and care needs for 6 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). These failures contributed to falls with major injuries for residents #1 and #9, who required hospitalization, surgery, and rehabilitation for hip fractures. There was likelihood residents #1 and #9 suffered excruciating pain, were placed at risk for blood clots, infection, pneumonia, pressure ulcers, and chronic pain. On [DATE] at approximately 12:15 AM, resident #4 had an unwitnessed fall and was found sitting on the floor near her bed. The Certified Nursing Assistant (CNA) who found resident #4 notified her assigned Registered Nurse (RN) H. Assigned night shift RN H documented in the medical record a brief Event Note that resident #4 was assessed as having no injury noted, no change in range of motion and there was to be continued monitoring, although there was no documentation specifying as to what the monitoring was. There was no documentation in the medical record of neurological assessments having been initiated, nor of the physician or family being contacted after the fall. The next day on [DATE] at 7:55 AM, RN F documented the CNA had stated resident #4 was not herself, had a headache and was alert, but confused. RN F did not document any notification to the physician regarding a change in condition, nor did she document any neurological assessments or other post fall monitoring of resident #4. Later that day, on [DATE] at 6:29 PM, assigned Licensed Practical Nurse (LPN) G documented in the medical record that resident #4 had been pronounced deceased at about 6:00 PM after she was notified the resident did not look well by the CNA. LPN G also did not document any post fall monitoring or neurological assessments of resident #4, nor did she document notification of a change in condition to the physician or the family until after resident #4 was pronounced deceased . The facility's failure to ensure licensed nurses initiated and documented post fall neurological assessments per recognized standards of practice for post fall care, and the facility's failure to ensure licenses nurses notified the physician of resident #4's change in condition in a timely manner, placed all residents in the facility at risk of serious impairment/injury/ death. In addition, between [DATE] and [DATE], the facility recorded 221 falls, of which 190 were unwitnessed. Resident #1 fell four times during self-transfers without necessary staff assistance and supervision. She suffered a hip fracture as a result of the fourth fall. Resident #9 fell nine times, and eight of these incidents occurred when she was left unsupervised in bed. Staff did not obtain the high-sided scoop mattress recommended by the IDT after her fifth fall, and she eventually fractured her hip from the seventh fall. After hospitalization and surgery, resident #9 was readmitted to the facility, still did not receive a scoop mattress, and fell from bed another two times. Resident #11 fell from her bed and suffered a leg fracture. She was hospitalized , treated, and readmitted to the facility but did not receive the raised scoop device for her mattress that was ordered to prevent another fall. Resident #8 fell when he tried to get out bed without assistance and the facility placed a scoop device on his mattress. Less than one month later, the resident again fell from his bed and hit his head, requiring transfer to the hospital for evaluation. It was discovered that resident #8's scoop device was not transferred to his new bed after a room change, and it was not in place at the time of the second fall. Resident #12 slid out of bed and a scoop mattress that was deemed necessary to prevent additional falls was not ordered as of one week after the fall. Due to inadequate review and analysis of each incident, selection of inappropriate or ineffective approaches to prevent falls, and/or lack of comprehensive oversight of the facility's fall management protocols, the residents remained at risk for repeated falls and fall-related injuries. The facility's failure to implement policies and procedures to prevent neglect and accidents by promptly and appropriately responding to fall risk and actual falls placed all residents who were at risk for falls at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE] and as of the exit date of [DATE], the Immediate Jeopardy was ongoing. Findings: Cross reference F607, F689, F835, F684, F726, and F842 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dementia, Type 2 Diabetes mellitus, chronic kidney disease, chronic lung disease, and heart failure. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had clear speech, was usually understood, and usually understood others, but had impaired vision. The assessment indicated resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating she was cognitively intact, and had no behaviors towards others or herself during the lookback period. The MDS assessment section G showed resident #4 needed extensive physical assistance from one staff for bed mobility and was totally dependent on at least two staff for transfers from surface to surface. Resident #4 did not walk during the lookback period but needed supervision and set up for eating. The assessment indicated resident #4 had no falls since the prior assessment, nor did she have any skin impairments. Review of the Order Summary Report dated [DATE] revealed resident #4 had physician orders to not be hospitalized dated [DATE] and to not be resuscitated dated [DATE]. She also had physician orders for 2 liters per minute of oxygen via nasal cannula, and for 81 milligrams (mg) of Aspirin daily related to heart disease. Aspirin is a type of medication called a blood thinner often used to prevent heart attacks and strokes by preventing a type of blood cell called platelets from clumping together to form a clot. The most common side effect of this medication is bleeding, so you should go to the hospital or call your doctor if you fell and might have hit your head, because you may have bleeding internally that you can't see (retrieved on [DATE] from The National Institutes of Health, Medline Plus website at www.medlineplus.gov). Resident #4 had a care plan for risk for falls initiated [DATE] related to impaired mobility, psychotropic and diabetic medications, history of falls, and use of anti-thrombotic medications which can put a resident at risk for bleeding. Interventions included frequent checks on resident during the day, observe for signs or symptoms of unstable blood sugar, and report to the physician any side effects associated with medication use. A care plan for actual falls with no injury was initiated on [DATE] related to poor balance and unsteady gait with intervention for frequent checks. The interventions did not indicate any post fall monitoring or post fall care. An additional care plan for risk for abnormal bruising, bleeding or hemorrhage related to antithrombotic medication use initiated on [DATE]. The goal was for the resident to be free of abnormal bleeding. Interventions included staff to observe for sudden changes in mental status and/or vital signs and to report to the physician any signs or symptoms. The care plan did not include any interventions related to falls in regard to this medication. Review of an event note dated [DATE] at 12:15 AM, revealed RN H documented resident #4 was observed sitting on the floor close to her bed. RN H reported no injury was noted, and there was no change in range of motion, but she would continue to monitor the resident. There was no documentation in the medical record by RN H of any post- fall assessments of resident #4, nor was there any documentation that she notified the physician or the family of resident #4's unwitnessed fall. No record of neurological assessments was found in the medical record after resident #4's fall on [DATE]. In a telephone interview with RN H on [DATE] at 9:24 AM, she recalled she worked the night shift on [DATE] when she was notified by the CNA in the early morning of [DATE] that resident #4 was found on the floor by her bed. RN H remembered she did not find any injuries on resident #4 after her fall, but her blood pressure was unusually high. She stated resident #4 refused vital signs to be taken by staff, but she could not recall notifying the physician or documenting the refusal. RN H stated nurses were supposed to do neurological assessments on all residents who fall for 72 hours, both on paper and in the computer but could not say why no neurological assessments were documented in resident #4's medical record. RN H did not explain why there was no documentation in the medical record of contacting the physician or the family of resident #4's fall. In a telephone interview on [DATE] at 3:28 PM, RN F stated she recalled being resident #4's nurse the night before she died on [DATE]. She explained she did not know the resident well as she did not regularly work on that unit. She explained that when the CNA notified her that resident #4 did not look herself that night shift, she assumed she might be having trouble with her blood sugar. RN F stated she did not know resident #4 had fallen the night before and had therefore not done any neurological assessments. She explained no one told her in shift report that resident #4 had an unwitnessed fall that morning. RN F stated she was worried about resident #4 during her shift but did not explain why she had not notified the physician of the change in condition. RN F stated if she had known resident #4 fell, she would have done neurological assessments per protocol and she would have called the physician about her change in condition to see if they wanted to send her to the hospital. She said neurological assessments were done for 72 hours for any unwitnessed fall, and should have been done for resident #4 for the next three days after she fell. In a telephone interview on [DATE] at 3:51 PM, LPN G stated she worked day shift on [DATE] and remembered resident #4's death in the facility. LPN G recalled earlier in the day, resident #4 had begged her to not to leave her alone, because she didn't want to be by herself, which was not her normal behavior. LPN G stated a CNA notified her of resident #4's condition that afternoon and when she went to her room she was not able to get vital signs. She then notified the Unit Manager (UM) and the Advance Practice Registered Nurse (APRN), who arrived a short while later and pronounced her dead. She stated she did not find out that resident #4 had fallen on [DATE] until after her death on [DATE]. LPN G said she thought she was told in report that morning that resident #4 was actively dying but said she did not call her physician and stated she was not able to reach her son until the end of the day to notify him. She explained resident #4 had Do Not Resuscitate (DNR) and Do Not Hospitalize orders so she did not think any interventions were called for. She recalled taking resident #4's vital signs and notifying the nurse practitioner who was at the facility that day but did not document any orders or interventions that were in place from the provider. She stated she could not recall if they were doing anything for resident #4. LPN G stated she recalled the APRN coming to look at resident #4 at some point after notifying her of resident #4's vital signs and even though they could not reach resident #4's son, she could not recall if they provided any interventions for resident #4's condition. LPN G did not explain why she did not document resident #4's change in condition, notification of the provider and family, her assessment or any other interventions for resident #4 until she died. In a telephone interview on [DATE] at 4:13 PM, resident #4's son was adamant he did not know his mother had fallen the day before she died. He explained he had visited his mother the day before she died, and she was acting her normal self. She was fine and in good spirits he recalled. He explained his mother had kidney failure and was told by her doctor a few months ago she needed dialysis so she was made a DNR and Do Not Hospitalize as the family had decided they would not put her through dialysis. Resident #4's son said he would have wanted his mother to get treatment for any injuries due to a fall or something like that, just not for her chronic diseases. He said no one from the facility mentioned she had fallen the day before she died to him. In a telephone interview on [DATE] at 4:06 PM, the APRN who worked under resident #4's primary physician stated she recalled the day when resident #4 died. The APRN recounted she saw resident #4 earlier in the day as she made her rounds but did not remember the nurse notifying her of anything abnormal. The APRN stated no one told her resident #4 had fallen the day before, so when the nurse called later in the day to tell her resident #4 was not doing well, she figured it was due to her chronic kidney condition and did not give any orders other than try to reach out to her son and make the UM aware of what was going on. The provider stated had she known resident #4 had an unwitnessed fall the day before, she would have given the family the option to send her to the hospital for her change in condition. She stated the nurses should have notified her or the physician on duty that she had fallen, and she would have discussed her concerns with her Primary Physician that day. In an interview on [DATE] at 11:45 AM, the A wing Unit Manager (UM) stated neurological assessments should be documented on paper by the nurse for 72 hours after a fall. She said the neurological assessment was done to check in case there was bleeding in the brain after a fall. The A wing UM said the physician should be immediately notified if a resident complained of a headache or had confusion after a fall as resident #4 did . She indicated the nurse should assess the resident who fell, start the neurological assessments, notify the physician and the family and document it all in the medical record. The A wing UM stated an order for Do Not Hospitalize did not mean that a resident would not get care for an acute injury such as from a fall. The A wing UM recalled on the day resident #4 died, by the time she found out she wasn't feeling well the APRN was here at the end of the shift around 6:00 PM. She said she was surprised that resident #4 had died, and neither she nor the APRN realized that resident #4 had a fall the previous day at that time. She recalled the APRN looked shocked when she saw resident #4 in her bed, moments before her death, breathing shallowly and said she had tried to call the son, but he had not picked up his phone. The UM indicated she thought the APRN just assumed it was part of her disease process, because they did not know she may have hit her head. In an interview on [DATE] at 3:17 PM, the Staff Development Coordinator stated she did not know of a specific protocol or education for post fall care for nursing staff. She was not able to explain what the facility protocol was for post fall care, but instead spoke of her own nursing experience. She explained policies were available to the nurses on the home page of their electronic charting system, but she was not aware of any education for change in condition or for care to be provided after a fall. In interviews on [DATE] at 3:39 PM and [DATE] at 11:08 AM, the Director of Nursing (DON) stated her expectation was nurses would document a note that explained what happened, what interventions were done, the outcome of their assessments as well as notification of the physician and the family after a fall. She said after an unwitnessed fall, aggressive neurological assessments should be initiated to check for signs of a bleed in the brain. The DON acknowledged resident #4 had displayed signs and symptoms of a brain bleed in the time before she died that facility nurses should have recognized. The DON explained a DNR or Do Not Hospitalize did not mean you would not provide care to a resident if they were acutely ill. She said it was a significant concern that nurses did not recognize the signs of a brain bleed and immediately contact the physician and family to provide further orders for care. The DON confirmed neurological assessments should have been done after resident #4's unwitnessed fall on [DATE] and acknowledged they had no documentation that nurses performed those assessments nor was there documentation that they notified the physician of resident #4's change in condition. She confirmed there was no note from the physician or APRN nor documentation from the nurse that resident #4 was assessed by a provider after her fall, but prior to her death on [DATE]. 2. Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, lack of coordination, anxiety, insomnia, dementia, and abnormal gait and mobility. The MDS Quarterly assessment with assessment reference date (ARD) of [DATE] showed resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderate cognitive impairment. The MDS assessment revealed resident #1 required extensive assistance from one person for bed mobility and toilet use, and extensive assistance from two or more people for transfers. Her balance during transfers between the bed and the wheelchair was not steady and she could only stabilize with staff assistance. Review of resident #1's medical record revealed a care plan for risk for falls related to self-care deficits, incontinence, and impaired mobility, vision, cognition, and communication was initiated on [DATE]; a care plan for activities of daily living (ADL) deficits was initiated on [DATE]; and a care plan for actual falls related to poor balance and unsteady gait was initiated on [DATE]. The care plan interventions included assist with ADLs, conduct frequent checks, offer reminders to use the call light and wait for assistance to arrive. On [DATE] at 12:00 PM, Occupational Therapist L explained one element of the facility's fall management process was the Nursing department would send a screening request to the Therapy department, and therapists would conduct assessments and make recommendations and/or develop interventions to prevent falls. She confirmed she evaluated resident #1 and found she was a moderate to high fall risk. Occupational Therapist L explained the resident required at least supervision during transfers and toileting due to her cognitive decline and functional status. She recalled resident #1 would even forget information provided during treatment sessions and she concluded the resident needed someone to maintain eyes on her during transfers and toileting, mostly related to her cognitive deficit. When asked how she communicated her evaluation findings and recommendations to the Nursing department to ensure resident #1 received adequate assistance and supervision for transfers and toileting, she stated she thought she informed the assigned nurse. Occupational Therapist L explained that was her usual practice. She acknowledged verbally relaying important safety information to one nurse was not the most effective method of communicating care needs. She stated the Therapy department had internal meetings to discuss each resident on caseload, but therapists did not participate in IDT meetings. On [DATE] at 3:06 PM, the Assistant Director of Nursing (ADON) reviewed resident #1's four fall incidents and her plan of care. She confirmed resident #1 had unwitnessed falls on [DATE] at 12:57 PM, [DATE] at 4:45 PM, [DATE] at 8:00 PM, and [DATE] at 2:00 PM. The ADON verified all falls occurred in the same location, during the same activity, when resident #1 attempted to transfer herself between her bed and her wheelchair without staff assistance or supervision. The ADON acknowledged the resident required increased monitoring to ensure her safety, but the intervention of frequent checks was not effective in preventing falls as the IDT did not designate the frequency. She confirmed the intervention regarding reminders to use the call light and wait was not appropriate as resident #1 had moderate to severe cognitive impairment. The ADON validated the assigned nurse did not implement an immediate fall prevention approach after the resident fell on [DATE], and the IDT did not follow its fall management process related to meeting and reviewing the fall incident the following day, to identify the cause of the fall and develop an appropriate approach to prevent further accidents. She acknowledged the resident suffered a hip fracture with her fourth fall about 18 hours later on [DATE]. On [DATE] at 1:46 PM, the ADON recalled many IDT discussions regarding resident #1's falls. She said, I even asked what could we do? I remember saying that she keeps doing the same thing. The ADON acknowledged the IDT was not aware of Occupational Therapist L's recommendation regarding resident #1's need for at least supervision with transfers and toileting due to declining cognitive status. She confirmed the IDT did not develop any fall prevention interventions that focused on resident #1's continuous self-transfers in her room and repeated falls beside her bed. 3. Review of the medical record revealed resident #9, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including right hip fracture, dementia, anxiety, and a history of falls. Her diagnosis list was updated on [DATE] to reflect a new left hip fracture, generalized muscle weakness, and abnormal gait and mobility. The MDS Significant Change in Status assessment with ARD of [DATE] revealed resident #9 had a BIMS score of 1 out of 15 which indicated severe cognitive impairment. The document indicated the resident exhibited fluctuating inattention and disorganized thinking, and she had trouble concentrating nearly every day. During the look back period, the resident required extensive assistance from one person for bed mobility, transfers, toilet use, and personal hygiene, and she did not walk. Her balance was unsteady during transfers, and she was only able to stabilize with assistance from staff. The MDS assessment showed resident #9 had impaired range of motion in both legs, and she used a wheelchair for mobility. Review of the facility's incident log and Risk Management documentation revealed resident #9 had nine unwitnessed falls on [DATE] at 7:50 PM, [DATE] at 5:15 PM, [DATE] at 2:45 PM, [DATE] at 7:57 PM, [DATE] at 2:00 PM, [DATE] at 10:30 PM, [DATE] at 1:50 AM, [DATE] at 11:00 PM, and [DATE] at 3:23 AM. The facility's incident reports showed resident #9 suffered a fracture from the seventh fall on [DATE] and indicated seven of the nine falls occurred when resident #9 was left unattended in bed. Review of resident #9's medical record with a care plan for actual falls due to poor balance and unsteady gait revealed the goal that resident #9 would resume normal activities without further incident. The document listed each fall with an associated fall prevention intervention as follows: offer frequent toileting opportunities ([DATE]), frequently remind the resident to use call light and wait for assistance ([DATE]), therapy evaluation ([DATE]), medication review by the pharmacist ([DATE]), placement of a scoop mattress ([DATE]), frequent checks ([DATE]), staff education on fall prevention interventions ([DATE]), provision of a bedside commode at night ([DATE]), and frequent checks for safe positioning ([DATE]). The care plan did not define the required frequency of monitoring nor focus on the resident's room as the location of the majority of her falls. On [DATE] at approximately 1:40 PM, during review of resident #9's fall incident documentation, fall care plans, and physician orders with the ADON, she acknowledged the fall prevention interventions selected by the IDT were either ineffective, inappropriate, and/or not implemented as ordered. She validated the care plan approaches did not show the care and services necessary to ensure resident #9's safety, as evidenced by repeated falls from her bed which culminated in a hip fracture, and then resumed after readmission. The ADON confirmed the IDT never determined or specified the frequency of monitoring required for resident #9's safety although she was a known high risk for falls. She stated the IDT did not consider one-to-one supervision by a designated staff member when the resident was in bed, or small group activities when out of bed. The ADON confirmed resident #9 fell out of bed and fractured her hip and had two additional falls after the IDT determined she needed a mattress with raised sides. On [DATE] at 1:46 PM, the ADON explained resident #9's UM was responsible for ensuring the scoop overlay or a scoop mattress was provided and that all fall prevention interventions were in place and effective. She stated her process was to document new approaches in the care plan and inform the UMs verbally. The ADON said, They are expected to follow up. On [DATE] at 1:33 PM, the Director of Nursing (DON) explained the facility utilized an IDT approach to review residents' falls. She explained there was a daily clinical meeting held every morning, Monday through Friday, during which members of the IDT including herself, the ADON, UMs, MDS nurses, and the Director of Rehab discussed the circumstances of every fall. The DON stated the fall management process involved the development and implementation of appropriate preventative interventions based on the cause of each fall, and the plans of care would be updated as indicated at the time of the meeting. The DON explained floor nurses did not revise care plans as she preferred nursing management to approve new interventions before they were added to the medical record. However, she stated assigned nurses were expected to implement an immediate intervention after a fall to at least prevent another fall occurring in the same manner. The DON acknowledged it was important to use person-centered approaches to mitigate fall risk and prevent injuries. On [DATE] at 4:10 PM, the Lead MDS Nurse stated residents' falls were discussed in the daily IDT meeting which she attended. She explained the ADON generally entered revised fall prevention approaches in the care plan. However, in conflict with the DON's statement, the Lead MDS Nurse stated she and her staff have offered to educate nurses on how to enter interventions in the care plans. She confirmed MDS nurses assessed residents, obtained input from direct care staff, and reviewed care plans at least quarterly to ensure the plan of care accurately reflected assessment findings. She reviewed resident #9's fall risk care plan and acknowledged some of the interventions were inappropriate based on the resident's functional and cognitive status. The Lead MDS Nurse stated she was not aware resident #9's scoop mattress was never provided. She acknowledged, We should be looking to see if the problems, goals, and interventions are appropriate and in place. 4. Review of the medical record revealed resident #11, an [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included a history of falls, abnormal gait and mobility, Alzheimer's disease, dementia, seizures, and a left above the knee amputation. The resident's diagnosis list was updated on [DATE] to reflect fractures of the right tibia and fibula, and right knee pain. The MDS Medicare 5-day assessment with ARD of [DATE] revealed resident #11 had a BIMS score of 7 out of 15 which indicated severe cognitive impairment, and she exhibited fluctuating inattention and disorganized thinking. The MDS assessment showed the resident required extensive assistance from two or more people for bed mobility. She had unsteady balance during transfers and was only able to stabilize with assistance from staff. Resident #11 had functional limitation in range of motion of her extremities on one side, and she used a wheelchair for mobility. The facility's incident log and Risk Management documentation revealed resident #11 had an unwitnessed fall from her bed on [DATE] at 11:00 AM, which resulted in a major injury. Review of the medical record revealed resident #11 had a care plan for risk for falls initiated on [DATE], and a care plan for an actual fall with serious injury, initiated on [DATE]. The interventions included keep the bed in the lowest position, conduct frequent checks throughout the day, and placement of a scoop mattress overlay for the resident's air mattress. On [DATE] at 9:50 AM, resident #11 was in bed, behind a partially closed curtain, and not easily seen from the doorway. The resident's bed was in high position, approximately three feet above the above the floor and she did not have a scoop mattress or scoop overlay device. Review of the Order Summary Report dated [DATE] showed resident #11's scoop mattress was never ordered and the order to keep her bed in the lowest position had been discontinued one week after her fall. On [DATE] at 11:20 AM, the Regional Nurse stated to her knowledge, resident#11's bed had a scoop overlay device, but it got soiled and was being cleaned. She did not respond when asked what approach was in place to ensure resident #11's safety while the scoop overlay was not on the bed. 5. Review of the medical record revealed resident #8, a [AGE] year-old-male, was admitted to the facility on [DATE] and readmitted on [DATE]. His primary diagnosis was a stroke with left side paralysis and weakness. His diagnosis list was updated on [DATE] to reflect new diagnoses of generalized muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. The MDS Medicare 5-day assessment with ARD of [DATE] revealed resident #8 had a BIMS score of 9 out of 15 which indicated moderate cognitive impairment. He was totally dependent on two or more staff for bed mobility and transfers and had functional limitation in range of motion due to impairment of his extremities on one side. The MDS assessment showed resident #8 was unsteady, could only stabilize with assistance from staff during transfers and when he moved from a seated to standing position, and he used a wheelchair for mobility. Resident #8 had a care plan for risk for falls initiated on [DATE], and a care plan for actual falls related to poor trunk control initiated on [DATE]. The interventions included frequent checks, encourage him to call for assistance with transfers, and placement of a scoop overlay device to his air mattress. On [DATE] at 1:17 PM, the 200 Wing UM confirmed resident #8's bed did not have a scoop overlay device. She acknowledged all fall prevention interventions should be in place, according to the plan of care. On [DATE] at 1:55 PM, the Central Supply staff member reviewed the group text message used by the IDT to inform her of equipment that needed to be ordered for residents. She stated she did not receive a request for a scoop mattress for resident #8. However, the ADON discovered IDT text message communication that showed a request regarding a scoop mattress for resident #8 on [DATE]. The Central Supply staff member explained the device was ordered when resident #8 was on the 400 Wing but might not have been transferred [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and implement effective fall prevention approaches including equipment, adequate assistance, and increased supervision for vulnerable, physically and cognitively impaired residents, to avoid falls and falls with injuries for 5 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). This failure contributed to numerous unwitnessed falls which resulted in injuries such as fractures, head injuries, and lacerations. There was likelihood residents #1 and #9 who sustained hip fractures suffered excruciating pain, and were placed at risk for blood clots, infection, pneumonia, pressure ulcers, and chronic pain. Between 3/01/23 and 8/16/23, the facility recorded 221 falls, of which 190 were unwitnessed. Resident #1 fell four times during self-transfers without necessary staff assistance and supervision. She suffered a hip fracture as a result of the fourth fall. Resident #9 fell nine times, and eight of these incidents occurred when she was left unsupervised in bed. Staff did not obtain the high-sided scoop mattress recommended by the Interdisciplinary Team (IDT) after her fifth fall, and she eventually fractured her hip from the seventh fall. After hospitalization and surgery, resident #9 was readmitted to the facility, still did not receive a scoop mattress, and fell from bed yet another two times. Resident #11 fell from her bed and suffered a leg fracture. She was hospitalized , treated, and readmitted to the facility but did not receive the raised scoop device for her mattress that was ordered as a fall intervention. Resident #8 fell when he tried to get out bed without assistance and the facility placed a scoop device on his mattress. However, less than one month later, the resident again fell from his bed and hit his head, requiring transfer to the hospital for evaluation. It was discovered that resident #8's scoop device was not transferred to his new bed after a room change, and it was not in place at the time of the second fall. Resident #12 slid out of bed and a scoop mattress that was deemed necessary as a fall intervention, but was not ordered as of one week after the fall. Due to inadequate review and analysis of each incident, selection of inappropriate or ineffective approaches to manage falls, and/or lack of comprehensive oversight of the facility's fall management protocols, the residents remained at risk for repeated falls and fall-related injuries. The facility's failure to identify and provide the appropriate level of supervision and frequency of monitoring, and ensure appropriate fall management approaches were developed, implemented, and revised as indicated for residents with known moderate to high risk for falls contributed to falls with major injuries for residents #1 and #9, and impacted the safety of residents #8, #11, and #12, and placed residents who were at risk for falls at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on 3/27/23. The Immediate Jeopardy was ongoing as of the exit date of 8/18/23. Findings: Cross reference F600, F607, F684, F726, F842 and F835. 1. Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness, lack of coordination, anxiety, insomnia, dementia, and abnormal gait and mobility. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 9/27/22 revealed the reason for resident #1's transfer from the hospital to the nursing facility was weakness. The document indicated she had a risk alert for falls and required assistance with ambulation and transfers. The resident's admission Data Collection form, dated 9/27/22, revealed she was alert and confused, and required extensive assistance for transfers, ambulation, locomotion, and toileting. The document indicated she had poor trunk control and was at risk for falls. A readmission Data Collection form, dated 6/16/23, revealed resident #1 had impaired cognition, speech, and vision. She remained alert with confusion and remained at risk for falls. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 7/06/23 showed resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. The MDS assessment revealed resident #1 required extensive assistance from one person for bed mobility and toilet use, and extensive assistance from two or more people for transfers. Her balance during transfers between the bed and the wheelchair was not steady and she could only stabilize with staff assistance. The document showed the resident had one fall with no injury since readmission on [DATE]. Review of resident #1's fall risk evaluation dated 6/27/23 revealed a score of 16 on a scale that deemed residents with scores of 10 and above as at risk for falls. The document showed the resident had one to two falls during the previous 90 days, ambulated with problems and devices, required partial physical support during the MDS Test for Balance, or stood but did not follow directions for the test. Review of resident #1's medical record revealed a care plan for risk for falls related to self-care deficits, incontinence, and impaired mobility, vision, cognition, and communication was initiated on 9/28/22. The goal was resident #1 would not sustain serious injury that required hospitalization. Care plan interventions included assist with activities of daily living (ADLs), reinforce safety awareness, place the call light within reach, and conduct frequent checks throughout the day. A care plan for ADL deficits was initiated on 10/04/22. The document indicated resident #1 required limited to extensive assistance from one to two people for ADLs and noted, She admits with decline in ambulation and activity tolerance, weakness to bilateral extremities, requiring verbal and tactile cues for ADL sequencing and safety. The facility's incident log revealed resident #1 had unwitnessed falls on 4/03/23 at 12:57 PM, 6/27/23 at 4:45 PM, 7/31/23 at 8:00 PM, and 8/01/23 at 2:00 PM. Review of the medical record showed a care plan for actual falls related to poor balance and unsteady gait was initiated on 4/03/23. The care plan goal for resident #1 was to resume normal activities without further incident. The document showed the fall prevention approach selected after the resident's first fall on 4/03/23 was to conduct frequent checks. This was the same intervention included in the fall risk care plan developed approximately six months before, but the frequency of monitoring to ensure the resident's safety was never defined. On 6/27/23, after the resident's second fall, a care plan approach was initiated to remind the resident to use the call light and wait for assistance to arrive. The care plan showed resident #1 fell again on 7/31/23; however, the document did not reflect any revisions for immediate interventions to prevent additional falls. On 8/01/23, the resident fell again. Review of the care plan for actual falls revealed fall prevention interventions for resident #1's last two falls were initiated on 8/08/23, one week after discharge, while she was in the hospital for surgical repair of a hip fracture. A Behavior Note dated 4/04/23 at 7:08 PM read, Family asked to remove resident's wheelchair in attempt to prevent her from transferring/falling. The note indicated a nurse informed the family that the resident had the right to use her wheelchair, so she could not remove it from bedside. The nurse indicated facility staff would conduct frequent checks or place the resident near the nurses' station to keep a visual on her as she would allow. On 8/11/23 at 4:22 PM, in a telephone interview, resident #1's daughter recalled on the evening of 7/31/23, a nurse called to inform her that her mother fell and hit her head but did not appear to be injured. The daughter stated she was unsure what the facility did to prevent another fall, but her mother fell again the next day. The daughter stated her mother called her the next day at about lunchtime and she was definitely experiencing excruciating pain. Her mother recounted that she fell when she tried to get from the bed to her wheelchair, and when she tried to stand she was in so much pain she fell to her knees. The daughter expressed dissatisfaction with the lack of follow-up after her mother's fall on 7/31/23 and wondered if her mother fell the following day due to an unnoticed injury, or if her hip fracture resulted from the fall on 8/01/23. Resident #1's daughter stated she was concerned about her mother's pain and possible injuries, so she notified Emergency Medical Services (EMS) herself. Review of resident #1's medical record revealed no documentation regarding her falls on 7/31/23 and 8/01/23. There were no nursing notes or change in condition forms that described the circumstances of the falls and communicated orders and interventions to prevent repeated falls and injuries. On 8/14/23 at 4:07 PM, Certified Nursing Assistant (CNA) M stated she was regularly assigned to care for resident #1. She recalled on the morning of 8/01/23, the off-going night nurse, Licensed Practical Nurse (LPN) K, told her the resident fell on the previous shift. When asked if she was informed of updated fall prevention interventions, CNA M said, They didn't tell us to do anything new that morning. She recalled resident #1 had lunch in her room and then came out to the unit in her wheelchair. CNA M stated a short time later, she discovered the resident in her bathroom. She stated she did not see when the resident returned to the room and acknowledged she must have transferred herself to the toilet without staff assistance. CNA M stated she helped with the toileting task and personal hygiene, then the resident got back into her wheelchair and again left the room. She recalled while she collected lunch trays, she heard someone repeatedly scream for help. CNA M stated she ran to the room and found resident #1 on her back on the floor beside her bed. She explained the resident appeared to have lost her balance as she got into or out of bed. On 8/14/23 at 4:20 PM, LPN T recalled on 8/01/23, resident #1 was not on her assignment, but she responded to the resident's fall as the assigned nurse was at lunch. LPN T stated the resident was on her back on the floor and told her she had been trying to get from her wheelchair to the bed. LPN T recalled she evaluated the resident while she was on the floor and noted no apparent distress or injuries. However, when assisted to stand, resident #1 cried out and pointed to the top of her left thigh. LPN T stated she left the room to notify the physician and received orders for an x-ray and pain medication. She explained the resident probably called her family, because by the time she entered the order for the x-ray and started the process of retrieving the pain medication, EMS personnel arrived. On 8/14/23 at 4:27 PM, Registered Nurse (RN) I confirmed she was resident #1's assigned nurse on 8/01/23 and was notified of the fall when she returned from her lunch break. RN I stated the resident could propel herself independently once in the wheelchair. She explained resident #1 required assistance from staff for ADLs, but she usually went to the bathroom by herself and did not use the call light. RN I stated the resident was not able to self-transfer safely as her legs were weak. She recalled someone told her resident #1 fell on 7/31/23, but she did not remember if any new fall prevention approaches were started. On 8/15/23 at 8:01 AM, LPN K verified resident #1 was on his assignment when she fell at the start of the night shift on 7/31/23. He stated prior to the fall, he administered her medication in the hallway and then continued attending to other residents. LPN K confirmed resident #1 usually self-propelled in her wheelchair and self-transferred between her wheelchair and the bed. He stated to his knowledge she was independent and did not require assistance from staff with those activities. LPN K stated when he exited another resident's room he heard resident #1's voice as she asked her roommate to turn on the call light to get help. He recalled when he arrived in the room, the resident was sitting on the floor beside the bed and the wheelchair was nearby. LPN K stated resident #1 informed him she fell when she tried to get into bed. He expressed surprise at the accident, and when informed she had fallen during self-transfers twice before, he did not recall if he was ever made aware of those incidents. LPN K explained he told the oncoming day shift nurse, RN I, about the fall and followed the facility's protocol regarding notification of the physician and family. He stated he felt all fall prevention interventions were in place at the time of the incident and he did not initiate any new approaches to avoid another fall. LPN K acknowledged sometimes residents were confused and they either forget or did not follow instructions. On 8/15/23 at 12:00 PM, Occupational Therapist L recalled resident #1 was on therapy caseload intermittently, most recently in July 2023 after a fall. She stated the resident informed staff of her concerns regarding transfers, specifically getting into the bathroom. Occupational Therapist L described resident #1 as a moderate to high fall risk, and stated she required at least supervision during transfers and toileting due to her cognitive decline and functional status. She recalled resident #1 would even forget information provided during treatment sessions and she concluded the resident needed someone to maintain eyes on her during transfers and toileting, mostly related to her cognitive deficit. Review of the Occupational Therapy evaluation dated 7/13/23 revealed resident #1 was referred for services secondary to a recent fall and decline in the areas of ability to performance of functional activities without physical assistance, dynamic balance, functional ambulation, functional mobility, static balance, and strength. The document included a fall risk assessment that showed the resident was unsteady when standing and walking and she worried about falling. The evaluation showed resident #1's mobility function score was 1 on a 0 to 12 scale with 12 being the highest function, and she had impaired safety awareness. On 8/16/23 at 12:28 PM, Speech Therapist N reviewed her notes and stated she evaluated resident #1's cognitive status on 10/01/22 and her overall diagnosis was moderate to severe cognitive impairment. On 8/16/23 at 3:46 PM, the Director of Nursing (DON) was informed of the progress note which documented the request by resident #1's family to remove her wheelchair from the bedside after her first fall in April 2023, to prevent additional falls during self-transfer. The DON stated that intervention would not guarantee the resident's safety as she might fall if she attempted to walk. When asked about the possibility of increased supervision, the DON said, There is a line between residents' rights and safety. The resident took herself where she wanted to, and the facility could not provide one-on-one [supervision] of the resident continuously or indefinitely. On 8/15/23 at 3:06 PM, during review of fall incidents and fall care plans with the ADON, she confirmed resident #1 fell on 4/03/23 when she tried to self-transfer from her bed to the wheelchair. She explained the incident report indicated the wheelchair brakes were not locked. The ADON confirmed the IDT approved frequent checks on the resident as an appropriate intervention to avoid further falls; however, she acknowledged since there was no designated frequency for monitoring, the determination of appropriate intervals was left up to the CNAs and nurses. Next, the ADON presented the incident report regarding resident #1's second fall on 6/27/23, which occurred when she attempted to transfer herself from the wheelchair to her bed without staff assistance and again failed to lock the brakes. The ADON stated the resident's statement was that she could not find the brakes. She confirmed the revised care plan showed the resident was to be encouraged to use the call light and wait for staff assistance. The ADON verified the selected intervention was not appropriate as resident #1 was assessed to have moderate to severe cognitive impairment which might impact her ability to recall and understand the important instruction. The ADON stated resident #1's third fall occurred on 7/31/23 when she was once more found on the floor by her bed and wheelchair. She confirmed the care plan was not updated at the time of the fall. The ADON then discussed resident #1's fourth fall, which occurred less than 24 hours later on 8/01/23, from which she sustained a hip fracture. She validated the resident was again found on the floor beside her bed, near her wheelchair. The ADON acknowledged there was no evidence to show resident #1's fall on 7/31/23 was addressed by either the assigned nurse or the interdisciplinary team (IDT) to ensure the resident did not continue to fall during self-transfers between the wheelchair and her bed. On 8/15/23 at 1:33 PM and 3:33 PM, the DON stated either herself, the Assistant Director of Nursing (ADON), Unit Managers (UMs), and/or MDS nurses reviewed the circumstances of every fall, developed and implemented appropriate preventative interventions based on findings, and updated the plan of care as indicated. The DON explained although nurses did not update care plans, they were expected to implement an immediate intervention to prevent another fall occurring in the same manner. The DON acknowledged it was important to use person-centered approaches to mitigate fall risk and prevent injuries. She stated there should be a fall screening tool completed after every fall in addition to developing a new, appropriate fall prevention intervention. The DON was informed neither was done for the resident's fall on 7/31/23. She reviewed resident #1's medical record and verified there were no effective person-centered interventions that focused on the resident's repeated falls during self-transfers between her wheelchair and bed. 2. Review of the medical record revealed resident #9, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including right hip fracture, dementia, anxiety, and a history of falling. Her diagnosis list was updated on 5/24/23 to reflect a new left hip fracture, generalized muscle weakness, and abnormal gait and mobility. The MDS Significant Change in Status assessment with ARD of 5/31/23 revealed resident #9 had a BIMS score of 1 which indicated severe cognitive impairment. The document indicated the resident exhibited fluctuating inattention and disorganized thinking, and she had trouble concentrating nearly every day. During the look back period, the resident required extensive assistance from one person for bed mobility, transfers, toilet use, and personal hygiene, and she did not walk. Her balance was unsteady during transfers, and she was only able to stabilize with assistance from staff. The MDS assessment showed resident #9 had impaired range of motion in both legs, and she used a wheelchair for mobility. The document revealed the resident's significant change was related to a recent fall with left hip fracture, and noted she was at risk for additional falls related to her cognition, generalized weakness, dementia, anxiety, loss of leg movement, visual impairment, and incontinence. Review of resident #9's fall risk evaluations dated 5/25/23, 6/21/23, and 8/02/23 revealed scores of 16, 24, and 22 respectively, on a scale that deemed residents with scores of 10 and above as at risk for falls. The evaluation forms showed the resident's continence status was elimination with assistance and her mobility status was confined to a wheelchair. She was not able to attempt the MDS Test for Balance without physical help. Review of the facility's incident log and Risk Management documentation revealed resident #9 had nine unwitnessed falls on 3/27/23 at 7:50 PM, 4/04/23 at 5:15 PM, 4/07/23 at 2:45 PM, 4/07/23 at 7:57 PM, 4/14/23 at 2:00 PM, 4/25/23 at 10:30 PM, 5/20/23 at 1:50 AM, 6/20/23 at 11:00 PM, and 8/02/23 at 3:23 AM. The facility's incident reports showed resident #9 suffered a fracture from the seventh fall on 5/20/23 and indicated seven of the nine falls occurred when resident #9 was left unattended in bed. Review of resident #9's medical record revealed a care plan for risk for falls was initiated on 2/11/23. The goal was to minimize injuries from falls. The interventions directed staff to anticipate and meet the resident's needs, assist with ADLs, keep the call light within reach, orient her to the room, and provide adaptive equipment or devices as needed. A care plan for actual falls due to poor balance and unsteady gait revealed the goal that resident #9 would resume normal activities without further incident. The document listed each fall with fall prevention interventions as follows: offer frequent toileting opportunities (2/17/23), frequently remind the resident to use call light and wait for assistance (3/27/23), therapy evaluation (4/04/23), medication review by the pharmacist (4/07/23), placement of a scoop mattress (4/14/23), frequent checks (4/25/23), staff education on fall prevention interventions (5/20/23), provision of a bedside commode at night (6/20/23), and frequent checks for safe positioning (8/02/23). The care plan did not define the required frequency of monitoring nor focus on the resident's room as the location of the majority of her falls. Review of the Order Summary Report dated 8/15/23 revealed no physician order for a scoop mattress to reflect the care plan intervention dated 4/14/23. The document showed an order dated 5/25/23 for an air mattress with a scoop overlay was initiated after resident #9's fall from bed which resulted in a hip fracture. A scoop mattress and an air mattress with a scoop overlay provide raised sides or bolsters that aid in fall prevention by keeping residents in the middle of the mattress and preventing them from rolling out of bed. On 8/14/23 at 1:54 PM, resident #9's bed was noted to have a regular, flat air mattress without raised sides. The resident was seated in a wheelchair in the hallway, facing the nurses' station. The wheelchair had elevated footrests, raised to approximately 30 degrees. Resident #9's feet were on the floor behind the footrests, and she wore regular smooth socks, rather than non-skid socks. The labels on the footrests and the socks indicated they did not belong to resident #9. There were two nursing staff seated at the nurses' station directly across from resident #9, and other staff walked past her in the busy hallway. The staff did not appear to notice the resident's placement of her feet behind the footrests and the absence of non-skid shoes or socks. On 8/14/23 at 1:58 PM and 2:21 PM, the Director of Rehab stated resident #9 fell recently and was placed on Physical Therapy caseload. She evaluated the resident and confirmed she did not have non-skid safety socks and the footrests on the wheelchair did not belong to that device. The Director of Rehab explained resident #9 fell frequently and it was important for her to utilize the correct elevated footrests as they helped with swelling and decreased the urge to stand. She stated the incorrect footrests were too long for the resident's legs, therefore, her feet did not touch the pedals and she was able to get her legs behind the footrest. The Director of Rehab confirmed resident #9 was at an increased risk for falls as she could now stand and trip over the footrests or pedals if she attempted to walk, and also because she wore smooth socks. On 8/14/23 at 2:06 PM, CNA J confirmed she was assigned to care for resident #9 during the 7:00 AM to 3:00 PM shift. She was informed the resident wore smooth socks and was seated in a wheelchair without the proper footrests. CNA J stated resident #9 was already dressed and in the wheelchair when she arrived on the unit earlier that morning. She explained she was assigned to the unit late, and therefore did not receive change of shift report or conduct walking rounds with the night shift CNA. She explained she was not familiar with resident #9 and did not recall being assigned to her before. She recalled the resident usually sat in front of the nurses' station which usually indicated she was at risk for falls. CNA J confirmed all residents had a CNA care plan or Kardex in the computer and when she was asked to retrieve the instructions for care, she had to be prompted on how to access care directives for resident #9. CNA J verified the safety interventions included frequent checks, frequent checks for safe positioning, offer frequent toileting opportunities, and a scoop mattress. When asked about the frequency of monitoring the resident, CNA J stated she did not toilet resident #9, but she checked her brief at about 9:00 AM and again at 11:40 AM and found it to be dry. CNA J was asked to verify that the resident had a scoop mattress and she stated she was not sure what a scoop mattress looked like. On 8/14/23 at 2:18 PM, LPN P verified resident #9's bed did not have either a scoop mattress or any device that provided raised sides around the flat edges of the mattress. On 8/14/23 at 3:22 PM, during observation of resident #9's room with CNA J, she confirmed there was no bedside commode for the resident as listed on the care plan as a fall prevention intervention. She pointed to a raised toilet seat in the bathroom but after she searched the resident's closet and room she confirmed there was no bucket to allow the raised seat to be used as a bedside commode. When asked which of the four residents in the room, including resident #9, used the bathroom, CNA J said, As I said, I don't work this floor. I'm not aware of who uses the bathroom. On 8/15/23 at 1:04 PM, the Central Supply staff member explained she was responsible for ordering all necessary equipment and devices for residents. She reviewed a group text message with equipment requests and showed a request dated 5/25/23 for an air mattress for resident #9, but she was unable to locate a request for the ordered scoop overlay device. On 8/17/23 at 9:38 AM, resident #9 was again seated in front of nurses' station with her feet on the floor behind the footrests of her wheelchair. None of the nursing staff seated at the nurses' station nor those who walked by the resident stopped to reposition her legs for safety. On 8/15/23 at approximately 1:40 PM, during review of resident #9's fall incidents and fall care plans with the ADON, she stated on 3/27/23 at 7:50 PM, the resident was found sitting on the floor in the hallway next to her room. The ADON explained the IDT selected the fall prevention intervention to frequently remind the resident to use the call light and wait for assistance. When asked if that intervention was appropriate for a resident with severe cognitive impairment, the ADON said, Personally, I do not think the resident would be able to remember the instruction. She described another fall from the bed on 4/04/23 at 5:15 PM, when resident #9 was found crawling on the floor in her room. Although the resident was assessed as requiring extensive assistance of one person for transfers, the ADON stated the IDT chose a therapy evaluation as a fall prevention intervention to ensure the resident got up as safely as possible. The incident reports showed resident #9 was found on the floor next to her bed on 4/07/23 at 2:45 PM. The ADON stated staff transferred her to the wheelchair and then placed non-skid socks on her feet. Resident #9 fell again later that day at 7:57 PM. The ADON stated the resident fell from her wheelchair where she was seated near the nurses' station. The ADON stated the facility's immediate fall prevention intervention was to return the resident to her wheelchair and position the wheelchair even closer to the desk. She reviewed the care plan and explained the IDT decided to obtain labs and request a pharmacy review of resident #9's medications to identify possible factors that contributed to her falls. The ADON stated there were no negative findings from the labs and medication review; however, the facility did not implement other approaches such as increased supervision and monitoring to prevent additional falls. The incident reports documented another fall one week later on 4/14/23 at 2:00 PM, when resident #9 was found on the floor beside her bed. The ADON stated she revised the care plan to include a scoop mattress. She reviewed the resident's medical record and confirmed there was no order for a scoop mattress. The Central Supply staff joined the interview, reviewed her group text messages, and informed the ADON she never received a request on 4/14/23 for a scoop mattress for the resident. Continued review of the incident reports revealed resident #9 was again found on the floor on 4/25/23 at 10:30 PM. The ADON stated the IDT's intervention to prevent additional falls was to conduct frequent checks. She explained her expectation was staff would check on the resident every 15 to 30 minutes. The ADON validated the interval was not defined and the frequency was left up to staff. Resident #9's next fall occurred approximately one month later on 5/20/23 at 1:50 AM. The ADON stated the resident was found on the floor beside her bed, complained of pain, and was subsequently transferred to the hospital and diagnosed with a hip fracture. The next incident report revealed after repair of the fracture and readmission to the facility, resident #9 was again found on the floor in her room on 6/20/23 at 11:00 PM. The ADON reviewed the care plan and noted the IDT's fall prevention intervention was to provide a bedside commode. When asked why a resident who had recently suffered a hip fracture and was unable to stand and self-transfer would be given a bedside commode, the ADON said, That's a great question. She acknowledged the intervention was definitely not appropriate for the resident. Resident #9 fell from bed on 8/02/23 at 3:23 AM and was found on her knees beside her bed and there was urine on the floor. The ADON acknowledged the IDT selected frequent checks as the approach to prevent additional falls. The ADON did not respond when asked why that intervention would be effective if it had been unsuccessful in preventing three falls since 4/25/23 when it was first initiated. She verified the frequency of monitoring was not defined. On 8/15/23 at 2:36 PM, the DON and ADON were informed of safety concerns observed while resident #9 was seated in front of nurses' station. They acknowledged placing the resident in front of nurses' station or any other high-traffic area did not necessarily ensure she was adequately supervised. 3. Review of the medical record revealed resident #11, an [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included a history of falling, abnormal gait and mobility, Alzheimer's disease, dementia, seizures, and a left above the knee amputation. The resident's diagnosis list was updated on 7/17/23 to reflect fractures of the right tibia and fibula, and right knee pain. The MDS Medicare 5-day assessment with ARD of 7/19/23 revealed resident #11 had a BIMS score of 7 which indicated severe cognitive impairment, and she exhibited fluctuating inattention and disorganized thinking. The MDS assessment showed the resident required extensive assistance from two or more people for bed mobility. She had unsteady balance during transfers and was only able to stabilize with assistance from staff. Resident #11 had functional limitation in range of motion of her extremities on one side, and she used a wheelchair for mobility. Review of the medical record revealed resident #11 had a care plan for risk for falls initiated on 11/18/20. The focus indicated c[TRUNCATED]

Based on observation, interview, and record review, the facility's administration failed to recognize and address trends related to repeated unwitnessed falls and fall-related injuries; and failed to direct its resources to provide adequate clinical oversight of the fall incident review process and implementation of fall management protocols to ensure the safety and well-being of 5 of 8 residents reviewed for falls, out of a total sample of 13 residents, (#1, #8, #9, #11, and #12). These failures contributed to falls with major injuries for residents #1 and #9, who required hospitalization, surgical intervention, and rehabilitation for hip fractures. There was likelihood residents #1 and #9 suffered excruciating pain, and were placed at risk for blood clots, infection, pneumonia, pressure ulcers, and chronic pain; and likelihood residents #8, #11, and #12 would suffer repeated falls with injuries. Between 3/01/23 and 8/16/23, the facility recorded 221 falls, of which 190 were unwitnessed. Resident #1 fell four times during self-transfers without necessary staff assistance and supervision. She suffered a hip fracture as a result of the fourth fall. Resident #9 fell nine times, and eight of these incidents occurred when she was left unsupervised in bed. Staff did not obtain the high-sided scoop mattress recommended by the IDT after her fifth fall, and she eventually fractured her hip from the seventh fall. After hospitalization and surgery, resident #9 was readmitted to the facility, still did not receive a scoop mattress, and fell from bed yet another two times. Resident #11 fell from her bed and suffered a leg fracture. She was hospitalized , treated, and readmitted to the facility but did not receive the raised scoop device for her mattress that was ordered to prevent another fall. Resident #8 fell when he tried to get out bed without assistance and the facility placed a scoop device on his mattress. However, less than one month later, the resident again fell from his bed and hit his head, requiring transfer to the hospital for evaluation. It was discovered that resident #8's scoop device was not transferred to his new bed after a room change, and it was not in place at the time of the second fall. Resident #12 slid out of bed and a scoop mattress that was deemed necessary to prevent additional falls was not ordered as of one week after the fall. Due to inadequate review and analysis of each incident, selection of inappropriate or ineffective approaches to prevent falls, and/or lack of comprehensive oversight of the facility's fall management protocols, the residents remained at risk for repeated falls and fall-related injuries. The facility's failure to maintain a systematic approach to consistently implement policies and procedures that prevented neglect and accidents, and ensured person-centered fall prevention approaches placed all residents at risk for falls at risk for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on 3/27/23 and as of the exit date of 8/18/23, the Immediate Jeopardy was ongoing. Findings: Cross reference F600, F607, and F689. Review of the facility's incident log from 3/01/23 to 8/16/23 revealed there were 221 resident falls reported in less than six months, and at least seven resulted in major injuries. The log showed 190 of the total falls were unwitnessed by staff. On 8/15/23 at 1:33 PM and 3:06 PM, and on 8/18/23 at 10:50 AM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) reviewed the facility's incident reports and Risk Management documentation regarding fall incidents for residents #1, #8, and #9. They acknowledged the interdisciplinary team's (IDT) fall analyses and selected fall prevention interventions for these residents were not effective as evidenced by repeated falls that involved similar locations, circumstances, and/or activities. The ADON stated the facility conducted daily IDT meetings and weekly Risk Management meetings which were attended by clinical leaders and nursing management. She stated the meetings involved discussions regarding all residents who fell, but she was unable to explain why these clinical leaders, either individually or as a group, had not accurately determined root causes for falls and developed effective interventions. The DON explained for a while, the lead Minimum Data Set (MDS) Nurse / Care Plan Coordinator did not attend daily IDT meetings. She acknowledged it was important for the correct staff members to attend team meetings to get the best results from discussions. The DON stated although the Director of Rehab participated in daily IDT meetings, essential safety recommendations for resident #1 were not shared with the team. She explained in the past, therapists completed communication forms to present recommendations to the Nursing department. On 8/16/23 at 11:34 AM, the ADON stated the DON was on extended leave for approximately six weeks, from mid-June to the end of July 2023. She acknowledged many of the fall incidents and injuries reviewed during the survey occurred during that timeframe. She explained she was made interim DON for that period and continued in her role as Risk Manager. The ADON described the situation as very challenging. On 8/17/23 at 1:46 PM, the ADON stated during IDT meetings, the team usually did not thoroughly review the active fall prevention interventions on the care plan. She said, We don't all bring our computers, but when we decide on an appropriate intervention either me or the Unit Manager put it on if it's not there. She explained the Lead MDS Nurse / Care Plan Coordinator brought her computer to the IDT meeting, but she was not expected to enter anything in the care plans at that time. The ADON said, We should probably be a little more thorough and discuss in more detail. On 8/17/23 at 2:24 PM, a meeting was held with representatives of the facility's administrative and clinical leadership team, the Executive Director, the DON, and the Regional Nurse: On 8/17/23 at approximately 2:26 PM, the DON explained she usually reviewed fall data every month, and lately she had been doing weekly review as she noted an increase in falls. She stated she was currently in the process of compiling data such as the shifts, times of day, and units associated with falls. The DON acknowledged she was responsible for overseeing the ADON's work, but she was not sure if she reviewed the content of all fall investigations including interventions that were done while she was on leave. On 8/17/23 at approximately 2:29 PM, the Regional Nurse confirmed the facility's Performance Improvement Plan related to fall management was still in the development stage. When informed of scoop mattresses and/or scoop overlay devices that were deemed necessary but not provided for resident #8, #9, #11, and #12, the Regional Nurse validated all members of the IDT were responsible for reviewing falls and ensuring interventions were implemented. On 8/17/23 at approximately 2:32 PM, the Executive Director was asked how the facility ensured adequate clinical leadership during the DON's 6-week absence. He explained the ADON had the support of the team including the Staff Development Coordinator (SDC), and in addition, a Licensed Practical Nurse with many years of experience with the company was made available to assist her. The Executive Director validated the SDC had her own job responsibilities and the ADON also had full-time job duties including that of Risk Manager. The Regional Nurse interjected that she was in the facility one day every week to support the ADON during the DON's absence. On 8/18/23 at 12:15 PM, the facility's Medical Director stated he received data on falls during monthly Quality Assurance and Performance Improvement meetings. He stated trends changed from month to month and from quarter to quarter, but he was not aware of a significant recent increase in falls. The Medical Director verified he was informed the ADON covered for the DON during her leave of absence, but he did not recall being given any specific information regarding arrangements for supplemental clinical leadership and support. Review of the job description for the Executive Director (dated 1/08/21) revealed he would provide .leadership and direction for overall facility operations to provide quality patient care. The document specified the Executive Director was ultimately responsible for every department, and his responsibilities included being aware of all incidents and accidents, taking proper actions, and consulting with department heads regarding resolution of issues. The job description for the Director of Nursing (dated 4/06/17) read, The Director of Nursing plans, organizes, develops, and directs the overall operation of the Nursing department to assure patient safety. Review of the Facility Assessment Tool, dated February 2023, revealed the facility would ensure sufficient staff to meet residents' care needs. The staffing plan listed nursing personnel who had administrative duties including the DON, ADON/Risk Manager, and SDC. The Facility Assessment Tool indicated the facility would evaluate accidents and incidents to identify if either a systems error or human error required re-training or policy change.