**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident's wishes related to health care treatments and procedures at the end of life were accurately recorded and readily available to nursing staff. As a result, the nursing staff failed to honor an Advance Directive that reflected the decision to withhold Cardiopulmonary Resuscitation (CPR) for 1 of 2 residents reviewed for CPR, of a total sample of 6 residents, (#1). These failures contributed to resident #1 receiving CPR against his wish for a natural, dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE], resident #1's sister/Healthcare Proxy signed a State of Florida Do Not Resuscitate Order (DNRO) and placed her brother in Hospice. He was readmitted to the facility on [DATE], at which time the DNRO had not yet been signed by the physician. On [DATE] the Hospice nurse handed the completed and signed DNRO form to the South Court Unit Manager (UM). The UM entered the DNRO Physician order in the Electronic Medical Record (EMR) and flagged the paper order in the Hospice chart instead of the Code Status Binder. Upon receipt of the DNRO form, per facility policy, the UM should have entered the order into the EMR, scanned the DNRO form into the EMR and placed the paper copy in the Code Status binder on the unit. The Code Status Binder was a quick reference the nursing staff utilized to confirm the residents' code status in case of an emergent situation. On [DATE], at approximately 10:00 PM the attending nurse, Licensed Practical Nurse (LPN) D found resident #1 unresponsive with no pulse or respirations. LPN D checked the EMR for physician orders and headed to the North Court to find the Director of Nursing (DON) who was working as a floor nurse at that time. LPN D informed the DON resident #1 expired, was in hospice and a DNR. The DON went to the South Court and LPN E informed her resident #1 had a Physician's order for DNRO in the EMR but no DNRO form scanned into the EMR nor placed in the Code Status Binder. The DON instructed LPN E to call 911 and have the crash cart brought to resident #1's room. The DON and LPN D went to resident #1's room and initiated CPR. CPR continued until Emergency Medical Services (EMS) arrived, assessed the resident, and pronounced the resident's time of death to be 10:20 PM. The facility's failure to honor the right to choose withholding of lifesaving interventions placed all residents with a DNRO at risk for serious psychosocial harm, physical trauma, and prolonged undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE], and the facility corrected the noncompliance at F678 on [DATE]. The noncompliance at F678 was determined to be past noncompliance. Findings: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral ischemia, chronic obstructive lung disease and respiratory failure with hypoxia. Review of the Minimum Data Set Significant Change in Status assessment with Assessment Reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 00 which indicated severe cognitive impairment. The document indicated the resident received Hospice services. Review of resident #1's medical record revealed a copy of the State of Florida DNRO canary yellow form signed by the resident's sister/Healthcare Proxy on [DATE]. The form was signed by the physician on [DATE]. The document showed the sister's signature under the statement, Based upon informed consent I, the undersigned hereby direct that CPR be withheld or withdrawn. The proxy box was checked. The physician's statement read, . I direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest. Review of the physician's order dated [DATE] read, Do Not Resuscitate. On [DATE] at 4:25 PM, the South Court UM stated when resident #1 returned from the hospital he was a full code. She explained the Hospice nurse informed her that although resident #1's sister had signed the DNRO form, the physician had not signed it and she would bring it to the facility once it was signed. The UM stated she received the now complete DNRO form from Hospice on [DATE]. She confirmed she entered the Physician's order for DNR in the EMR. She explained she then incorrectly placed the DNRO form in resident #1's Hospice chart instead of the Code Status binder. The UM recalled, I remember that I flagged it so I would get back to it. I am not sure what happened after that. The UM noted DNR forms were usually completed by the Social Worker or Admissions staff and were scanned into the electronic medical record. The UM stated scanning the document into the electronic medical record had always been the facility's process, but the new process was to place the document in the Code Status binder. She acknowledged she had received training and was aware of the process to place the DNRO form into the Code Status binder. She stated resident #1's canary yellow DNRO form was later found lying on the chart rack instead of being in the Code Status binder. On [DATE] at 5:04 PM, Registered Nurse (RN) A stated on [DATE] he worked on the North Court with the DON when LPN D informed resident #1 had expired. He said the DON and LPN D proceeded to the resident's room. RN A explained he went to the resident's room shortly after and the DON instructed him to take over chest compressions so she could call Hospice to clarify resident #1's code status. RN A stated he performed CPR for about 2-3 minutes before EMS arrived. He recalled EMS did not perform CPR and stopped the code. He explained the DON came back to the room at that moment and said resident #1 was not to be resuscitated. On [DATE] at 5:30 PM, Certified Nursing Assistant (CNA) B stated she was assigned to resident #1 on [DATE]. She recalled resident #1 was awake when she provided incontinence care between 9:00-9:30 PM. She stated CNA F checked on him after she provided incontinence care, and he was watching television at that time. On [DATE] at 12:34 PM, during a telephone interview, the DON who no longer worked at the facility, described the sequence of events on [DATE]. She stated on [DATE] she worked the 3 PM to 11 PM shift. She said she worked extra shifts to avoid using agency and it gave her a chance to work with the staff and get to know the residents better. She recalled LPN D came to the unit and informed her resident #1 was not breathing, did not have a pulse and was a DNR. The former DON remembered as she proceeded to resident #1's room, LPN F said resident #1 was a full code as there was no canary yellow DNR form in the Code Status binder. She said, I looked for the Hospice binder but could not find it, so I looked in the medical record for the scanned DNR copy. I questioned whether the physician's DNR order was entered in error as there was no yellow DNR form located. She indicated she and LPN D proceeded to the resident's room and started CPR. She explained when RN A arrived, she instructed him to take over chest compressions and she left to verify the resident's code status with Hospice. She said Hospice services verified resident #1 had advance directives for DNR. She recalled when she returned to resident #1's room, EMS had already stopped the code. On [DATE] at 4:36 PM, during a telephone interview resident #1's sister stated her brother went on Hospice services and she signed the DNR form. She explained she wanted her brother to die in peace and not endure any prolonged suffering. She said she was informed the facility performed CPR against their wishes and, That made me very upset because he was a DNR and then they did do it after I said not to do it. It really irritates me. On [DATE] at 4:04 PM, an interview with the Administrator, Interim DON, Assistant Director of Nursing (ADON), and Corporate Nurse Consultant was conducted to review the incident. The Administrator stated a full investigation was completed following the incident with resident #1 and all nurses involved were suspended pending the investigation. He said the DON was terminated after the investigation was completed and LPN D who was an agency nurse was put on the Do Not Return list. The Administrator said the root cause was the Code Status binder was not updated. The ADON stated the Code Status binder was a new process that began in February and all nursing staff were educated. She said the nurse who received the canary yellow DNRO form should have placed the form in the Code Status binder. The Administrator said the Social Service Director (SSD) should have verified the Code Status of all residents monthly. On [DATE] at 5:30 PM, the SSD stated she previously completed monthly audits of resident charts for code status but now did them weekly. She explained the process included review of the Code Status on the profile and ensured it matched the order from the doctor. She said now she also checked care plans and verified the code sheet was scanned into the electronic medical record. The SSD stated all resident charts were reviewed in morning meetings. The SSD acknowledged she missed resident #1's order and said, I was getting behind in my charting and wanted to create a more effective process. Review of Advanced Directives Code Status policy dated 1/2024 read: Do Not Resuscitate (DNR)- A DNR code status would indicate the person would not want CPR performed and would be allowed to die naturally if their heart stopped beating and/or they stopped breathing. Review of the facility's corrective actions were verified by the survey team and included the following: On [DATE], the Attending Physician, Medical Director, Administrator, and family were notified of the incident and an investigation was initiated. On [DATE] an Ad Hoc Quality Assurance Performance Improvement (QAPI) was completed with the Medical Director, Administrator, Assistant Director of Nursing and additional administrative staff members on the adherence to policy and procedures for Advanced Directives code status related to the Electronic Health record, Code Status binders, following physician orders and a review of the root cause analysis. The ADON completed an audit of Code Status binders for current residents residing in the facility to validate DNR forms were in the appropriate binder. No additional concerns were identified. On [DATE] and [DATE], and [DATE], QAPI meetings were held with the Administrator, Director of Nursing, Medical Director, and administrative staff. Education, audits, and drills were reviewed and revised as indicated. On [DATE] to [DATE], 27 of 29 licensed nurses were educated on Advanced Directives Code Status standards and guidelines with emphasis on updating Code Status binders with the appropriate form when Code Status orders were obtained, ensure DNR form was scanned into the medical record and on following Code Status orders. Code Status Competencies were completed with licensed nurses to validate education received. Two of 29 nurses were currently on leave and were to be educated prior to return to work. Any contracted nurses at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet. New hired nurses at the facility will receive the above education during orientation and prior to working an assignment. From [DATE] through [DATE], a total of twenty-nine mock code drills were completed to ensure competency of Code Blue process. All nurses attended the drill and were given a posttest after the drill was completed. On [DATE], the Social Services Director received education on Advanced Directives Code Status standards and guidelines with emphasis on Social Services' roles and responsibilities from Regional Nurse Consultant. Weekly audits were conducted to ensure the EMR and Code Status binder matched, knowledge checks with 5 nursing staff to conduct knowledge of training, new admissions/readmissions, and residents with changes in Code Status orders verified three times a week for accuracy. Reviews completed [DATE], [DATE], [DATE], [DATE], [DATE] with 100% compliance. From [DATE] to [DATE], the facility took actions to reduce the risk of future occurrences. All staff were educated regarding the policy and procedure related to Advanced Directives with a focus on Code Status and following the Physician's orders with post-test. New Hire staff orientation to include Code Blue response and verification of Code Status in EMR and Code Status Binder, Code Status and Advanced Directives confirmed at the time of admission and orders placed in EMR. Code Status and Code Blue Drills (includes verifying Code Status, Advance Directives and DNRO). Interviews conducted on [DATE] to [DATE] with staff members (8 Certified Nursing Assistants, 4 Licensed Practical Nurses, 5 RNs, and the SSD) indicated they were knowledgeable of Advance Directives and where to verify the Code Status in the EMR and Code Status binder prior to providing CPR. The surveyors validated the education with attendance sheets for Code Blue drills and in-services. Review of QAPI audits revealed the audits were completed as described per Performance Improvement plan. The resident sample was expanded to include eight additional residents who elected DNR status. Interviews and record reviews revealed no concerns for residents #7, #8, #9, #10, #11, #12, #13, #14 related to Advance Directives. Residents #13 and #14 expired in the facility and their DNR status was honored. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance as of [DATE].

**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 failing to provide necessary care and services to prevent falls with major injuries and failed to develop and revise fall management approaches to mitigate the fall risk for 1 of 6 residents reviewed for falls of a total sample of 6 residents, (#4). These failures contributed to falls with major injury for resident #4 who required hospitalization, surgery, and rehabilitation for hip fracture. Resident #4 suffered excruciating pain, and was placed at risk blood clots, infection, pneumonia and decline in function. Resident #4 was a physically and severely cognitively impaired resident identified at high risk for falls. The resident sustained 11 falls in the past 10 months. On 8/08/2023, he sustained a fall that resulted in a fracture of his left femur (hip bone) that required hospitalization and surgical repair. The facility relied on safety equipment and staff monitoring at 15-minute to 30-minute intervals for 72 hours to prevent falls. These approaches proved ineffective as resident #4 had two additional falls in 5 days after he returned from the hospital from hip surgery. The facility did not increase or individualize supervision and monitoring of the resident in his plan of care to prevent falls with major injuries. The facility's failure to provide necessary fall prevention care and services to mitigate the risk for falls with major injury contributed to resident #4's fall with major injury and placed all residents at risk for falls at risk for injury/impairment/death. This failure resulted in Immediate Jeopardy which began on 8/08/2023 and was removed on 9/02/2023. Findings: Cross reference F689 Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital after hip surgery with diagnoses of repeated falls, osteopenia (bone weakness), osteoporosis (weak, thin, and brittle bones), displaced fracture of left femur, hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, lack of coordination, muscle weakness, epilepsy, cognitive function and awareness impairment, and severe dementia. A displaced fracture of the femur is a type of fracture where the trauma moves the bone fragments out of alignment. Complications from surgery may include pneumonia, infection, pain, bleeding, blood clots, embolism, nerve damage, and malalignment of bones, (retrieved on 9/08/2023 from the John Hopkins Medicine website at www.hopkinsmedicine.org). The Minimum Data Set (MDS) Discharge Return Anticipated assessment with Assessment Reference Date of 8/11/2023 revealed resident #4 had a fall with major injury and an unplanned discharge to the hospital. The assessment showed he had memory problems, severely impaired cognitive skills for daily decision-making, walked in his room and the corridor during the 7 day look back period, and had two or more falls since the assessment, three months prior. Review of the Comprehensive Care Plan noted resident #4 was at risk for falls and injury related to history of falls, seizures, and impaired mobility. He had impaired cognitive function with interventions to cue, supervise, and reorient the resident. He required monitoring for complications of a femur fracture, and was at risk for decrease in self-functioning. The goal included that the resident would not sustain a serious fall related injury. On 8/14/23, fall prevention interventions were revised and noted staff were to remind, and reinforce safety awareness; educate resident to request assistance prior to ambulation, place fall mats to both sides of the bed, and a scoop mattress. An intervention for staff to remind the resident to use his call light when he attempted to ambulate, or transfer had been in place since 6/02/2020. On 8/29/2023 at 10:20 AM, the MDS Coordinator said residents' care plan interventions were updated during the Interdisciplinary Team (IDT) morning meeting. She said all interventions implemented after falls were included in the Comprehensive Care Plan. She explained a MDS Significant Change in Status assessment with ARD 8/15/2023 was done after resident #4 sustained a fall with major injury and had a decline in his Activities of Daily Living (ADLs). The Safety Check Log dated 8/08/2023, completed and signed by the Assistant Director of Nursing (ADON) showed from 7:00 AM to 10:45 AM resident #4 was checked every 15 minutes at various locations in the facility. Entries documented at 10:15 AM he was in the hallway near the North Court nurses' station, in his room at 10:30 AM, and he was sent out to the hospital at 10:45 AM. The Post Fall Evaluation report dated 8/08/2023 documented at 10:28 AM, resident #4 was in his room, fell while sitting in his wheelchair and he experienced a 10 out of 10 on a Numeric Rating Scale for pain intensity (numeric pain scale from 0 to 10 with 0 being no pain and 10 being the worst pain imaginable). The report indicated 911 emergency transportation was required to transport the resident to the hospital. On n 8/29/2023 at 9:18 AM, the North Court Unit Manager stated on 8/08/2023, she and the ADON jointly responded to resident #4's fall. She explained she observed the resident on the floor lying flat on his back in front of the sink in his room. She said the resident fell from his wheelchair while he attempted to transfer himself. On 8/31/23 at 10:39 AM, the ADON recalled on 8/08/2023, she worked on the North Court Unit with a regular shift assignment. She stated when she was administering medications to another resident, a Certified Nursing Assistant (CNA) alerted her the resident was on the floor in his room. She said when she observed him on the floor, he moaned very loudly in pain and pointed to his groin area. She said she was very concerned because, he doesn't cry like that. A late entry Progress Notes completed by the Advance Practice Registered Nurse (APRN) effective 8/08/2023 noted nurses asked her to examine resident #4 after he fell out of his wheelchair. The assessment documented the APRN had examined the resident while he was sitting in the wheelchair and read, Patient is complaining of left groin pain and unable to move. Patient is crying in pain which is unusual for him. The IDT Post Fall Review report dated 8/09/2023 documented resident #4 had history of falls, dementia, stroke, cognitive deficits, and he took cardiovascular and anti-seizure medications that may have contributed to his fall on 8/08/2023 when he sustained a displaced hip fracture. The report showed the IDT reviewed the incident and recommended the equipment, parameter mattress. There was no evidence the facility discussed increased supervision of the resident to prevent further falls after he sustained a fall with hip fracture. On 8/29/2023 at 4:17 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) reviewed their investigation of resident #4's fall with major injury of 8/08/2023. The DON said the facility had a standard policy for fall prevention and safety which included nurses to complete neurological checks for 24 hours and as needed, and 30 minute checks for 72 hours on any resident who fell. The DON did not indicate whether any enhanced supervision of the resident was considered post fall other than half hour checks for 3 days. On 8/29/2023 at 12:37 PM, the Rehabilitation Manager said he participated in IDT morning meetings. He said the IDT discussion of falls and intervention approaches were collaborative decisions. He recalled resident #4 was a known high fall risk with a history of multiple falls while attempting to self-transfer. He said the resident received skilled therapy services at various times. He could not recall any discussions about an intervention for increased staff supervision for the resident to prevent falls. On 8/31/2023 at 1:17 PM, CNA B said he knew resident #4 well and had cared for him many times. He recalled when the resident fell on 8/08/23 he observed him on the floor in his room as he was walking by the room. He stated after the fall, he completed a handwritten statement within about 10 minutes and gave it to the North Court Unit Manager. He said he wrote on the document that he had not witnessed the fall and that was all the information he had provided. He said CNA tasks specific to residents were listed on the software program and included any safety checks or special instructions. He said he was not aware of any extra supervision or fall safety duties that were required from CNAs for the resident. On 8/29/2023 a 2:45 PM, Licensed Practical Nurse (LPN) A said nurses were responsible for checking residents on fall and neurological safety checks every 15 to 30 minutes for 72 hours after falls. She stated she knew resident #4 well as she had him on her assignments. She recalled there were no restrictions or person-centered supervision interventions for the resident, and he was able to propel himself anywhere in and around the facility. She said she had worked at the facility for about 9 months and one on one supervision had been utilized in the past to prevent falls for a different resident but not for resident #4. On 8/31/2023 at 10:39 AM, the Assistant Director of Nursing (ADON) said she had known and cared for resident #4 for many years, and he had a poor capacity to remember he needed help to transfer from the bed or chair. She said the resident frequently spent time off the unit in the reception area, and nurses checked on him there when he was on safety checks. She said she participated in the morning Interdisciplinary Team (IDT) meetings, and all falls were discussed. She recalled no fall prevention supervision had been discussed or considered for the resident, aside from the 15 to 30 minute checks by nurses for 72 hours after a fall. She said the facility had implemented one on one supervision for safety in the past with other residents. She did not explain why one to one supervision was not implemented for resident #4 who sustained 11 falls in the past 10 months and a recent fall with hip fracture. The medical Progress Note dated 8/08/2023 documented the Advanced Practice Registered Nurse (APRN) assessed the resident after nursing reported he had a fall from his wheelchair. It was noted the resident was known to transfer himself without using the call light to request assistance and had several falls attempting to transfer himself from his wheelchair to bed and vice versa. It was noted the resident continued to self-propel his wheelchair around the halls and he often sat in the facility lobby watching television or socializing. The Plan of Care included a diagnosis of history of falls and read, -frequent visual of patient to assist with care and prevent falls - continue fall precautions. Review of the medical record included 7 Morse Fall Scale (source: Morse, J. M. (1997), Preventing Patient Falls, 1st edition. Thousand Oaks, California: SAGE Publications, Inc., 1997). evaluations from 4/30/2023 to 8/11/2023 that indicated resident #4's scores continued to increase from 35 (moderate risk) on 4/30/2023, 55 (high risk) on 7/17/2023, 75 (high risk) on 8/08/2023, and 95 (high risk) on 8/11/2023. The Incident Status report showed resident #4 had 2 entries that read, Fall - Unwitnessed after he returned to the facility from the hospital for surgical repair of fractured hip on 8/11/2023. The report showed he sustained a fall the day he returned at 7:36 PM. The Post Fall Evaluation dated 8/11/23 showed the facility's intervention for the fall was low bed frequent checks to coincide with neurological checks and non-skid footwear. There was no indication of any enhanced monitoring of the resident after he had just returned to the facility from recent fractured hip surgery and fell. It was noted the resident had another fall five days after his readmission, on 8/16/2023 at 1:50 PM. The evaluation report noted resident #4 fell from his bed during an unassisted transfer. The intervention added was therapy referral for seating and positioning in wheelchair. Review of the MDS Significant Change assessment with Assessment Reference Date of 8/15/2023 revealed resident #4 scored 3 out of 15 on the Brief Interview for Mental Status which indicated severe cognitive impairment. The assessment showed a decline in functional status since the previous assessment as the resident required extensive assistance of 2 staff for bed mobility and toileting, was unable to use the toilet, and was dependent on staff to move between locations in his room and off the unit. He was unsteady during transfer transitions and was only able to stabilize with staff assistance. The assessment noted the resident had two or more falls since the discharge assessment on 8/08/2023. On 8/29/2023 at 11:33 AM, Physical Therapist (PT) E said she knew resident #4 and had treated him for skilled physical therapy before and after his fall on 8/08/2023. She recalled the resident independently propelled himself around the facility in his wheelchair and was able to walk about 25 feet with moderate staff assistance before he fell. She explained the resident returned from the hospital from hip surgery with functional declines that required skilled therapy services at least 5 days per week. She recalled, the resident was, quick, and had multiple falls mostly because of his impaired cognition and poor safety awareness. The medical Progress Note dated 8/15/2023 by the Advanced Practice Registered Nurse (APRN) showed she examined the resident after he had returned to the facility after hospitalization for left hip fracture surgery. It was noted the resident was known to transfer himself without assistance without using the call light and had several falls attempting to transfer himself from his wheelchair to bed and vice versa. It was noted the resident continued to self-propel his wheelchair around the halls and he often sat in the facility lobby watching television or socializing. The Plan of Care included Repeated Falls and History of Falls with comments that read, -frequent visual of patient to assist with care and prevent falls - continue fall precautions. On 8/29/2023 at 1:31 PM, Occupational Therapist (OT) D said she knew resident #4 well and treated him frequently. She recalled the resident, and explained after he returned from the hospital his cognition and abilities to complete ADL functions were worsened. She stated, he was different; he had a decline. The Physical Therapy Evaluation and Plan of Treatment completed on 8/14/2023 revealed after resident #4 returned from the hospital he showed a decline in his functional mobility, was dependent on staff to transfer and use a wheelchair, had impaired decision making for routine activities, complexities of dementia, and he required inpatient skilled PT as without it, he was at risk for falls, contractures, skin injury, and rehospitalization. On 8/31/2023 at 12:50 PM, CNA C said she knew resident #4 very well, and she had cared for him frequently. She recalled there had been no safety or fall check duties aside from the 15 or 30 minute checks by the nurse assigned to the resident. She noted he had multiple falls and she tried to remind him to ask for help. She explained, after the resident returned from the hospital, he required more assistance and supervision. She said the resident became worse as the week progressed. She stated she was concerned and informed nurses the resident had not been eating well, and he coughed a lot, especially when she assisted him to eat. On 8/29/2023 at 4:28 PM, the DON said falls were reviewed by the IDT during morning clinical meetings where interventions were discussed, and the plan of care was updated and revised. She checked resident #4's medical record and reviewed 14 falls from 11/05/2022 to 8/16/2023. In 9 months, 13 falls occurred while the resident transferred himself, 9 from his bed, and 4 from his wheelchair. One fall occurred during staff assisted wheelchair transport. The interventions that were implemented after the falls included, 15 to 30 minute nurse checks, a non-slip cushion added to the wheelchair, a scoop (perimeter) mattress added to the bed, floor mats added to both sides of the bed, bed in low position, non-skid footwear, leg rests added to the wheelchair, therapy services, and scheduled ADL assistance. On 8/31/2023 at 10:13 AM, the DON said the facility investigated resident #4's fall with major injury of 8/08/2023. She explained she took statements from several nurses and CNAs who worked with the resident. She explained the resident fell out of bed while attempting to transfer himself. She provided typewritten, unsigned and undated documents as statements she received from nurses and CNAs. She said the facility added a perimeter mattress to the resident's bed before he returned from the hospital as an intervention to prevent further falls. She was not able to provide a statement from the North Court Unit Manager who assessed the resident immediately after the fall. She did not explain why there was not any additional supervision of the resident implemented aside from the half hour checks for 3 days. She provided all Safety Check Logs implemented after the resident returned from the hospital. The logs were dated from 8/11/2023 at 11:45 AM to 8/12/2023 at 7:00 AM with 30 minute checks, and 15 minute checks from 8/12/2023 at 7:00 AM to 8/13/2023 at 3:00 PM. There was no documentation that addressed why the 15 to 30 minute Safety Checks continued to be implemented after each fall but proved to be ineffective to prevent further falls that caused a fracture. On 9/01/2023 at 10:02 AM, the APRN said she knew resident #4 well. She said the resident had very poor cognition and was not able to understand safety concerns. She acknowledged her notes mentioned the plan of care was for frequent visual of patients to prevent falls. She clarified that by frequent, she meant for staff to follow the facility's policy. She said she was aware the facility routinely utilized 15 to 30 minute checks after falls occurred. She recalled the facility had implemented one on one supervision in the past for resident safety concerns, and she was not aware of why it had not been implemented for resident #4. She stated a chair or bed alarm could have alerted staff when the resident attempted to get up but did not explain why this measure was not used for resident #4. On 9/01/2023 at 5:34 PM, the facility's Medical Director said he was not aware resident #4 fell 11 times in 8 months prior to the fall that resulted in a major injury until after the resident returned from the hospital. He recalled the facility reported to him that there were therapy interventions that had not been documented or done. He stated the facility could improve their processes so they could catch potential problems earlier. The facility's policies and procedures titled, Abuse, Neglect, and Exploitation revised 10/01/2022, read, Policy . facility to provide protection for the health, welfare, and rights of each resident . and prevent abuse, neglect, and exploitation . Neglect means failure of the facility, it's employees, or it's service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 8/28/2023, licensed nurse education was initiated on the facility's Fall Prevention Program that included providing resident care and services to minimize the likelihood of falls and reviewing and updating care plans when residents fell. *On 8/28/2023, the facility conducted an ad hoc Quality Assurance and Performance Improvement Committee meeting for fall prevention and follow up actions post fall. *On 8/29/2023, Morse Fall Scale Evaluations were completed on all residents to identify their risk *On 8/30/2023, the IDT reviewed and revised fall care plan interventions for residents at moderate to high level of fall risk. *On 8/30/2023, Fall Prevention Program education for licensed nurses was completed and included: providing resident care and services to minimize the likelihood of falls, reviewing and updating care plans when residents sustain a fall, newly hired nurses to receive same education during orientation. All nurses with the exception of 6 were educated, and the remaining 6 were to receive the education prior to working. Agency nurses were to receive education prior to acceptance of an assignment. *On 9/02/2023, the nursing management team was educated by the DON for staff monitoring and audits of implemented fall interventions to ensure appropriateness and verify implementation. The Unit Manager or designee to conduct at minimum daily unit rounds to verify interventions are in place. IDT clinical meetings will include discussions. A dedicated Fall Monitor staff position was implemented for duty from 7:00 AM to 11:00 PM every day tasked to hourly visualize 17 residents identified as high fall risk. The Fall Monitor will notify the Charge Nurse should a resident concern for fall safety arise. The resident with an identified concern will be placed on one to one supervision until the IDT reviews the resident and determines if enhanced supervision is needed. New resident admissions or readmissions who have undergone orthopedic surgery will be included in the Fall Monitor's rounds assignment regardless of their fall risk status until the IDT team reviews the resident and determines Fall Monitor supervision is no longer necessary. Review of in-service attendance sheets revealed education completion reports and staff signatures to reflect participation in education on topics listed above. From 8/29/2023 to 9/02/2023, interviews were conducted with 16 staff members that included 5 CNAs, 5 LPNs, 3 RNs, 1 PT, 1 OT, the APRN, Admissions Coordinator, Activities Assistant, Staffing Coordinator, and Fall Monitor verbalized understanding of the education provided. *On 9/02/2023, 62 out of 67 nurses and CNAs were re-educated in person, onsite, and remotely. No clinical staff will be permitted to work without receiving in person education. Newly hired staff will receive the above education in orientation. The resident sample was expanded to include 5 additional vulnerable residents at risk for falls. Observations, interviews, and record review revealed no concerns related to falls for residents #1, #2, #3, #5, and #6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and provide effective fall management approaches and increased supervision for physically and cognitively impaired residents to avoid falls with major injury for 1 of 6 residents reviewed for falls, (#4). Resident #4 was a physically and severely cognitively impaired resident identified at high risk for falls. The resident sustained 11 falls in the past 10 months. On [DATE], he sustained a fall that resulted in a fracture of his left femur (hip bone) that required hospitalization and surgical repair. The resident returned from the hospital on [DATE] and fell two more times, on the day of readmission and again on [DATE]. The facility's failure to develop and implement appropriate fall management interventions and provide the level of staff supervision required to ensure his safety, contributed to resident #4's fall with major injury and placed all residents who were at risk for falls at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F600, and F777 Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital after hip surgery with diagnoses of repeated falls, osteopenia (bone weakness), osteoporosis (weak, thin, and brittle bones), displaced fracture of left femur, hemiplegia (paralysis) and hemiparesis (weakness) of the left non-dominant side, lack of coordination, muscle weakness, epilepsy, cognitive function and awareness impairment, and severe dementia. A displaced fracture of the femur is a type of fracture where the trauma moves the bone fragments out of alignment. Complications from surgery may include pneumonia, infection, pain, bleeding, blood clots, embolism, nerve damage, and malalignment of bones, (retrieved on [DATE] from the John Hopkins Medicine website at www.hopkinsmedicine.org). Review of the Incident Status Report included an entry for resident #4, that read, Fall - Unwitnessed on [DATE] at 10:29 AM. The Hospital Transfer Form completed by the Assistant Director of Nursing (ADON) dated [DATE] did not note, High Fall Risk under the section, Risk Alerts. A Risk Alert for seizures was checked. Activities of Daily Living (ADLs) was noted as the resident required assistance. The section titled, Usual Mental Status/Cognitive Function before the Acute Change in Condition was noted as, Alert, oriented, follows instructions. The Minimum Data Set (MDS) Discharge Return Anticipated assessment with Assessment Reference Date of [DATE] revealed resident #4 had a fall with major injury and an unplanned discharge to the hospital. The assessment showed he had memory problems, severely impaired cognitive skills for daily decision-making, walked in his room and the corridor during the 7 day look back period, and he had two or more falls since the assessment, three months prior. Review of resident #4's Medication Administration Record (MAR) for [DATE] showed active physicians orders for medications that included Heparin (blood thinner) 5000 units every 12 hours to prevent blood clots after surgery, Hydralazine 50 milligrams (MG) every 12 hours for hypertension, Keppra (anti-seizure) 750 MG every 12 hours for seizures, Oxycodone 5-325 MG every 4 hours as needed for pain, Amlodipine 2.5 MG once a day for hypertension, Lisinopril 40 MG once a day for hypertension, Metoprolol Tartrate 50 MG two times a day for hypertension, Aspirin 81 MG once a day for heart disease, and Lasix 20 MG once a day for edema, The Treatment Administration Record (TAR) for [DATE] noted on [DATE], resident #4 had a surgical wound on his left hip that required daily skilled nursing care and treatments. On [DATE] at 1:17 PM, Certified Nursing Assistant (CNA) B said he knew resident #4 well and had cared for him many times. He recalled when the resident fell on [DATE] he observed him on the floor in his room as he was walking by the room. He stated after the fall, he completed a handwritten statement within about 10 minutes and gave it to the North Court Unit Manager. He said CNA tasks specific to residents were listed on the software program and included any safety checks or special instructions. He said he was not aware of any extra supervision or fall safety duties that were required from CNAs for the resident. On n [DATE] at 9:18 AM, the North Court Unit Manager stated on [DATE], she and the Assistant Director of Nursing (ADON) jointly responded to resident #4's fall. She explained she observed the resident on the floor lying flat on his back in front of the sink in his room. She said the resident fell from his wheelchair while he attempted to transfer himself. On [DATE] at 10:39 AM, the ADON said she had known and cared for resident #4 for many years, and he had a poor capacity to remember he needed help to transfer from the bed or chair. She said the resident frequently spent time off the unit in the reception area, and nurses checked on him when he was on safety checks. She said she participated in the morning Interdisciplinary Team (IDT) meetings, and all falls were discussed. She recalled no fall prevention supervision had been discussed or considered for the resident, aside from the 15 to 30 minute checks by nurses for 72 hours after a fall. She said the facility had implemented one to one supervision for safety in the past with other residents but could not remember resident #4 being on one to one supervision. She stated CNAs used the [NAME] included in the medical record for residents' plan of care, safety concerns, and to document the tasks they completed. She recalled on [DATE], she worked on the North Court Unit with a regular shift assignment. She stated when she administered medications to another resident, a CNA alerted her that resident #4 was on the floor in his room. She said when she observed him on the floor, he moaned very loudly in pain and pointed to his groin area. She said she was very concerned because, he doesn't cry like that. On [DATE] a 2:45 PM, Licensed Practical Nurse (LPN) A said nurses were responsible for checking residents on fall and neurological safety checks every 15 to 30 minutes for 72 hours after falls. She said she knew resident #4 well as she was assigned to care for him many times. She recalled there were no restrictions or person-centered supervision interventions for the resident, and he was able to propel himself anywhere around the facility. She said she had worked at the facility for about 9 months and one on one supervision had been utilized in the past to prevent falls for a different resident but not for resident #4. On [DATE] at 4:17 PM, the Director of Nursing (DON) said the facility had a standard policy for fall prevention and safety which included nurses to conduct neurological checks for 24 hours and as needed, and 30 minute checks for 72 hours for any resident who fell. Review of the Comprehensive Care Plan noted resident #4 was at risk for falls and injury related to history of falls, seizures, and impaired mobility, risk for injury related to osteopenia and osteoporosis, impaired cognitive function with interventions to cue, supervise, and reorient the resident, as needed, monitoring for complications of a femur fracture, risk for decrease in ADL self-functioning as the resident required cueing for safety and staff assistance to complete ADLs with goals that he would maintain his level of functioning, risk and monitoring for adverse effects of anti-seizure and diuretic (fluid excretion) medications, risk for injury or complications of medications that could cause abnormal or excess bleeding. Goals included that the resident would not sustain a serious fall related injury. On [DATE], fall prevention interventions were revised and noted staff were to remind, and reinforce safety awareness; educate resident to request assistance prior to ambulation, place fall mats to both sides of the bed, and a scoop mattress. An intervention for staff to remind the resident to use his call light when he attempted to ambulate, or transfer had been in place since [DATE] despite the resident's impaired cognition and poor safety awareness. The physician's Progress Note dated [DATE] documented the Advanced Practice Registered Nurse (APRN) assessed resident #4 after nursing reported he fell from his wheelchair. It was noted the resident was known to transfer himself without assistance without using the call light and had several falls attempting to transfer himself from his wheelchair to bed and vice versa. The note included the resident continued to self-propel his wheelchair around the halls and he often sat in the facility lobby watching television or socializing. The Plan of Care included a diagnosis of history of falls that read, frequent visual of patient to assist with care and prevent falls-continue fall precautions. The Late Entry Progress Notes completed by the APRN effective [DATE] noted nurses asked her to examine resident #4 after he fell out of his wheelchair. The assessment documented the APRN had examined the resident while he was sitting in the wheelchair and read, Patient is complaining of left groin pain and unable to move. Patient is crying in pain which is unusual for him. The Safety Check Log dated [DATE], completed and signed by the ADON showed from 7:00 AM to 10:45 AM, resident #4 was checked every 15 minutes at various locations in the facility. Entries documented at 10:15 AM he was in the hallway near the North Court nurses' station, in his room at 10:30 AM, and he was sent out to the hospital at 10:45 AM. The Post Fall Evaluation report dated [DATE] documented at 10:28 AM, resident #4 was in his room and fell while sitting in his wheelchair and he experienced a 10 out of 10 on a Numeric Rating Scale for pain intensity (numeric pain scale, from 0 to 10 with 0 being no pain and 10 being the worst pain imaginable). The report indicated 911 emergency transportation was required to transport the resident to the hospital. The IDT Post Fall Review report dated [DATE] documented resident #4 had a history of falls, dementia, stroke, cognitive deficits, and he took cardiovascular and anti-seizure medications that may have contributed to his fall on [DATE] when he sustained a displaced hip fracture. The report showed the IDT reviewed the incident and recommended the equipment, parameter mattress. The Incident Status Report showed resident #4 had 2 additional unwitnessed falls when he returned from the hospital post hip fracture surgery, on [DATE] at 7:36 PM, the same day he returned, and again on [DATE] at 1:50 PM. The Post Fall Evaluation report dated [DATE] documented at 7:30 PM, resident #4 fell from his bed during an unassisted transfer. Immediate interventions read, low bed frequent checks to coincide with neuro checks and non-skid footwear. Review of the medical record included 7 Morse Fall Scale (source Morse, J. M. Preventing Patient Falls 1st edition. Thousand Oaks, California: SAGE Publications. Inc., 1997) evaluations from [DATE] to [DATE] that indicated resident #4's scores continued to increase from 35 (moderate risk) on [DATE], to 55 (high risk) on [DATE], 75 (high risk) on [DATE], and 95 (high risk) on [DATE]. Review of the resident's care plans did not show any evidence that any increased monitoring or supervision of the resident was implemented when his risk of falls changed from medium risk to high risk. On [DATE] at 11:33 AM, Physical Therapist (PT) E said she knew resident #4 and had treated him for skilled physical therapy before and after his fall on [DATE]. She recalled the resident independently propelled himself around the facility in his wheelchair and was able to walk about 25 feet with moderate staff assistance before he fell. She explained the resident returned from the hospital from hip surgery with functional declines that required skilled therapy services at least 5 days per week. She recalled, the resident was, quick, and had multiple falls mostly because of his impaired cognition and poor safety awareness. On [DATE] at 10:20 AM, the MDS Coordinator said residents' care plan interventions were updated during the IDT morning meeting. She said all interventions implemented after falls were included in the Comprehensive Care Plan. She said the date of revision was the date the intervention was added or revised. She said a MDS Significant Change in Status assessment with ARD [DATE] was done after resident #4 sustained a fall with major injury and had a decline in his ADLs. Review of the MDS Significant Change assessment with Assessment Reference Date of [DATE] revealed resident #4 scored 3 out of 15 on the Brief Interview for Mental Status which indicated severe cognitive impairment. The assessment showed a decline in functional status since the previous assessment as the resident required extensive assistance of 2 staff for bed mobility and toileting, was unable to use the toilet, and he was dependent on staff to move between locations in his room and off the unit. He was unsteady during transfer transitions and was only able to stabilize with staff assistance. The assessment noted the resident had two or more falls since the discharge assessment on [DATE]. The physician's Progress Note dated [DATE] by the APRN showed she examined the resident after he returned to the facility from the hospital after left hip surgery. It was noted the resident was known to transfer himself without assistance without using the call light and had several falls attempting to transfer himself from his wheelchair to bed and vice versa. It was noted the resident continued to self-propel his wheelchair around the halls and he often sat in the facility lobby watching television or socializing. The Plan of Care again included diagnosis of history of falls with -frequent visual of patient to assist with care and prevent falls - continue fall precautions. On [DATE] at 12:50 PM, CNA C said she knew resident #4 very well, and she had cared for him frequently. She recalled there had been no safety or fall check duties aside from the 15 or 30 minute checks by the nurse assigned to the resident, and he had multiple falls even though she tried to remind him to ask for help. She did not explain how the resident would be able to remember to ask staff for help with his severe cognitive impairment. She explained, after the resident returned from the hospital, he required more assistance and supervision. She said the resident became worse as the week progressed. She stated she was concerned and informed nurses the resident not been eating well, and he coughed a lot, especially when she assisted him to eat. The IDT Post Fall Review report dated [DATE] documented resident #4 had a history of falls, dementia, stroke, cognitive deficits, and he took cardiovascular and anti-seizure medications that may have contributed to the fall from his wheelchair on [DATE]. The report showed the IDT reviewed the incident and recommended, therapy referral for seating and positioning in wheelchair. On [DATE] at 12:37 PM, the Rehabilitation Manager said he participated in IDT morning meetings. He said the IDT falls and intervention approaches were collaborative decisions. He recalled resident #4 was a known high fall risk with a history of multiple falls while attempting to self-transfer. He said the resident received skilled therapy services at various times. He could not recall any discussions about an intervention for increased staff supervision for the resident to prevent falls. On [DATE] at 10:13 AM, the DON said the facility investigated resident #4's fall with major injury on [DATE]. She explained she took statements from several nurses and CNAs who worked with the resident. She said the resident had fallen out of bed while attempting to transfer himself. She provided typewritten, unsigned and undated documents as statements she received from nurses and CNAs. She said the facility added a perimeter mattress to the resident's bed before he returned from the hospital as an intervention to prevent further falls. She was not able to provide a statement from the North Court Unit Manager who assessed the resident immediately after the fall. On [DATE] at 1:31 PM, Occupational Therapist (OT) D said she knew resident #4 well and treated him frequently. She recalled the resident, and explained after he returned from the hospital his cognition and abilities to complete ADL functions were worsened. She stated, he was different; he had a decline. On [DATE] at 4:28 PM, the DON said falls were reviewed during morning clinical meetings and plan of care was updated and revised. She checked resident #4's medical record and reviewed 14 falls from [DATE] to [DATE]. In 9 months, 13 falls occurred while the resident transferred himself, 9 from his bed, and 4 from his wheelchair. One fall occurred during staff assisted wheelchair transport. The interventions that were implemented after the falls included, 15 to 30 minute nurse checks, a non-slip cushion added to the wheelchair, a scoop (perimeter) mattress added to the bed, floor mats added to both sides of the bed, bed in low position, non-skid footwear, leg rests added to the wheelchair, therapy services, and scheduled ADL assistance. The DON did not explain if any increased supervision or monitoring of the resident was implemented after he sustained 14 falls in 9 months. On [DATE] at 10:02 AM, the APRN said she knew resident #4 well. She said the resident had very poor cognition and was not able to understand safety concerns. She acknowledged her notes mentioned the plan of care was for frequent visual of patients to prevent falls. She clarified that by frequent, she meant for staff to follow the facility's policy. She said she was aware the facility routinely utilized 15 to 30 minute checks after falls occurred. She recalled the facility had implemented one on one supervision in the past for resident safety concerns, and she was not aware of why it had not been implemented for resident #4. She stated a chair or bed alarm could have alerted staff when the resident attempted to get up but did not explain why it was not utilized for resident #4. The MDS quarterly assessment with Assessment Reference Date of [DATE] noted resident #4 scored 3 out of 15 on the Brief Interview for Mental Status which indicated severe cognitive impairment. The assessment showed there were no behavioral symptoms or rejections of care or treatment. Functional Status noted the resident required the assistance of 1 staff to complete ADLs, was not steady during transitions from seated to standing, and he was independent to move from locations in his room and off the unit. The assessment indicated the resident had two or more falls in the three months prior to the assessment. The DON provided all Safety Check Logs implemented after the resident returned from the hospital. The logs were dated from [DATE] at 11:45 AM to [DATE] at 7:00 AM with 30 minute checks, and 15 minute checks from [DATE] at 7:00 AM to [DATE] at 3:00 PM. The medical record contained Post Fall Evaluation and IDT Post Fall Review reports for 11 falls resident #4 sustained over 9 months prior to [DATE] when he sustained a fall with major injury. No documentation was found that addressed the 15 to 30 minute nurse Safety Checks that were implemented multiple times failed and were proved ineffective to prevent falls that could have caused major injuries/impairment/death. The Occupational Therapy Evaluation and Plan of Treatment completed on [DATE] revealed resident #4 was cognitively impaired and difficult to redirect, did not feel unsteady when standing, scored 3 out of 12 on the Self Care Function Score, varied from dependency to having required substantial/maximum assistance in his functional mobility (bed, transfers) and to complete ADLs, was not appropriate/safe to use of adaptive equipment, unable to problem solve, and he had severely impaired decision making abilities and capacity for new learning with a severe cognitive decline and exacerbation of cognitive impairment that required maximum cognitive redirection. The Assessment Summary showed after the resident returned from the hospital, he required therapy services and the assessment read, pt (patient) presents /c (with) functional decline in ADLs, generalized weakness, decreased functional mobility, impaired mentation, pt requires skilled OT services to max (maximize) ADL for safe return to NRS/LTC (Nursing Long Term Care) for ease of caregiver burden is skilled OT services pt remains at risk for falls, functional decline, or rehospitalization. Complexities . Lacks insight into condition and risk factors. Multiple medical conditions/history/medications/Other (h/o (history of) agitation/resistant behaviors.). The Physical Therapy Evaluation and Plan of Treatment completed on [DATE] revealed after resident #4 returned from the hospital he showed a decline in his functional mobility, was dependent on staff to transfer and use a wheelchair, had impaired decision making for routine activities, complexities of dementia, and he required inpatient skilled PT as without it, he was at risk for falls, contractures, skin injury, and rehospitalization. On [DATE] at 4:23 PM, the DON acknowledged there were conflicting versions between the North Court Unit Manager and the ADON who responded to the resident immediately after he fell. She was unable to locate a statement from the North Court Unit Manager in the fall investigation record. She explained, the facility's investigation concluded the resident fell because he transferred himself while he was unsupervised. She stated, there was nothing we could have done to prevent it. On [DATE] at 5:34 PM, the facility's Medical Director said he was not aware resident #4 fell 11 times in 8 months prior to the fall that resulted in a major injury until after the resident returned from the hospital. He recalled the facility reported to him that there were therapy interventions that had not been documented or done. He stated the facility could improve their processes so they could catch potential problems earlier. Review of the hospital medical records revealed on [DATE] resident #4 was admitted to the Intensive Care Unit and assessed by the physician to have acute hypoxemic (low levels of oxygen in your body tissues) respiratory failure due to pneumonia, sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection) due to pneumonia, suspect aspiration, hypernatremia (low blood sodium), acute kidney injury, acute metabolic encephalopathy (brain dysfunction), recent fall with hip fracture and surgical repair, and anemia. Records documented the resident died on [DATE], 2 days after he was admitted . The facility's Fall Prevention Program revised [DATE], read, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 5. High Risk Protocols: a. Provide patient centered interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. b. Provide additional interventions . including but not limited to . increased frequency of rounds. 6. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 7. When any resident experiences a fall, the facility will: . e. Review the resident's care plan and update as indicated. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE], licensed nurse education was initiated on the facility's Fall Prevention Program that included providing resident care and services to minimize the likelihood of falls and reviewing and updating care plans when residents fell. *On [DATE], the facility conducted an ad hoc Quality Assurance and Performance Improvement Committee meeting for fall prevention and follow up actions post fall. *On [DATE], Morse Fall Scale Evaluations were completed on all residents to identify their risk *On [DATE], the IDT reviewed and revised fall care plan interventions for residents at moderate to high level of fall risk. *On [DATE], Fall Prevention Program education for licensed nurses was completed and included: providing resident care and services to minimize the likelihood of falls, reviewing and updating care plans when residents sustain a fall, newly hired nurses to receive same education during orientation. All nurses with the exception of 6 were educated, and the remaining 6 were to receive the education prior to working. Agency nurses were to receive education prior to acceptance of an assignment. *On [DATE], the nursing management team was educated by the DON for staff monitoring and audits of implemented fall interventions to ensure appropriateness and verify implementation. The Unit Manager or designee to conduct at minimum daily unit rounds to verify interventions are in place. IDT clinical meetings will include discussions. A dedicated Fall Monitor staff position was implemented for duty from 7:00 AM to 11:00 PM every day tasked to hourly visualize 17 residents identified as high fall risk. The Fall Monitor will notify the Charge Nurse should a resident concern for fall safety arise. The resident with an identified concern will be placed on one to one supervision until the IDT reviews the resident and determines if enhanced supervision is needed. New resident admissions or readmissions who have undergone orthopedic surgery will be included in the Fall Monitor's rounds assignment regardless of their fall risk status until the IDT team reviews the resident and determines Fall Monitor supervision is no longer necessary. Review of in-service attendance sheets revealed education completion reports and staff signatures to reflect participation in education on topics listed above. From [DATE] to [DATE], interviews were conducted with 16 staff members that included 5 CNAs, 5 LPNs, 3 RNs, 1 PT, 1 OT, the APRN, Admissions Coordinator, Activities Assistant, Staffing Coordinator, and Fall Monitor verbalized understanding of the education provided. *On [DATE], 62 out of 67 nurses and CNAs were re-educated in person, onsite, and remotely. No clinical staff will be permitted to work without receiving in person education. Newly hired staff will receive the above education in orientation. The resident sample was expanded to include 5 additional vulnerable residents at risk for falls. Observations, interviews, and record review revealed no concerns related to falls for residents #1, #2, #3, #5, and #6.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow the process for a verbal physician order for chest x-ray for 1 of 3 residents reviewed for diagnostic services out of a total sample of 5 residents, (#4). On [DATE] at 8 PM, the facility failed to obtain radiology diagnostic services for a resident with increased cough, 3 days post-surgery for fractured hip. A verbal order was given by the Advance Practice Registered Nurse (APRN) which was not entered into the electronic record and not processed by the nurse. On [DATE], the resident experienced acute respiratory distress and was transferred to the hospital where he died two days later of pneumonia. The facility's failure to process and implement a verbal order to obtain diagnostic services for resident #4's respiratory decline resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross reference F689 Review of the medical record revealed resident #4, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital after hip surgery with diagnoses of repeated falls, displaced fracture of left femur, hemiplegia and hemiparesis of the left non-dominant side, lack of coordination, muscle weakness, epilepsy, cognitive function and awareness impairment, and severe dementia. A displaced fracture of the femur is a type of fracture where the trauma moves the bone fragments out of alignment. Complications from surgery may include pneumonia, infection, pain, bleeding, blood clots, embolism, nerve damage, and malalignment of bones, (retrieved on [DATE] from the John Hopkins Medicine website at www.hopkinsmedicine.org). The record noted the resident was non-ambulatory and required assistance with transfers. The Minimum Data Set (MDS) Discharge Return Anticipated assessment with Assessment Reference Date of [DATE] revealed resident #4 had a fall with major injury and an unplanned discharge to the hospital. The assessment showed he had memory problems, severely impaired cognitive skills for daily decision-making, walked in his room and the corridor during the 7 day look back period, and he had two or more falls since the assessment, three months prior. On [DATE] at 2:45 PM, during an interview, Licensed Practical Nurse, (LPN) A said she was giving medications near resident #4's room when she heard him coughing. She explained it was a continuous cough, and he coughed up phlegm. She said she listened to his lung sounds that were clear, and his oxygen saturation (percentage of the blood is saturated with oxygen) was at 97% on room air. She said she notified the Unit Manager (UM) of resident #4's increased cough. Review of resident #4's medical record noted nursing progress notes dated [DATE] at 8:05 PM, by the North Court UM documented the resident was noted to have increased cough. Thick phlegm noted, able to clear throat. HOB (head of bed) elevated and Advance Practice Registered Nurse (APRN) notified. Chest x-ray ordered 2 views. A nursing progress on [DATE] at 9:00 AM read, resident noted to be coughing during meals, primary physician and PT (physical therapy) made aware, ST (speech therapy) to see, Power of Attorney aware. On [DATE] at 8:27 AM, the progress note showed resident lethargic b/p (blood pressure) 186/96 (mm/Hg) temperature 102.9 (degrees Fahrenheit) heart rate 138 (beats per minute) oxygen saturation 70% - arousable but not speaking clearly. Sudden onset- refused meds and ate poorly drank health shake twice. Certified Nursing Assistant (CNA) called nurse to room for sudden onset of SOB. (shortness of breath). Resident placed on O2 (oxygen) via face mask at 5 L/M- (liters/minute) brought up to 82%. APRN called and order to send to Emergency department - 911 called and took resident to hospital. A nursing progress note on [DATE] at 12:25 AM, noted the resident was admitted to the Intensive Care Unit with diagnosis of pneumonia. A Progress Notes completed by the North Court Unit Manager on [DATE] noted resident #4 was lethargic, had been eating poorly, not speaking clearly, and was in respiratory distress when he was transferred to the hospital. A late entry Progress Note completed by the APRN on [DATE] showed that resident #4 was assessed for respiratory distress. It was noted the resident had abnormal vital signs with a fever of 102.8 degrees Fahrenheit, a heart rate of 130 beats per minute, blood pressure reading of 186 systolic over 96 diastolic, mmHg and his respirations were 55 breaths per minute. He had been administered 5 liters of supplemental oxygen per minute, and his blood oxygen saturation with oxygen was 82%. The resident was transported to the hospital by 911 emergency services where he was admitted to the Intensive Care Unit. Review of the resident's medical record revealed there was no physician order documented in the electronic record for the chest x-ray to be done. There was no documentation the x-ray company had been contacted nor any documentation the portable x-ray (radiology) company reported to the facility to complete a chest x-ray for resident #4. On [DATE] at 1:52 PM, the APRN stated she entered her own orders in the facility's electronic system and also gave verbal orders to nurses. She remembered during the morning meeting on [DATE], she was informed resident #4 had increased cough and gave a verbal order for a chest x-ray to be done. She said she did not know why it was not done, and indicated the nurse maybe got distracted and did not enter the order. She said if the x-ray had been done, she would have started the resident on antibiotics. She said she examined the resident on [DATE] but did not check for the x-ray results. She added the nurses should have been checking the resident's temperature regularly since he recently had surgery but noted she had not ordered additional vital signs including temperatures to be taken. She stated she was very upset when she found out the x-ray had not been done. On [DATE] at 3:00 PM, during an interview with the Unit Manager who received the telephone order from the APRN on [DATE] at 3:00 PM, she related she did not call the x-ray company as the APRN told her that she would put in the order and take care of it after the morning clinical meeting. She said most of the time, the APRN entered her own orders. She indicated if the APRN was not in the facility, the nurses implemented the orders. She explained she did not enter the verbal order on [DATE] at 8 PM as she was busy and did not ensure the order was entered in the electronic system. She said the next day, she was not at the morning meeting as staff had called off sick and she worked on the unit. She did not check if order was carried out. In an interview with the Director of Nursing on [DATE] at 1:15 PM, she related it was an expectation of the facility that when any verbal order was obtained from the physician or APRN, it was to be entered and transcribed in the medical record as soon as possible and followed up by the nurse during her shift. She confirmed the chest x-ray order for resident #4 was not entered into the medical record and the resident did not receive the chest x-ray as ordered by the APRN. Review of the hospital medical records revealed on [DATE] resident #4 was admitted to the Intensive Care Unit and assessed by the physician to have acute hypoxemic respiratory failure due to pneumonia, sepsis due to pneumonia, suspect aspiration, recent fall with hip fracture and surgical repair, and anemia. Records documented the resident died on [DATE], 2 days after he was admitted . An interview was conducted with the Medical Director on [DATE] at 5:34 PM. He said he was aware of the missed x-ray and noted perhaps the resident would have been transferred to the hospital earlier. He conveyed that missing an x-ray was inexcusable. He said he reviewed the resident's medical record including the hospital records and explained the resident was admitted and treated for pneumonia. He noted the resident's condition declined and palliative measures were provided by the hospital. He was aware of the lack of monitoring for resident #4 and said it was his understanding that staff checked vital signs at least daily especially temperature for post operative residents. I ' m sure there is room for improvement in every situation. Review of the facility policy entitled, Verbal Orders, reviewed February 2023, read under Policy Explanation and Compliance Guidelines: #4. Write T.O. (telephone order) or V.O. (verbal order) including date, time, name of resident, the complete order, and sign the name of the physician or health care provider and nurse or sign off the electronic order as per the software guidelines. #6 Follow through with orders by making appropriate contact or notification (e.g. lab or pharmacy) Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] the facility conducted an Ad hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting. Root Cause Analysis performed re: chest x-ray not being completed. *On [DATE], the ordering process was reviewed with APRN and Medical Director during Ad hoc QAPI Committee Meeting. *On [DATE], the DON completed review of progress notes for diagnostic orders and physician orders for current residents for last 30 days to ensure diagnostic orders were transcribed and completed. No additional concerns were identified. *On [DATE], Licensed Nurse education initiated on Radiology Services and Reporting to include order transcription in electronic health record and placing orders with the radiology company. *On [DATE] to [DATE] Licensed Nurse education on Radiology Services and Reporting continued to include order transcription in electronic health record and placing orders with the radiology company continued and completed. Newly hired nurses will be educated during orientation. 1 remaining facility nurse will be educated prior to working. Agency nurses will be educated prior to accepting nursing assignment. *On [DATE], the DON educated additional provider on ordering process and follow up. 10 remaining providers will be educated prior to next consultation in facility. *Review of in-service attendance sheets revealed education completion reports and staff signatures to reflect participation in education on topics listed above. *From [DATE] to [DATE], interviews were conducted with 5 LPNs, 3 RNs, 2 therapists, the APRN. They verbalized understanding of the education provided. *The resident sample was expanded to include 5 additional vulnerable residents at risk for falls. Observations, interviews, and record review revealed no concerns related to diagnostic tests not performed for residents #1, #2, #3, #5, and #6.