**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility neglected to implement a system to identify and instruct staff in the required level of transfer assistance needed, and the specific mechanical lift required for residents that required assistance with transfers for 1 resident of a total sample of 12 residents, (#1). This failure contributed to the use of an inappropriate mechanical device, and resulted in a left humeral fracture for the resident. On 2/16/23 at 10:30 AM, Certified Nursing Assistant (CNA) A transferred resident #1 from her bed to her wheelchair using a pivot to stand transfer technique and transported her to the shower room. After her shower, CNA A used a sit to stand mechanical lift to transfer the resident from the shower chair to her wheelchair. Resident #1 slipped from the lift, and the lift's sling slid down her left arm. The resident was suspended in the lift with her left arm in the air. CNA A called for help, and CNA B, and Registered Nurse (RN) C assisted the resident to her wheelchair. The resident sustained a skin tear to her left hand and complained of pain to her left shoulder. The resident was transferred to the hospital following the incident where it was identified the resident sustained a left humeral neck fracture. The facility's failure to identify the type of lift and provide the required level of assistance for transfers placed all residents requiring mechanical lifts at risk for serious harm or serious injury and resulted in Immediate Jeopardy starting on 02/16/2023. The Immediate Jeopardy was removed on 02/24/2023. Findings: Cross Reference F689 Resident #1 an [AGE] year-old female was admitted to facility on 8/30/21. Her diagnoses included, epilepsy, pain in the left ankle and joints of the left foot, pain in the left knee, difficulty in walking, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, dementia, and generalized muscle weakness. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 12/08/22 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 10 out of 115. Review of the resident's annual MDS assessment with ARD of 9/07/22 revealed the resident required extensive assistance with two-person physical assist for transfers. Review of the resident's care plan for Activities of Daily living (ADL) self-care performance deficit related to hemiplegia and hemiparesis, and generalized muscle weakness, initiated on 9/17/21 and revised on 12/03/21 revealed, the resident is totally dependent on 2 staff for transfers. Review of a Change in condition form and progress note dated 2/16/23, revealed the resident fell from the mechanical lift while being transferred to her wheelchair. She sustained a laceration to her left hand, and complained of pain to her left shoulder. The resident was transferred to the hospital on 2/16/23 and x-rays showed the resident sustained a left humeral neck fracture. On 2/21/23 at 10:56 AM, the Director of Clinical Services (DCS), and the Assistant DCS explained that on 2/16/23 at 10:30 AM, resident #1 was transferred by CNA A with a sit to stand mechanical lift from the shower chair to her wheelchair in the shower room. The CNA told them, that she had completed the resident's shower, and was placing an incontinent brief on the resident while the resident was in the sit to stand lift, when the resident slipped out of the lift. The lift's sling slid down her left arm, and the resident was suspended from the lift. The DCS stated the resident complained of left shoulder pain and was transferred to the ER, where x-ray showed a left humerus neck fracture. They indicated the resident was a 2 person transfer and CNA A did not seek assistance when transferring her. They acknowledged the resident's care plan did not specify the type of lift to be used, until it was updated on 2/17/23, after the incident. On 2/21/23 at 12:25 PM, in a telephone interview, CNA A, recalled she lifted the resident from her bed and pivoted her to her wheelchair and took the resident to the shower room in a shower chair. She stated that after the shower, she removed the resident from the shower in the shower chair, then placed the sit to stand lift sling around the resident's waist and put the lift up. CNA A said the resident was standing and held on to the lift with her right hand. She explained that she moved the shower chair back, and placed the resident's wheelchair behind her, and attempted to put an incontinent brief on the resident to complete pulling up her pants. The CNA said the resident let go of the lift, took her hand out of the sling, and slipped down, with her left arm suspended in the air. CNA A said when the resident pulled her hand from the sling, there was a bruise to her left hand, due to being suspended in the lift. When asked the how the resident should have been transferred, CNA A explained that she was supposed to review the resident's [NAME] to find out how the resident should be transferred. She said she did not check the resident's [NAME], but asked another CNA how the resident was transferred, and was told she could stand and pivot. She stated she knew better and should not have transferred the resident by herself and should not have used the sit to stand lift. On 2/21/23 at 4:50 PM, in an interview with the Interim Executive Director, the Divisional Nurse Consultant, and the DCS, the Divisional Nurse Consultant recalled the facility interviewed CNA A who said she was sorry, and that she knew resident#1 required assist of two persons. The CNA reported she did not review the resident's [NAME], but asked another CNA how the resident was transferred. The Divisional Nurse Consultant stated the facility verified neglect based on the evidence obtained during the investigation, and the Root Cause Analysis (RCA) was, A single appropriately trained CNA with documented competency dated 5/25/2020, and 4/28/22 made the decision on her own not to follow facility standard of practice . The single CNA did not seek assistance from nurse or other trained direct care staff when transferring resident via mechanical lift. However, the RCA did not identify the omission on the resident's care plan, and [NAME] of the type of mechanical lift required for the resident's transfer as a contributing factor to the incident which resulted in the fall with major injury for resident #1. On 2/22/23 at 3:52 PM, the Divisional Consultant Nurse stated that prior to the incident on 2/16/23 with resident #1, care plans and [NAME] never identified the type of mechanical lift to be used for transfer. She verbalized that on 2/17/23 the resident's care plan and [NAME] was updated to include the type of mechanical lift required for resident transfers. On 2/23/23 at 10:53 AM, the DCS stated that prior to the incident on 2/16/23, the plan of care did not identify the type of mechanical lift required for transfer. However, after the incident the care plan and [NAME] was updated to specify whether a sit to stand or a total mechanical lift was required. The facility's policy Abuse, Neglect, Exploitation & Misappropriation with effective date of 11/30/2014, and revision date of 11/16/2022 described neglect as the failure of the center, its employees .to provide goods and services to a resident that are necessary to avoid physical harm. Review of the job description for CNA, created September 2018 revealed the job duties and responsibilities included providing direct care in accordance with treatment plans, and to follow established safety precautions in the performance of all duties. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following which were verified by the survey team: *On 2/16/23 at 2:00 PM, resident #1 was transferred to the hospital. *On 2/16/23 at 7:00 PM, the facility made aware that resident #1 sustained a left humeral fracture. *On 2/16/23 CNA A was suspended pending investigation. The Immediate report was submitted to the Agency For Health Care Administration, and to the Department of Family and Children. *On 2/17/23 the Interim Executive Director (ED) conducted investigation to include re-enactment of the event. Statements were obtained from nurses and CNAs who worked on the South Unit on 2/16/23. The DCS in collaboration with the therapy department established a list of residents requiring mechanical lifts for transfers. Residents were rescreened by the Therapy Director between 2/17/23 to 2/22/23 to ensure appropriate transfer procedure was in place. Care plans were updated by the MDS Coordinator to include which mechanical lift is to be used during transfers. On 2/23/23, and 2/24/23 interviews were conducted with three RNs, one LPN, and 12 CNAs. All verbalized understanding of the education provided. The resident sample was expanded to include seven additional residents who were identified as requiring a sit to stand mechanical lift for transfer, and two residents at risk for falls/actual falls. Observations, interviews, and record reviews revealed no concerns, and as of 2/23/23 following rescreen by therapy, only resident #2 and #5 now required a sit to stand lift for transfers. Review of the in-service attendance sheets validated mechanical lift education accompanied by competencies and posttest were completed using the facility's policy and procedure for Transfer/Mobility Evaluation Low Lift for facility and Agency staff, with 91% completion as of 2/23/23. New hires will receive education in orientation, and certified letters were mailed to staff members who were unable to attend the training, to set up appointment for the in-service. Interviews conducted from 2/23/23 to 2/24/23 with 15 facility staff including 2 RNs, 1 LPNs, and 12 CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or [NAME] to identify number of persons, and type of mechanical lift required for resident transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent an avoidable accident with major injury for a vulnerable, physically, and cognitively impaired resident, and failed to identify and provide the required level of transfer assistance required for 1 of 12 residents sampled for accidents, (#1). This failure contributed to the use of an inappropriate mechanical device, and resulted in the resident sustaining a left humeral neck fracture. On 2/16/23 at 10:30 AM, Certified Nursing Assistant (CNA) A transferred resident #1 from her bed to her wheelchair using a pivot to stand transfer technique and transported her to the shower room. After her shower, CNA A used a sit to stand mechanical lift to transfer the resident from the shower chair to her wheelchair. Resident #1 slipped from the lift, and the lift's sling slid down her left arm. The resident was suspended in the lift with her left arm in the air. CNA A called for help, and CNA B, and Registered Nurse (RN) C assisted the resident to her wheelchair. The resident sustained a skin tear to her left hand and complained of pain to her left shoulder. The resident was transferred to the hospital following the incident where it was identified the resident sustained a left humeral neck fracture. The facility's failure to identify the type of lift and provide the required level of assistance for transfers placed all residents requiring mechanical lifts at risk for serious harm or serious injury and resulted in Immediate Jeopardy starting on 02/16/2023. The Immediate Jeopardy was removed on 02/24/2023. Findings: Cross Reference F600, F656 Resident #1, an [AGE] year-old was admitted to the facility on [DATE]. Her diagnoses included, epilepsy, pain in the left ankle and joints of the left foot, pain in the left knee, difficulty in walking, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, dementia, and generalized muscle weakness. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 12/08/22 revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status (BIMS) score of 10/15. The assessment indicated transfers occurred only once or twice during the review period, and resident #1 was totally dependent on one staff person for personal hygiene. The resident's balance during transition and walking was assessed as being not steady, and she was only able to stabilize with staff assistance when moving from seated to standing position, and surface-to-surface transfers. She had impairment in functional limitation in range of motion on one side of her upper and lower extremities. Review of the resident's annual MDS assessment with ARD of 9/07/22 revealed the resident required extensive assistance with two-person physical assist for transfers. Review of the medical record revealed the resident received Physical Therapy (PT) from 1/22/22 to 2/18/22. On discharge from PT on 2/18/22, the resident required maximum assistance with transfers. The note identified the resident was dependent on staff for transfers and was not ambulatory. There was no indication from therapy that a mechanical lift was to be used to transfer resident #1. A Change in Condition form and nursing progress noted both dated 2/16/23, revealed the resident fell from the mechanical lift while being transferred to her wheelchair. The resident sustained a laceration to her left hand, and complained of pain to her left shoulder which was scored as 6 on a 0-10 numerical scale. Physician orders were received to transfer the resident to the emergency room (ER). The Hospital Emergency Report dated 2/16/22 at 4:39 PM, revealed x-ray of the humerus done in the ER showed the resident sustained a left humeral neck fracture. On 2/21/23 at 10:56 AM, the incident was discussed with the Director of Clinical Services (DCS), and the Assistant DCS. They explained that on 2/16/23 at 10:30 AM, resident #1 was being transferred by CNA A using a sit to stand mechanical lift from the shower chair to her wheelchair in the shower room. CNA A reported she had completed the resident's shower and was trying to put an incontinence brief on the resident while the resident was in the sit to stand lift. The CNA transferred the resident by herself, the resident slipped out of the lift, the sling pad slid down her left arm, and the resident was suspended from the lift. CNA A called for assistance and CNA B responded. Both CNAs attempted to transfer the resident from the lift to her wheelchair, but could not, and they called for Registered Nurse (RN) C to assist. The three staff then transferred the resident to her wheelchair. RN C notified the ADCS and the physician was contacted. the resident was transferred to the ER. The ADCS stated she called the ER later to ascertain the resident's status and was informed that the x-ray showed a left humerus neck head fracture. Review of the resident's care plan with the DCS, and the Divisional Consultant Nurse for Activities of Daily living (ADL) revised on 12/03/21 included, the resident is totally dependent on 2 staff for transfers. The care plan did not specify the type of lift to be used, until it was updated on 2/17/23 after the incident on 2/16/23 to include the specific mechanical lift. On 2/21/23 at 11:45 AM, resident #1 was lying in bed. She pointed to her left arm which had a sling in place and a dressing was noted to the top of her left hand. The resident nodded yes when asked in Spanish if she had pain but was not able to answer additional questions. On 2/21/23 at 11:47 AM, Licensed Practical Nurse (LPN) D, stated she was aware of the incident with resident #1. She stated the resident was a 2 person assist for transfers and the CNA did not use the appropriate transfer. LPN D verbalized the resident's left arm was contracted and a sit to stand lift should not have been used. On 2/21/23 at 11:55 AM, RN C recalled she was in the South Wing on 2/16/23, when CNA B told her she had to go to the shower room to assist another CNA. RN C stated when she went into the shower room, resident#1 was in the sit to stand lift with her right arm down by her side, and her left arm up in the air. RN C reported a laceration was noted to her left hand, and CNA A, was holding on to the resident. She verbalized the three of them transferred the resident into her wheelchair and returned her to her bed. She noted the resident complained of left arm pain and the physician was notified. She said the physician gave orders to send the resident to the hospital due to the left-hand laceration and pain to her left shoulder. RN C recalled when she returned to work the next day, she found out the resident sustained a fracture. RN C stated she did not know why CNA A used the sit to stand lift as the resident had a contracted left hand and would not have been able to hold on to the bar of the lift. She added the resident was skinny,and the sling used was probably too big. The sit to stand lift was observed with the RN C. She acknowledged there was no individual sling for each resident to be used with the lift. On 2/21/23 at 12:25 PM, in a telephone interview, CNA A confirmed she was assigned to resident #1 for the 7:00 AM to 3:00 PM shift on 2/16/23. She verbalized the resident was quiet, spoke Spanish, but was able to point and make her needs known. She verified the resident had a contracted left hand. She stated that on 2/16/23, she lifted the resident from her bed and pivoted her to her wheelchair and transported the resident to the shower room onto a shower chair. She recalled she showered the resident and placed her pants partially on while she was sitting in the shower chair. She stated she then placed the sit to stand lift sling around the resident's waist, and moved the lift up which placed the resident in a standing position. CNA A said the resident stood and held on to the lift with her right hand. She explained she then moved the shower chair back, and placed the resident's wheelchair behind her, and attempted to put an incontinence brief on the resident to complete pulling up her pants. The CNA said the resident let go of the lift, took her hand out of the sling and slipped down, with her left arm suspended. She indicated the resident did not fall on the floor. She said she reached over, moved the wheelchair, and pulled the emergency light for help. CNA A recalled CNA B responded and helped her to lower the lift. She said RN C came to assist and the three of them transferred the resident into the wheelchair and back into bed. She noted the resident sustained a bruise and cut to her left hand and RN C assessed her for any further injuries. CNA A reported she was supposed to review the resident's chart to know how the resident should be transferred. She said she did not check the resident's [NAME] but was told the resident could stand and pivot. She said she knew better, and should not have transferred the resident by herself. She verbalized when the resident was sitting in the shower chair, she looked uncomfortable, and at the time she could not find anyone to help her, so she took the chance of doing the transfer by herself. She did not explain why she used a sit to stand lift to transfer the resident. On 2/21/23 at 1:10 PM, the Director of Rehab stated that part of therapy assessment included functional mobility, and the therapist determined how much assistance the residents required based on their initial evaluation. He explained mechanical lift use was determined by the nursing department and therapy determined the resident's required level of assistance. He indicated the sit to stand mechanical lift had certain requirements for use, and included the resident's ability to bear weight, and if the resident had enough upper extremity strength to grip the handles of the lift. He said that as a rule therapy did not make the determination of whether residents required mechanical lifts for transfers. He noted that therapy staff determined the level of assistance a resident required for transfers and then nursing would decide which lift device to use. He recalled resident #1 was on Occupational Therapy (OT) from 10/09/22 to 10/31/22, for spasticity of her left hand and wrist, and a splint for her left wrist and hand was addressed. He stated the resident received Physical Therapy (PT) from 1/22/22 to 2/18/22 and required maximum assist for transfer, requiring at least 75% help. The Director of Rehab verbalized that if the resident was assessed as requiring maximum assist with PT, for safety, a mechanical lift would be fine for the resident. He explained that based on requirements of the sit to stand lift, and due to the spasticity of the resident's left hand, the resident would not be able to hold the bar of the sit to stand lift and a total mechanical lift would be appropriate for her. He stated he heard about the incident with the resident in the shower room on 2/16/23, and said it was a wrong decision by CNA A to use the sit to stand lift, especially when staff was using the total mechanical lift before, and clearly the resident could not have been able to grasp the handlebars of the sit to stand lift. On 2/21/23 at 2:38 PM, in a telephone interview, resident #1's Power of Attorney (POA) stated the facility called him on 2/16/23, and he spoke to the supervisor. He said a nurse called and told him that there was an incident in the shower when they tried to lift the resident with a lift. He stated the resident had a stroke, and had weakness to her left side, her left hand was contracted, and she was not able to hold anything with her left hand. He said she did not have a strong left arm. On 2/21/23 at 4:50 PM, in an interview with the Executive Director (ED), the Divisional Nurse Consultant, and the DCS, the Divisional Nurse Consultant recalled the facility interviewed CNA A who said she knew resident #1 required assist of two persons for transfers. The CNA reported she did not review the resident's [NAME], but asked another CNA how the resident was transferred. The Divisional Nurse Consultant stated the facility verified there was neglect based on the evidence obtained during the investigation, and the root cause analysis was that, an appropriately trained CNA with documented competencies dated 5/25/2020, and 4/28/22 made the decision on her own not to follow facility standard of practice with regard to utilization of a fully and functioning mechanical lift. She added the CNA did not seek assistance from a nurse or other trained direct care staff when transferring resident #1 with an inappropriate mechanical lift. On 2/22/23 at 10:57 AM, CNA B recalled on 2/16/23, CNA A called for help from the shower room. She went to help and found resident #1 in the sit to stand lift with her knees touching the footpad of the lift, and her left arm was extended behind her. She remembered she and CNA A tried to sit the resident in her wheelchair from the lift, but could not, so she called RN C, and they all helped to transfer the resident to her wheelchair. CNA B stated the resident was transferred back to her bed and RN C assessed the resident. She indicated the resident had injuries to her left hand and complained of pain to her left shoulder. CNA B stated she had been assigned to resident #1 before and since the resident was very light weight, two persons would transfer her from bed to chair without a lift, but when taking a shower, they would use the total mechanical lift to transfer her to the shower bed. She stated the resident's left hand was contracted, and she could not use her left hand to hold the grab bars on the lift. She said the resident could not stand, because she did not have strength in her legs, so the sit to stand lift was not appropriate for the resident. CNA B stated CNA A did not ask her for help prior to the incident in the shower room. On 2/24/23 at 11:30 AM, the Advanced Practice Registered Nurse (APRN) stated the facility notified him that resident #1 fell from the lift and that her left arm was hurting. The APRN recalled he was not in the facility, so he directed staff to transfer the resident to the hospital. He said he saw the resident when she returned to the facility but she was not able to give him any details of what happened. He verbalized he gave orders for pain medication and noted the resident was at her baseline, did not appear distraught or anxious, so there was no need for a psychiatric evaluation. On 2/24/23 at 11:36 AM, in a telephone interview, the Medical Director (MD) stated she was the resident's Primary Care Physician. She was aware the resident was transferred with a mechanical lift by one CNA and sustained a fracture. She said she was involved in the AdHoc Quality Assurance Performance Improvement (QAPI), meeting. She indicated staff knew that 2 staff were required to transfer residents with a mechanical lift. She explained the resident could not be transferred with a sit to stand lift as her hand was contracted. Review of the job description for CNA, created September 2018 revealed her job duties and responsibilities included providing direct care in accordance with treatment plans, and to follow established safety precautions in the performance of all duties. The facility's policy Transfer/Mobility Evaluation Low Lift with effective date 11/30/2014, and revision date of 11/01/2019 read, Center will evaluate the transfer and lifting needs of the resident to safely and comfortably transfer according to their individualized needs .Two staff members are required when using a mechanical lift. Lift status will be indicated on the resident's care plan and [NAME]. Review of the Facility Assessment Tool dated 2/13/2023 revealed that services and care offered was based on resident needs and included mobility and fall/fall with injury prevention. The assessment showed the facility would provide person-centered care, and would use the facility's resources to provide competent care for residents including staff, staff training/education and competencies. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following which were verified by the survey team: *On 2/16/23 at 2:00 PM, resident #1 was transferred to the hospital. *On 2/16/23 at 7:00 PM, the facility made aware that resident #1 sustained a left humeral fracture. *On 2/16/23 CNA A was suspended pending investigation. The Immediate report was submitted to the Agency For Health Care Administration, and to the Department of Family and Children. *On 2/17/23 the Interim Executive Director (ED) conducted investigation to include re-enactment of the event. Statements were obtained from nurses and CNAs who worked on the South Unit on 2/16/23. The DCS in collaboration with the therapy department established a list of residents requiring mechanical lifts for transfers. Residents were rescreened by the Therapy Director between 2/17/23 to 2/22/23 to ensure appropriate transfer procedure was in place. Care plans were updated by the MDS Coordinator to include which mechanical lift is to be used during transfers. On 2/23/23, and 2/24/23 interviews were conducted with three RNs, one LPN, and 12 CNAs. All verbalized understanding of the education provided. The resident sample was expanded to include seven additional residents who were identified as requiring a sit to stand mechanical lift for transfer, and two residents at risk for falls/actual falls. Observations, interviews, and record reviews revealed no concerns, and as of 2/23/23 following rescreen by therapy, only resident #2 and #5 now required a sit to stand lift for transfers. Review of the in-service attendance sheets validated mechanical lift education accompanied by competencies and posttest were completed using the facility's policy and procedure for Transfer/Mobility Evaluation Low Lift for facility and Agency staff, with 91% completion as of 2/23/23. New hires will receive education in orientation, and certified letters were mailed to staff members who were unable to attend the training, to set up appointment for the in-service. Interviews conducted from 2/23/23 to 2/24/23 with 15 facility staff including 2 RNs, 1 LPNs, and 12 CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or [NAME] to identify number of persons, and type of mechanical lift required for resident transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility neglected to develop and/or implement procedures to identify, communicate, and provide necessary care and services to ensure the safety of a resident who was at high risk for falls; and neglected to follow standards of practice related to post-fall response, for 1 of 6 residents reviewed for falls, out of a total sample of 8 residents, (#1). These failures contributed to unwitnessed falls, serious head injury, and the resident's subsequent death. There was likelihood resident #1 suffered severe pain as a result of her injuries and brain surgery prior to her death. On Friday, [DATE], resident #1 arrived at the facility from the hospital. Nursing staff did not have access to the electronic medical record system and her admission assessment was only partially completed on paper forms. The resident's fall risk evaluation was inaccurate, and nurses failed to create a baseline care plan with fall prevention interventions. Resident #1 was never provided with a wheelchair although therapy and nursing staff deemed her unsafe to ambulate. Despite the resident's confusion and continuous attempts to stand and walk without assistance, facility staff neither adequately increased supervision nor arranged for an assistive device. Resident #1 suffered an unknown number of falls over the weekend, none of which were documented, reported, or investigated. On Monday, [DATE] at approximately 8:00 PM, resident #1 was discovered lying on her left side in the bathroom, with evidence of incontinence on her clothing and the floor. The resident had a swelling on the left side of her forehead and was minimally responsive. The assigned nurse called 911 at 8:21 PM and Emergency Medical Services (EMS) personnel arrived at 8:27 PM. Resident #1 was transported to the hospital where Emergency Department (ED) staff assumed her care at 9:01 PM, approximately one hour after she was found on the floor. The resident was diagnosed with a brain bleed and required emergency surgical intervention. Her condition deteriorated after surgery, and she died the following day on hospice services. The facility's failure to implement policies and procedures to prevent neglect and effectively respond to fall incidents 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]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F607, F655, F689, and F842. Resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on Friday, [DATE]. Her diagnoses included confusion, altered mental status, cirrhosis of the liver, and stroke. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was confusion, and she was alert and disoriented but could follow simple instructions. She had a risk alert for falls and was incontinent of bowel and bladder. The form showed resident #1 was not ambulatory, required the assistance of two persons for transfers, used a wheelchair for mobility, and was not able to bear weight on her legs. Review of resident #1's admission / readmission Data Collection form dated [DATE] at 6:00 PM, revealed she required assistance of one person for transfers rather than two persons as indicated on the hospital transfer form. The admission assessment described the resident as independent with ambulation but requiring wheelchair only. The document included a Fall Risk Evaluation with scored responses to determine if the resident was at risk for falls was incomplete as some sections were left blank and inaccurate responses were selected in other sections. There was no total score for determination of the resident's level of risk for falls. On [DATE] at 12:53 PM, Registered Nurse (RN) A confirmed he was the assigned nurse on the day resident #1 was admitted . He recalled the facility's electronic medical record (EMR) system was down that day and he was accustomed to completing new admission documentation in the computer. RN A explained the resident arrived late in his shift, almost at 7:00 PM as he was getting ready to go home. He stated he started the required paperwork but did not complete it. On review of the resident's chart, he confirmed he did not initiate a baseline care plan and the fall risk evaluation and other sections of the assessment form were not done. RN A said, If we do not do it, the Unit Manager checks all the paperwork when he comes in. He acknowledged he assessed the resident's ability to transfer, stand, and ambulate, and noted she was unable to walk due to significant weakness in her legs. RN A confirmed resident #1 required a wheelchair for safety but she did not have one. He stated to his knowledge, a Physical Therapist had to evaluate her before she received a wheelchair. RN A acknowledged the resident was very confused and at risk for falls but he did not initiate any fall prevention interventions before he completed his shift and left the facility. When asked what could have been done to ensure the resident's safety, RN A stated it would have been possible to increase supervision by Certified Nursing Assistants (CNAs) if he had been able to enter it as a task or care directive in the EMR. On [DATE] at 2:20 PM, Physical Therapist I stated he evaluated resident #1 on Saturday, [DATE], and deemed her to be at high risk for falls. He explained the resident required a walker and support with a gait belt to ambulate a distance of five feet. Physical Therapist I stated the resident required a wheelchair to get to the bathroom and CNAs would have to use a gait belt to support her during transfers from the wheelchair to the toilet. He verified resident #1 did not have a wheelchair in her room and explained it was the responsibility of nursing staff to obtain one from Central Supply. Physical Therapist I said, My evaluation is the basis for care. However, he did not recall if he communicated his recommendations regarding resident #1's care and safety needs with nursing staff. Physical Therapist I stated there was no facility protocol to guide communication between the therapy and nursing departments. He explained other facilities utilized communication forms to ensure important information regarding safety alerts and therapy recommendations was available. Physical Therapist I stated if he had significant concerns he would relay them to the Rehab Director who would in turn communicate with nursing management. On [DATE] at 4:40 PM, the Director of Rehab stated he would expect therapists to communicate necessary interventions to the Weekend Nursing Supervisor, especially if there was a safety issue. He reviewed resident #1's Physical and Occupational Therapy notes and confirmed there was no documentation that nursing staff were notified of the resident's fall risk or provided with recommendations for assistance with mobility and toileting. When asked why therapists did not provide resident #1 with a wheelchair, the Director of Rehab stated therapy staff did not provide wheelchairs. He explained he attended interdepartmental meetings during which clinical team members including either the Director of Nursing (DON) or the Assistant DON (ADON) collaboratively reviewed all residents on therapy caseload. The Director of Rehab stated all residents who were admitted on weekends were discussed during the team meeting on Mondays, but he did not recall discussion of resident #1's therapy evaluations and recommendations, her fall risk, or need for a wheelchair on Monday, [DATE] On [DATE] at 10:43 AM, the North Wing Unit Manager (UM) explained he attended clinical management team meetings and participated in chart reviews on Monday mornings for residents who were admitted over the weekend. He did not recall participating in the review of resident #1's chart and said, Somebody else did it. The UM was asked to review the resident's medical record and acknowledged the fall risk evaluation was inaccurate, incomplete, and did not identify risk for falls. He confirmed he completed the baseline care plan on Monday [DATE] based on information he obtained from the inaccurate, incomplete admission assessment done by RN A. The UM validated RN A had not completed the continence tracking form either. He explained both forms were usually done in the EMR which had not been available to staff for approximately two weeks. The UM acknowledged there needed to be effective communication within the nursing department and between nursing and other departments to facilitate good care. He confirmed any safety issue such as escalating confusion and high fall risk needed immediate interventions which should be noted in the chart. The UM verified nursing staff did not appropriately determine resident #1's risk for falls, implement fall prevention approaches or notify the physician as her likelihood for falls increased over the weekend. He stated no member of his staff informed him of resident #1's behavioral or safety concerns on Monday when he returned to work. He confirmed nurses could have initiated one-to-one supervision, called the attending physician, or reported their concerns to a supervisor. The UM stated he expressed concerns to facility administration in the past regarding weekend admissions as there were no clinical managers except the weekend supervisor onsite to thoroughly review all assessments and ensure paperwork was completed. Review of the facility's policy and procedure Fall Management revised on [DATE], revealed residents would be evaluated for fall risk, and patient-centered interventions would be initiated as indicated. The purpose was . to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. Post-fall strategies directed staff to first evaluate the resident and provide post-fall care, then initiate neurological checks according to the facility policy. Next, the nurse was to notify the physician and family and re-evaluate the resident utilizing a Post Fall Evaluation tool. The interdisciplinary team would review fall documentation, complete a root cause analysis, and develop new care plan interventions to prevent additional falls. On [DATE] at 3:22 PM, resident #8 informed the Divisional Nurse Consultant and the DON that over the weekend resident #1 had been her roommate and fell at least four times. Resident #8 informed them nursing staff were aware as they picked resident #1 up off the floor and returned her to bed each time. On [DATE] at 3:57 PM, the DON stated nursing staff neither documented nor reported that resident #1 fell over the weekend. The DON stated her expectation was nurses would take appropriate post-fall actions such as thorough assessments, neurological checks, notification of the physician and family, and complete a fall investigation packet for each incident. The DON said, In this situation, if the interdisciplinary team had been aware the resident fell once or more on the weekend, other interventions would have been put in place. On [DATE] at 6:55 PM, in a telephone interview with RN B (who worked for a staffing agency), she confirmed she was assigned to resident #1 during the 7:00 PM to 7:00 AM shift on [DATE]. RN B recalled the off going nurse informed her the resident was admitted two days prior and was a fall risk and required constant redirection during the day shift as she kept attempting to ambulate without assistance. RN B stated she worked for a staffing agency and was not knowledgeable about the facility's fall prevention protocols and initiating interventions such as increased supervision. RN B described her assignment as overwhelming that evening and change of shift report lasted from 6:45 PM to almost 7:30 PM. She said, I had maybe 30 plus patients and my first admission came in at 7:45 PM, so before I could do rounds on the unit I had to handle that. She recalled at approximately 8:00 PM, a CNA informed her a resident was on the floor. RN B confirmed she responded and found resident #1 lying on the floor in a mixture of urine and feces and she noted a bump on the left side of her forehead. She said, I asked the CNAs if she was alert at baseline and they said they had been talking to her before. When I tried to speak to her she had no clear words, just low sounds. RN B stated the resident's eyes were closed and when she tried to open her eyelids, she squinted. RN B explained she checked resident #1's vital signs and blood glucose level and noted they were normal. When asked if she initiated neurological checks, she stated she did not as she realized the resident would have to go to the hospital. RN B then left the resident with a CNA and returned to the nurses' station. She said, I'm going to be honest with you. I didn't have a computer system, so it took time to get the DON's phone number, find the chart and locate the [History and Physical] to answer questions for EMS. RN B explained only facility nurses had access to the EMR and the other nurse on the unit with her was also from a staffing agency. RN B explained she was hindered by lack of basic information such as a demographic sheet, in the paper chart. In addition, the copier on the unit did not work so she had to ask a CNA to copy paperwork required for the hospital transfer on the other unit. RN B stated she called the DON twice, did not get a response, and then decided to call 911. She estimated approximately 30 minutes elapsed between the discovery of the resident on the floor and the call to 911. RN B stated she notified the resident's daughter after EMS arrived, but she could not recall when she notified the attending physician. On [DATE] at 3:23 PM, in a telephone interview, the facility's Medical Director was informed of the sequence of events after resident #1's last fall. She said, If [resident #1] was obtunded, they should have called 911 first, then let the physician know. She explained her expectation was nurses would notify the physician first as medical providers should be the ones to determine necessary interventions to diagnose or treat a resident after a fall. She explained the standard of practice for an unwitnessed fall was to send the resident to the hospital for testing due to the risk of head injury. Review of a Fire Department Event Report dated [DATE] revealed a 911 call was received from the facility at 8:21 PM. EMS personnel were dispatched at 8:22 PM and they arrived at the facility in five minutes, at 8:27 PM. EMS departed the facility with resident #1 at 8:48 PM and arrived at the hospital ED at 9:01 PM. The Event Notes Addendum indicated resident #1 had a chief complaint of falls. The document showed she had a head injury and she is not responding normally (not completely alert). Caller Statement: PT FOUND ON FLOOR IN BATHROOM UNABLE TO COMMUNICATE NOW POSSIBLY HIT HEAD. On [DATE] at 5:45 PM, an interview was conducted with the Administrator and DON. The DON stated post-fall interviews with staff showed CNAs and nurses were aware of resident #1's fall risk. The Administrator verified that a few hours before the resident fell on Monday, [DATE], the assigned CNA observed the resident ambulating while leaning on and rolling the overbed table. He provided a written statement that showed the assigned day shift nurse informed the night nurse the resident continuously tried to get up from her chair and walk throughout the day. The DON said, They knew they had to keep an eye on her. She was checked approximately every 30 minutes. She had confusion. When asked about appropriate nursing interventions for a confused resident at risk for falls, the DON said, I would expect more frequent supervision. The DON acknowledged neither staff statements nor the plan of care reflected a specific frequency of monitoring, level of supervision, or defined fall prevention approaches. The DON explained admission nurses would identify residents' needs during the initial assessment and create a baseline care plan which could be updated by any nurse as needed. She reviewed resident #1's medical record and validated the admission assessment was incomplete, the fall risk evaluation was inaccurate, and the documentation in the progress notes did not reflect the extent of the resident's behavior and confusion or include fall prevention interventions. The DON confirmed resident #1's admission assessment and hospital transfer form indicated she required a wheelchair. The DON was informed the resident was never provided with a wheelchair during her three-day stay in the facility. The Administrator stated staff statements indicated resident #1 was last seen by her assigned CNA, seated in a chair at bedside, at 7:40 PM and was found on the floor at approximately 8:00 PM. The DON stated the assigned nurse attempted to contact her and left a voicemail regarding the resident's fall with head injury at 8:14 PM. On [DATE] at 3:57 PM, the DON explained the facility's EMR system was hacked (unauthorized entry into a computer system) on [DATE], and although facility staff gained access to the EMR after a couple weeks, agency nurses only received access within the past 24 hours. The DON stated there were challenges in keeping paper records current and accurate and not all nurses documented as required. She confirmed the sequence of RN B's actions after resident #1's fall was wrong. The DON said, In my experience, the call to 911 should have been first, then the physician should have been told. She explained preparation of paperwork, and notification of the DON and the family should have occurred afterward. The DON confirmed a CNA corroborated resident #8's description of resident #1's fall during the weekend. On [DATE] at 5:04 PM, CNA D stated she worked for a staffing agency and was assigned to resident #1 on Monday, [DATE], during the 3:00 PM to 11:00 PM shift. She explained she relied on verbal report from other staff to get information on how to care for her assigned residents. CNA D stated that evening was her first shift with resident #1 and since there was no wheelchair provided, she assumed the resident could walk. CNA D said, It's hard to get report. The only thing I was told was to keep an eye on her. There is no [CNA care plan] here, and no written instructions on what the residents need. On [DATE] at 3:40 PM, in a telephone interview, Licensed Practical Nurse (LPN) C stated she worked for a staffing agency and was assigned to resident #1 on Monday, [DATE], during the 7:00 AM to 7:00 PM shift. She did not recall passing on any information regarding resident #1's fall risk in change of shift report. LPN C explained only staff with access to the EMR would have accurate information on residents' plans of care. She explained the facility did not have paper care plans so she would need to ask other nurses for information on care needs and safety concerns. On [DATE] at 3:33 PM, in a telephone interview, the Weekend Nursing Supervisor stated she usually tried to see all newly admitted residents on the weekends, and she checked to ensure all assessments were done. She recalled she put resident #1's paperwork together and built her chart on Saturday, [DATE], the day after admission. The Weekend Nursing Supervisor was informed resident #1 fell on Monday, [DATE] and the assigned nurse was hindered by lack of a face sheet with important demographic information. She said, Typically, I do put a face sheet, but that weekend I did not have access to the electronic chart so I couldn't print one. The Weekend Nursing Supervisor did not recall if she checked the nursing admission assessments for accuracy, and to verify if the the plan of care was appropriate. She was not aware a baseline care plan was not initiated. She explained, Care plans should have been done by the admission nurse, so we know what their needs might be. The Weekend Nursing Supervisor stated she thought the facility's policy was that wheelchairs required approval by the therapy department. Review of the facility's policy and procedure Abuse, Neglect, Exploitation & Misappropriation revised on [DATE], revealed the facility recognized each resident had the right to be free from Neglect. The document included the definition, Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy indicated an example of Neglect was failure to take precautionary measures to protect the health and safety of the resident. The Facility Assessment Tool dated [DATE] revealed the facility could meet the needs of residents with impaired cognition, behavior that needed interventions, and cirrhosis. The document indicated facility staff would be trained and demonstrate competence in .rights of the resident and the responsibilities of a facility to properly care for its residents. 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], resident #1 was discharged from the facility to the hospital. *On [DATE], the Divisional Nurse Consultant educated the Administrator, DON, ADON, and the Social Services Director (SSD) regarding Abuse, neglect, and Exploitation. *On [DATE], the SSD initiated education of all current facility staff to include all departments regarding Abuse, Neglect, and Exploitation. The facility educated 95 of 135 staff members as of [DATE]. Certified letters were sent out to those staff members who were unable to attend the education. Any facility or contracted staff who did not receive education will not be permitted to work until education is completed and validated by the DON or designee. *On [DATE], the DON and ADON initiated education with all licensed nurses including agency nurses regarding assessment of residents post fall to include policy and procedures for neurological evaluation for any unwitnessed falls, notification of change in condition, code of ethics rule to ensure falls are reported with emphasis on no retaliation policy, fall management policy and procedure, baseline care plan policy, and to notify DON of all resident falls once physician and/or emergency services have been notified. Education was accompanied by post-testing. As of [DATE], the facility educated 10 of 22 licensed nursing staff. Certified letters were sent out to those staff members who were unable to attend the education. Any facility or contracted staff who did not receive education will not be permitted to work until education is completed and validated by the DON or designee. *On [DATE], the facility submitted the Agency for Health Care Administration (Florida state survey agency) Federal Report regarding a Neglect allegation. *On [DATE], the facility evaluated 116 in-house residents for fall risk. Care plans of those residents identified as high risk for falls were reviewed and updated as needed for supervision. Review of resident falls from [DATE] to [DATE] was done to ensure fall management process was in place to include appropriate supervision for those residents at risk with current interventions. *On [DATE], the Divisional Nurse Consultant educated the DON, ADON, UM, and Weekend Nursing Supervisor regarding the process for morning clinical meeting, clinical stand down process, and expectations for the Weekend Nursing Supervisor to review new admission charts and charts for residents with recent falls to ensure policy and procedures are implemented. The Divisional Nurse Consultant will attend at least one clinical meeting each week to validate the process is being followed. *On [DATE], the Divisional Nurse Consultant educated the Medical Records Coordinator regarding the requirement to ensure nursing staff has access to the resident EMR or a complete paper chart to include a resident facesheet. *On [DATE], the Divisional Nurse Consultant educated the Administrator, DON, and ADON regarding how to complete a thorough investigation following an event. *On [DATE], the Rehabilitation Program Manager educated therapy staff regarding timely communication between therapy and nursing departments regarding resident mobility, care needs, and assistive devices for transfers. *As of [DATE], all nursing staff to include agency nurses had access to the EMR. *As of [DATE], the interdisciplinary team including the Administrator, DON, ADON, Unit Manager, Minimum Data Set Coordinator, and SSD will review all residents who have fallen during the morning clinical meeting and follow up during clinical stand down. The nursing house supervisor will review new admission charts for residents who fell during the weekend to ensure fall evaluations were complete and accurate, appropriate interventions were implemented to include increased supervision as necessary, care plan updated with appropriate interventions and provides written report to DON. *As of [DATE], the DON or designee will review clinical records of all residents who fell on a weekly basis to validate documentation is in place to include appropriate resident-centered fall prevention interventions, appropriate supervision, and that baseline and/or comprehensive care plans were updated. The Divisional Nurse Consultant will be provided a copy of the weekly audit to provide additional oversight. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, the DON , and the Medical Director. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Preventing Abuse/Neglect/Exploitation/Misappropriation, Falls / Change in Condition / Baseline CP / Neuro checks, Fall Management/Incident Management, Complete Medical Record, Effective Investigation of Falls, Education/Communication Between Therapy and Nursing Regarding Assistive Devices, and Code of Conduct. On [DATE], interviews were conducted with three RNs, one LPN, six CNAs, one Activity staff, one Maintenance staff, and one Dietary staff. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who were at risk for falls. Observations, interviews, and record reviews revealed no concerns for residents #2, #3, #4, #7, and #8 related to neglect, to include provision of appropriate care and services to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a person-centered baseline care plan with appropriate interventions within 48 hours of admission, and failed to involve the resident representative to promote collaborative care and ensure the immediate health and safety needs were met for 1 of 6 residents reviewed for falls of a total sample of 8 residents, (#1). These failures contributed to unwitnessed falls, serious head injury, and the resident's subsequent death. There was likelihood resident #1 suffered pain as a result of her injuries and brain surgery prior to her death. On Friday, [DATE], resident #1 arrived at the facility from the hospital. Nursing staff did not have access to the electronic medical record system and her admission assessment was only partially completed on paper forms. The resident's fall risk evaluation was inaccurate, and nurses failed to create a baseline care plan with fall prevention interventions. Resident #1 was never provided with a wheelchair although therapy and nursing staff deemed her unsafe to ambulate. Despite the resident's confusion and continuous attempts to stand and walk without assistance, facility staff neither adequately increased supervision nor arranged for an assistive device. Resident #1 suffered an unknown number of falls over the weekend, none of which were documented, reported, or investigated. On Monday, [DATE] at approximately 8:00 PM, resident #1 was discovered lying on her left side in the bathroom, with evidence of incontinence on her clothing and the floor. The resident had swelling to the left side of her forehead and was minimally responsive. The assigned nurse called 911 at 8:21 PM and Emergency Medical Services (EMS) personnel arrived at 8:27 PM. Resident #1 was transported to the hospital where Emergency Department staff assumed her care at 9:01 PM, approximately one hour after she was found on the floor. The resident was diagnosed with a brain bleed and required emergency surgical intervention. Her condition deteriorated after surgery, and she died the following day on hospice services. The facility's failure to initiate a baseline care plan placed all newly admitted residents who were at risk for falls at likelihood for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600, F607, F689, and F842. Resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on Friday, [DATE]. Her diagnoses included confusion, altered mental status, cirrhosis of the liver, and stroke. On [DATE] at 12:27 PM, in a telephone interview with resident #1's daughter, she explained her mother required long-term care in a skilled nursing facility due to her diagnosis of cirrhosis of the liver and associated medical issues such as increased ammonia levels and altered mental status. The daughter stated her mother was at risk for falls due to physical and cognitive issues, often overestimated her abilities, and therefore required close supervision. She recalled conversations with admission Department staff prior to her mother's admission, and a lengthy telephone call with the Social Services Director after admission. Resident #1's daughter stated she did not speak to anyone else during her mother's three-day stay in the facility, until a nurse called her on the night of [DATE] to inform her that her mother fell, hit her head, and would be transferred to the hospital. When asked if she spoke with nursing staff regarding her mother's baseline care plan, the daughter reiterated that she had not been contacted by anyone else from the facility. Resident #1's daughter explained her mother suffered a severe head injury that required emergency surgery, and she died the following day. The daughter said, Communication with the facility was an issue. I am disgusted and hurt. I feel like it could have been avoided. Review of the daughter's cell phone call log from [DATE] to [DATE] revealed a 28-minute incoming call from the facility on [DATE] at 1:03 PM, confirmed to be from the SSD. On [DATE] at 8:41 PM, the daughter's call log showed an incoming call from a personal cell phone. The call was confirmed to be from resident #1's assigned nurse, RN B, regarding notification of the fall. The call log did not include any incoming calls from the facility or any unknown numbers. Review of resident #1's medical record revealed the Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE], which showed her primary diagnosis was confusion. The document indicated she was alert and disoriented but could follow simple instructions and was at risk for falls. Resident #1 was not ambulatory, required the assistance of two persons for transfers, used a wheelchair for mobility, and was not able to bear weight on her legs. The admission / readmission Data Collection packet dated [DATE] at 6:00 PM, revealed the resident's admission diagnoses included confusion. The document indicated resident #1 required assistance of one person for transfers rather than two persons as indicated on the hospital transfer form. The sections of the admission packet related to fall risk evaluation, pain evaluation, mood and behavior, and review of medications were either blank, incomplete, and/or inaccurate. On [DATE] at 12:53 PM, Registered Nurse (RN) A stated he received resident #1 when she arrived at the facility on [DATE] and started the admission paperwork. RN A confirmed he did not initiate a baseline care plan on admission to address the issues he identified during his assessment of the resident. Resident #1's Physical Therapy evaluation dated [DATE] revealed she required moderate assistance to change positions. The document read, Patient presents with strength impairments, balance deficits, and decreased safety awareness. The Occupational Therapy evaluation dated [DATE] indicated resident #1 required maximum assistance for toileting tasks including transfers and hygiene. The document indicated she had impaired strength in both arms, could not stand for ten seconds without upper extremity support. On [DATE] at 2:20 PM, Physical Therapist I stated he evaluated resident #1 on [DATE] and determined she was at high risk for falls. He explained the resident would need a wheelchair to get to the bathroom safely, and then should use grab bars while a CNA held a gait belt to assist and support her as she transferred to the toilet. Review of the facility's policy and procedure Plans of Care revised [DATE] revealed the interdisciplinary team would develop a person-centered care plan in conjunction with the resident and/or the representative. The procedure directed staff to develop and implement an individualized Person-Centered baseline care plan within 48 hours of admission that includes. areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed. Review of the resident's medical record revealed a Baseline Care Plan and Summary dated [DATE], signed by the North Wing Unit Manager (UM). The designated signature lines for resident #1 and/or her representative were blank. The form showed the resident was admitted on [DATE] at 6:00 PM, therefore the baseline care plan should have been created and reviewed with the resident's daughter by [DATE] at 6:00 PM. The baseline care plan did not reflect information noted on the hospital transfer form and the admission assessment. The UM noted resident #1 would be discharged to the community rather than remain in the facility. The baseline care plan for falls and safety had a goal that resident #1 would remain free from injury. However, the interventions did not appropriately address the resident's high risk for falls and significant confusion. The UM noted resident #1 had self-care deficits and required the assistance of only one person for all activities of daily living (ADLs). The document did not include use of a wheelchair, walker, or gait belt, and any other recommendations for transfers based on Physical and Occupational therapy evaluations. On [DATE] at 10:43 AM, the North Wing UM acknowledged RN A was responsible for initiating resident #1's baseline care plan and confirmed the results of therapy evaluations should have been utilized to revise the document. The UM verified the resident's baseline care plan was completed on Monday [DATE], based on review of the medical record including the incomplete and inaccurate admission assessment. He acknowledged the importance of the baseline care plan as a communication tool to facilitate good care. The UM confirmed safety issues such as confusion and fall risk required immediate interventions which should be documented in the chart. On [DATE] at 7:50 PM, the Director of Nursing (DON) stated the facility's process for care of a newly admitted resident involved a chart audit in the daily clinical meeting. She explained that for residents admitted on the weekend, the audit was done on Monday morning. The DON stated the clinical management team would ensure all assessments and documents were completed properly, including the baseline care plan. She did not recall discussions regarding resident #1's incomplete admission assessment or lack of a baseline care plan. On [DATE] at 3:57 PM, the DON stated the admission nurse was expected to document assessments, resident/ family education, and basic safety and comfort interventions. She explained the facility could not schedule or assign a specific nurse to complete admission documentation including baseline care plans as the exact time of arrival was never known. She added the Weekend Nursing Supervisor should have reviewed resident #1's chart on Saturday, [DATE], to verify all documentation was complete for the newly admitted resident. 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], resident #1 was discharged from the facility to the hospital. *On [DATE], the DON or other nursing management team members initiated education with all licensed nurses including agency nurses regarding provision of supervision of residents to reduce risk of falls. The education included notification of the DON or designee when residents are exhibiting increased behaviors that may lead to falls, initiation or provision of increased supervision if needed, and notification of the DON of all unwitnessed falls once physician and/or emergency services have been notified. Education was accompanied by post-testing. The facility educated 10 of 22 licensed nursing staff. Those nurses who did not receive education will receive education prior to their next scheduled shift. *On [DATE], the facility evaluated 116 in-house residents for fall risk. Care plans of those residents identified as high risk for falls were reviewed and updated as needed for supervision. Review of resident falls from [DATE] to [DATE] was done to ensure fall management process was in place to include appropriate supervision for those residents at high risk. *As of [DATE], nursing leadership will develop and implement plans to stagger hours to provide support and assistance for afterhours admissions to the facility. *On [DATE], the interdisciplinary team to include the Administrator, DON, ADON, UM, Social Services Director, and Minimum Data Set Coordinator will review newly admitted residents during morning clinical meeting to identify fall risk and review baseline care plans to ensure appropriate interventions are in place, to include appropriate amount of supervision based on resident assessment and behaviors. *As of [DATE], nurse leadership will implement baseline care plan binders to be placed at each nursing station. Baseline care plans will be reviewed by the Weekend Nursing Supervisor for new admissions and residents with recent falls. Nurse leadership will bring binders to morning clinical meetings for review. *As of [DATE], the DON or designee will review clinical records of all residents who fell on a weekly basis to validate documentation is in place to include appropriate resident-centered fall prevention interventions, appropriate supervision, and that baseline and/or comprehensive care plans were updated. The Divisional Nurse Consultant will be provided a copy of the weekly audit to provide additional oversight. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement committee meeting was held to discuss the identified non-compliance and staff education. Attendees included the Administrator, the DON , and the Medical Director. Review of in-service attendance sheets revealed staff signatures to reflect participation in education on topics including Preventing Abuse/Neglect/Exploitation/Misappropriation, Falls / Change in Condition / Baseline CP / Neuro checks, Fall Management/Incident Management, Complete Medical Record, Effective Investigation of Falls, Education/Communication Between Therapy and Nursing Regarding Assistive Devices, and Code of Conduct. On [DATE], interviews were conducted with three RNs, one LPN, six CNAs, one Activity staff, one Maintenance staff, and one Dietary staff. All verbalized understanding of the education provided. The resident sample was expanded to include five additional residents who were at risk for falls. Observations, interviews, and record reviews revealed no concerns for residents #2, #3, #4, #7, and #8 related to baseline care plans, to include fall prevention and behavioral interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision and monitoring for a vulnerable, physically and cognitively impaired resident to prevent falls for 1 of 6 residents reviewed for falls, of a total sample of 8 residents, (#1). This failure contributed to unwitnessed falls, serious head injury, and the resident's subsequent death. There was likelihood resident #1 suffered pain as a result of her injuries and brain surgery prior to her death. On Friday, [DATE], resident #1 arrived at the facility from the hospital. Nursing staff did not have access to the electronic medical record system and her admission assessment was only partially completed on paper forms. The resident's fall risk evaluation was inaccurate, and nurses failed to create a baseline care plan with fall prevention interventions. Resident #1 was never provided with a wheelchair although therapy and nursing staff deemed her unsafe to ambulate. Despite the resident's confusion and continuous attempts to stand and walk without assistance, facility staff neither adequately increased supervision nor arranged for an assistive device. Resident #1 suffered an unknown number of falls over the weekend, none of which were documented, reported, or investigated. On Monday, [DATE] at approximately 8:00 PM, resident #1 was discovered lying on her left side in the bathroom, with evidence of incontinence on her clothing and the floor. The resident had a swelling to the left side of her forehead and was minimally responsive. The assigned nurse called 911 at 8:21 PM, and Emergency Medical Services (EMS) personnel arrived at 8:27 PM. Resident #1 was transported to the hospital where Emergency Department (ED) staff assumed her care at 9:01 PM, approximately one hour after she was found on the floor. The resident was diagnosed with a brain bleed and required emergency surgical intervention. Her condition deteriorated after surgery, and she died the following day on hospice services. The facility's failure to identify and provide the appropriate level of supervision and frequency of monitoring for a resident with a known high risk for falls contributed to resident #1's fall(s) with head injury and placed all residents who were at risk for falls at likelihood for serious injury/impairment/death. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Cross reference F600, F607, F655, and F842. Resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on Friday, [DATE]. Her diagnoses included confusion, altered mental status, cirrhosis of the liver, and stroke. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1's primary diagnosis was confusion, and she had impaired sight and hearing. The document indicated she was alert and disoriented but could follow simple instructions. She had a risk alert for falls and was incontinent of bowel and bladder. The form showed resident #1 was not ambulatory, required the assistance of two persons for transfers, used a wheelchair for mobility, and was not able to bear weight on her legs. Resident #1 was to be evaluated and treated by Physical, Occupational and Speech Therapists as indicated, but her rehabilitation potential was deemed to be poor. Resident #1's admission / readmission Data Collection form dated [DATE] at 6:00 PM, was completed by Registered Nurse (RN) A. The document revealed the resident's admission diagnoses included confusion. RN A noted resident #1 was alert and oriented to person and place, had long term memory problems, and modified independence in cognitive skills for decision-making. RN A noted resident #1 required assistance of one person for transfers rather than two persons as indicated on the hospital transfer form. The admission assessment described the resident as independent with ambulation but requiring wheelchair only. The document included a Fall Risk Evaluation with scored responses to determine if the resident was at risk for falls. RN A noted resident #1's mental status was alert and oriented instead of intermittent confusion to reflect her primary diagnosis of confusion. The resident's ambulation and continence status was noted as chairbound although RN A had assessed her as ambulatory and incontinent. The document revealed the resident's vision was adequate rather than impaired, and the section related to gait and balance noted only that resident #1 required an assistive device but failed to include the resident's gait and balance problems. RN A did not select any responses regarding medications and predisposing diseases that contributed to the resident's risk for falls. The fall risk evaluation form was incomplete, inaccurate, and did not provide a total score for determination of the resident's level of risk for falls. Review of resident #1's medical record revealed an additional fall risk evaluation tool, the Morse Fall Scale. The responses were inaccurate and/or incomplete regarding resident #1's secondary diagnoses, ambulatory aids, and gait. The evaluation tool was not scored to designate resident #1 as low, medium, or high risk for falls. Resident #1's Medication Administration Record revealed she received medication that could increase her risk for falls. She had physician orders for Amlodipine 5 milligrams (mg) once daily for hypertension, Mirtazapine 7.5 mg at bedtime for depression, Spironolactone 50 mg once daily for fluid retention, and Lactulose 15 milliliters three times daily for liver cirrhosis. Spironolactone is a diuretic or water pill that prevents the body from absorbing too much salt by increasing urine output. Lactulose is a medication used to decrease blood ammonia levels that cause confusion in patients with liver cirrhosis. This medication pulls water into the colon and causes excretion of ammonia in soft or liquid stools (retrieved on [DATE] from www.drugs.com). On [DATE] at 12:53 PM, RN A stated he received resident #1 when she arrived at the facility on [DATE] and started the admission paperwork. He recalled the resident was very confused. RN A said, I evaluated her for ambulation. She was very combative, and I had to sit and talk to her to get her to cooperate. She had weakness in her legs. I held her hands and she could only make one step before she had to sit down. RN A stated resident #1 was not admitted with a wheelchair, but she needed one. He explained he thought the therapy department would provide a wheelchair. RN A reviewed the fall risk evaluation form, acknowledged it was incomplete, and stated he did not initiate baseline care plans to address the issues he identified. He verified if residents were at high risk for falls or exhibited behavioral symptoms, nurses should implement increased supervision. On [DATE] at 12:27 PM, in a telephone interview with resident #1's family, the daughter explained her mother was previously a resident of an Assisted Living Facility, but due to her diagnosis of cirrhosis of the liver and associated medical issues such as increased ammonia levels and altered mental status, she required a skilled nursing facility for a higher level of clinical monitoring and closer supervision as her disease worsened. The daughter recalled she and her husband told several facility staff including admissions staff, the Social Services Director, and nurses about her mother's confusion and risk for falls. Resident #1's son-in-law stated he visited the facility at lunch time on Saturday [DATE], the day after admission, and found his mother-in-law seated on the edge of her bed and he was concerned she was left in the room unsupervised. The son-in-law stated he approached the assigned male nurse and requested that someone assist his mother-in-law to a supervised group activity. The son-in-law said, I explained to [the male nurse] she was a fall risk. He stated there was no wheelchair at her bedside at the time of his visit. Resident #1's daughter described her mother as quite confused and stated she often overestimated her abilities. She recalled on the evening of [DATE], a nurse notified her that her mother had fallen. The daughter said, She minimized her condition and made it sound like it was precautionary to send her to the hospital. However, by the time the family got to the hospital, they were told her mother was unresponsive and needed surgery. The daughter stated her mother died soon after surgery and the family was told her death was due to brain injury from the fall. She said, I am disgusted and hurt. I feel like it could have been avoided. On [DATE] at 6:36 PM, the facility's admission Department Care Liaison confirmed she spoke with resident #1's daughter prior to admission to obtain as much information as possible. The Care Liaison confirmed her pre-admission notes read, fall precautions and indicated the resident could be stubborn and was confused at times, more so at night. On [DATE] at 4:40 PM, the Director of Rehab provided resident #1's therapy evaluations and explained the documents showed she required staff to support her by holding a gait belt around her waist, with additional support of a walker if she walked. He stated without these interventions, resident #1 would lose her balance and fall. The Director of Rehab stated based on the Occupational and Physical Therapy evaluations, resident #1 would need to be transferred from her bed or a regular chair to a wheelchair in order to go to the bathroom or anywhere else as she would not be able to walk safely. He said, Especially during the early stages of therapy, I would not recommend walking to the bathroom until she had more gait training. The Director of Rehab stated he would expect therapists to communicate necessary interventions to the nursing supervisor, especially if there was a safety issue. He confirmed the therapists' documentation did not show notifications were made to the nursing staff regarding the resident's fall risk or their recommendations for assistance with mobility and toileting. When asked why therapists did not provide resident #1 with a wheelchair, the Director of Rehab stated therapy staff did not provide wheelchairs. On [DATE] at 2:20 PM, Physical Therapist I recalled resident #1 was seated in a chair beside her bed when he arrived to evaluate her on the morning of [DATE]. He described the resident as confused, but lucid at some points. Physical Therapist I explained he brought a walker and gait belt to conduct the evaluation and confirmed the resident did not have a wheelchair. He stated the common practice in the facility was that every resident should be given a wheelchair on admission. He explained nursing staff had access to wheelchairs as they were kept in Central Supply, not in the Therapy Department. He stated his fall risk assessment resulted in a score of greater than 78% which indicated a high risk for falls. He recalled resident #1 could not initiate and complete the motion to stand from the chair without assistance and was only able to ambulate about five feet with a walker and his support. Physical Therapist I stated the resident would have needed a wheelchair to get to the bathroom safely, and she would need to use grab bars while a CNA held a gait belt to assist and support her as she transferred to the toilet. Physical Therapist I stated the assigned nurse was busy with medication administration that morning and he did not recall whether he gave a verbal report with recommendations to nursing staff. Resident #1's Physical Therapy evaluation dated [DATE] revealed she required moderate assistance to change positions from lying to sitting and sitting to standing. She also needed moderate assistance to ambulate five feet with a two-wheeled walker. The document read, Patient presents with strength impairments, balance deficits, and decreased safety awareness. and required skilled Physical Therapy service to minimize falls and decrease dependence on staff. The document indicated the resident did not use a wheelchair and was unable to complete a 30-second chair rise without physical assistance. The Occupational Therapy evaluation dated [DATE] indicated resident #1 required maximum assistance for toileting tasks including transfers and hygiene. The document indicated she had impaired strength in both arms, could not stand for ten seconds without upper extremity support, and had impaired safety awareness. Review of resident #1's electronic and paper charts revealed therapy notes with evaluation findings and fall prevention recommendations were not included in her medical record. The resident's charts showed no nursing care plans were initiated on admission to ensure appropriate fall prevention and behavioral management approaches were in place to ensure her safety. Review of Interdisciplinary Progress Notes revealed on [DATE] during the 7:00 AM to 7:00 PM shift, resident #1 was seated in a chair at bedside and was seen by rehab staff. The note indicated she was confused, required redirection and was .closely supervised for safety. The progress note confirmed the resident's family visited but did not address the son-in-law's concerns regarding her being left unsupervised in the room. The nursing note did not reflect any discussion with the Physical Therapist regarding the resident's fall risk, required mobility device, and the level of assistance necessary for transfers and ambulation. A note dated [DATE] at 12:00 AM, written by Licensed Practical Nurse (LPN) J, read, Resident reminded not to use bedside table to ambulate in room. Alert [with] confusion. The note did not indicate approaches were initiated to ensure the resident's safety or that a supervisor was notified. A progress note dated [DATE] at 2:00 PM, revealed resident #1 remained a fall risk and staff continued to check on her. The note did not describe the level of supervision or frequency of monitoring required. Later that afternoon at 4:00 PM, the nurse wrote, New orders for psych consult due to confusion & increased agitation per Administrator. Left voicemail for [name of practitioner]. Awaiting call back. The progress note did not show the attending physician and the resident's emergency contact were notified of concerns related to resident #1's behavior and safety. The nursing note did not include any fall prevention interventions initiated despite documentation of the resident's confusion, behavioral symptoms, and attempts to ambulate without assistance. The Hospital Transfer Form dated [DATE] revealed resident #1 was transferred to the hospital after a fall. Review of resident #1's hospital record revealed a Hospitalist Discharge Summary dated [DATE] at 11:51 AM. The note indicated resident #1 was brought to the ED due to altered mental status after being found on the bathroom floor of a nursing home. A computerized tomography or CT scan of her brain showed an acute subdural hematoma (SDH) with midline shift. Resident #1 was intubated, placed on mechanical ventilation, and had an emergency craniotomy with evacuation of the bleed. The note read, Patient clinically deteriorated, no brain stem reflexes. Repeat CT showed a large right SDH with worsening midline shift and transtentorial herniation. The resident was discharged to hospice services with a diagnosis of subdural hematoma. A subdural hematoma is a collection of blood between the covering of the brain and the surface of the brain. It is often caused by a severe head injury which results in bleeding that fills the brain area and compresses brain tissue (retrieved on [DATE] from www.medlineplus.gov). Midline shift refers to a displacement of brain tissue across the center line of the brain. It may occur after a traumatic brain injury which pushes the brain towards one side. Herniation occurs when parts of the brain are squeezed through structures within the cranium. Midline shift and herniation are a medical emergency and can be fatal (retrieved on [DATE] from www.acquiredbraininjury-education.[NAME].nhs.uk). Review of a Certification Of Death form revealed resident #1's date of death was [DATE] at 2:23 PM and her manner of death was an accident. The document indicated her cause of death was a subdural hematoma due to blunt head trauma on [DATE] in an unwitnessed fall in nursing home. On [DATE] at 7:55 PM, in a telephone interview, Certified Nursing Assistant (CNA) E stated she was assigned to resident #1 on Friday, [DATE], the evening she was admitted to the facility. CNA E recalled the resident wore a bracelet that indicated she was a fall risk. She described the resident as alert, but very confused. CNA E stated she was again assigned to care for resident #1 on Monday, [DATE], from 3:00 PM to 4:00 PM. She explained resident #1 had diarrhea and soiled her brief. CNA E said, I think the nurse walked her to the bathroom and I came in and took over. She explained after she provided the resident with incontinence care in the bathroom, she walked her back to a chair. She said, I wouldn't trust her walking by herself. CNA E stated resident #1 would not use the call light and she once even caught her walking around the room pushing the over bed table. She confirmed the resident did not have a wheelchair. CNA E stated she did not inform the nurse about the resident walking with the table, and she was never told by the nurse to remain in the room with the resident or bring her out to the common area. CNA E explained there were other residents on the unit who were at risk for falls and she did not think the facility had enough staff to provide them with one-to-one supervision. On [DATE] at 7:22 PM, in a telephone interview, CNA D, stated she assumed care of resident #1 from CNA E on [DATE] at 4:00 PM when the North Wing staffing assignments were adjusted. CNA D stated she had never cared for the resident before, and CNA E told her resident #1 did not have a wheelchair and tried to walk around by grabbing walls and using the rolling overbed table. CNA D recalled resident #1 asked to be taken outside. She said, I told her since she could not walk and did not have a wheelchair I could not take her out. She tried to get me to take the other resident's wheelchair. CNA D stated CNA E also informed her that resident #1 was able to walk to the bathroom with help but should be encouraged to use her brief instead. CNA D stated she tried to check on the resident every 30 to 60 minutes between caring for her assignment of ten to twelve other residents. She stated at one point she discovered resident #1 walking as she pushed the rolling table towards the door. CNA D stated she asked CNA E to assist her as it was difficult to redirect the resident. She said, We did not tell the nurse. I try to handle that, not report to the nurse. I tried to distract her and change the subject. I was afraid she would fall. CNA D acknowledged resident #1 was at high risk for falls. She explained she got verbal report on how to care for resident #1, but there was no CNA care plan or other written instructions. CNA D stated she last saw resident #1 at about 7:40 PM as she passed by her room on the way to take care of another resident. She recalled she was in the hallway at approximately 8:00 PM when another resident alerted staff that resident #1 was on the floor. CNA D stated she rushed to the room and found the resident on the floor, partially in the bathroom, with a large swelling on the side of her forehead. She stated there was feces in a chair, and feces and urine on the floor. CNA D explained she tapped the resident's shoulder and called her name, but the resident was non-verbal and only moaned softly. On [DATE] at 6:55 PM, in a telephone interview with RN B, she confirmed she was assigned to resident #1 for the 7:00 PM to 7:00 AM shift on [DATE]. RN B recalled the off going nurse informed her the resident was admitted two days prior and was a fall risk. RN B said, She told me she had to remind the patient constantly to sit down because she was confused and trying to walk on her own. RN B stated she was told resident #1 displayed that behavior throughout the day shift and the day nurse and the CNA had to redirect the resident frequently while they cared for other residents. RN B was asked if either she or the off going nurse implemented any fall prevention interventions to address the safety issue. She said, I am not their employee, so I do not know what their protocol is for fall risks. RN B stated she did not know if she could have initiated one-to-one supervision, scheduled monitoring with increased frequency, or any other intervention, and she was unsure of the facility's process for updating care plans. When asked about possible interventions to prevent falls, she said, If I were concerned about fall risk, I would make sure she had correct footwear and put her at the nurses' station for increased monitoring. She stated at approximately 8:00 PM, a CNA informed her a resident was on the floor. RN B confirmed she responded and found resident #1 lying in a mixture of urine and feces and there was no wheelchair in the room, neither by her bed nor in the bathroom. RN B explained she did not receive any information on the resident's mobility status or activities of daily living (ADL) needs in report, and there were no Physical Therapy notes in the chart. On [DATE] at 2:53 PM, resident #8 recalled her roommate, resident #1, was admitted on a Friday night and said, It was quite a weekend! Resident #8 stated during the few days they shared a room, resident #1 argued, yelled, screamed, and fell at least four times. Resident #8 said, She was very, I mean extremely, confused . She kept coming over to my side of the room to ask for and search through my things. She was using her rolling table to walk around the room, and she also wanted to use my wheelchair. Resident #8 stated over the weekend, resident #1 walked across to her side of the room and fell at the foot of her bed. She said, It had to have been between 10:00 PM and midnight. I'm not sure if she hit her head. She was on the floor, and she couldn't get up by herself. I used my call light to call someone, but at the same time I yelled for help for her. Two staffers, a CNA and a med nurse, came in and they helped her up. Resident #8 stated on another occasion that weekend her roommate also fell near the bathroom as she walked while pushing the over bed table. Resident #8 recalled her roommate fell twice on her last day in the facility, Monday [DATE]. She stated the first time was after dinner. It was not the big fall. They, some staff, got her up and put her back in the chair. Resident #8 stated later that evening she heard resident #7 yell, Patient down! She explained, If it wasn't for [name of resident #7], I don't think anyone would have known for a while because I didn't see that one. On [DATE] at 3:00 PM, in a telephone interview, LPN J confirmed she was assigned to resident #1 for the night shifts on Saturday [DATE] and Sunday [DATE]. She recalled during shift change report she was told to keep an eye out for her. LPN J said, I wound up going into the room with her several times that shift, and she kept trying to get up and walk. I would keep going back and she was trying to walk, and her legs were swollen. I told the CNA to keep an eye on her. I did not stay with her as I had a lot of residents. At one point, she was pushing her overbed table down the hallway. I yelled to the CNA, and we ran down the hallway to get her. She must have gotten halfway down the hallway, between her room and the nurses' station. LPN J explained she asked the CNA to monitor the resident, but never specified a frequency or tried to arrange one-to-one supervision. She stated it was not possible to offer closer monitoring as the CNA had other residents who were at risk for falls who also had to be watched. LPN J denied any knowledge of resident #1 falling during the night shift as reported by the resident's roommate. She acknowledged she did not report the safety concerns to the physician or a supervisor. On [DATE] at 3:12 PM, in a telephone interview, CNA K stated she was assigned to care for resident #1 on one night shift, but she could not recall the date. CNA K stated she was not sure of the time, but she remembered the call light sounded and resident #8 shouted for help. CNA K stated when she arrived in the room she saw resident #1 seated on the floor by her roommate's bed. She explained she ran to notify LPN J who was the assigned nurse and they both returned to the room. CNA K stated resident #1 denied hitting her head when questioned by LPN J, and they both lifted her to a standing position and carried her back to bed. The CNA explained resident #1 was not able to stand on her own and could not really walk because her legs were so swollen. She stated she assumed the nurse would complete the necessary paperwork, so she did not report the fall to anyone else. CNA K stated resident #1 was not placed on frequent or continuous monitoring after the fall. On [DATE] at 3:33 PM, in a telephone interview, the Weekend Nursing Supervisor stated she was informed resident #1 was confused. She said, If a resident is confused or if there is a safety issue, nurses could ask if they felt they needed more staff. She explained the admission nurse was responsible for creating a baseline care plan to inform nursing staff of care needs. She said, Normally they would not be allowed to ambulate without assistance until assessed by physical therapy. The Weekend Nursing Supervisor stated no staff told her resident #1 fell on the weekend. On [DATE] at 10:43 AM, the North Wing Unit Manager (UM) reviewed resident #1's medical record and acknowledged the fall risk evaluation was inaccurate, incomplete, and did not clearly deem her at risk for falls. The UM explained the admission nurse did not initiate a required continence tracking form for evaluation of resident #1's elimination patterns to determine an appropriate toileting schedule. The UM denied receiving any reports from nursing staff regarding the resident's constant attempts to ambulate without assistance or absence of a wheelchair. He confirmed any safety issue such as escalating confusion and high fall risk needed immediate interventions which should be noted in the chart. The UM verified nursing staff did not appropriately determine resident #1's risk for falls, implement fall prevention approaches or notify the physician as her likelihood for falls increased over the weekend. On [DATE] at 7:50 PM, the Director of Nursing (DON) recalled on [DATE] at approximately 1:00 PM, as she rounded on the North Wing, resident #1's assigned nurse asked her if the resident always stood up and asked to leave the building. The DON stated she told the nurse resident #1 was newly admitted and staff had to continue evaluating her. The DON stated during her final rounds at approximately 4:00 PM, she was informed the assigned nurse had initiated a psychiatric consult and CNAs were checking on resident #1 every 20 to 30 minutes. On [DATE] at 3:23 PM, in a telephone interview, the facility's Medical Director confirmed resident #1's falls should have been reported according to protocol. She explained her expectation was nurses would notify the physician first as medical providers should be the ones to determine necessary interventions to diagnose or treat a resident after a fall. When informed resident #1 possibly had multiple unwitnessed falls over the weekend, the Medical Director stated the standard of practice was to send residents out to the hospital after unwitnessed falls due to the possibility of head injuries. On [DATE] at 3:57 PM, the DON confirmed every fall should have been reported. She said, In this situation, if the interdisciplinary team had been aware the resident fell once or more on the weekend, other interventions would have been put in place. Review of the facility's policy and procedure Fall Management revised on [DATE], revealed residents would be evaluated for fall risk, and patient-centered interventions would be initiated as indicated. The purpose was . to identify residents at risk for falls and establish/modify interventions to decrease the risk of a future fall(s) and minimize the potential for a resulting injury. The document indicated a resident's fall risk was based on results of the Fall Risk Evaluation and contributing factors including medications, diagnoses, and the environment. The process involved development of interventions based on risk factors and updating nurse and CNA care plans. The policy directed staff to notify the physician and family after a fall and re-evaluate the resident utilizing a Post Fall Evaluation tool. The interdisciplinary team was expected to review fall documentation, complete a root cause analysis, and develop new care plan interventions to prevent additional falls. Review of the Facility Assessment Tool dated [DATE] revealed the facility could meet the needs of residents with impaired cognition, behavior that needed interventions, and cirrhosis. The document indicated the facility offered services including assistance with activities of daily living, mobility, prevention of falls and falls with injury, mental health and behaviors, and therapy. The assessment showed the facility would provide person-centered care, ensure direct-care staff had relevant information to provide that care, and identify hazards and risks for residents. 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], resident #1 was discharged from the facility to the hospital. *On [DATE], the facility initiated education of all licensed nursing staff including agency nurses. The DON or other nurse management team members provided education on provision of supervision of residents to reduce risk of falls. Topics included notification of the DON or designee when residents exhibited increased behaviors that may lead to falls, provision or initiation of increased supervision if needed, notification of DON of all unwitnessed falls once the physician and/or EMS was notified. Education was accompanied by post testing. The facility educated 10 of 22 licensed nursing staff as of [DATE]. Those nurses not educated will receive education prior to the next scheduled shift. *On [DATE], the facility evaluated 116 in-house residents for fall risk. Care plans of those residents identified as high risk for falls were reviewed and updated as needed for supervision. Review of resident falls from [DATE] to [DATE] was done to ensure fall management process was in place to include appropriate supervision for those residents at risk. *As of [DATE], Code of Ethics training was completed by the Administrator and department heads to include the responsibility to report all resident falls to ensure fall prevention measures are implemented for resident safety. Training included a No Retaliation rule for staff and/or residents who make such reports. The Administrator will add Code of Ethics training to monthly [NAME] Hall Agenda for all facility staff. The facility educated 52 of 135 staff on Code of Ethics. *On [DATE], the facility sent certified letters to those staff members who were unable to attend education. Any facility or contracted[TRUNCATED]