**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility's policy and procedure, staff, and resident interview the facility failed to implement a systemic approach to identify risk factors and implement appropriate interventions to prevent avoidable fall related serious injuries for 5 (Resident #20, #85, #193, #392, and #292) and 2 (Resident #27, and #192) with multiple falls, of 10 residents sampled with falls or fall related injuries. Resident #20 was admitted to the facility on [DATE] and was dependent on staff for repositioning. On 1/22/22 the resident rolled out of bed during care and sustained a nasal bone fracture. Resident #85 was admitted to the facility on [DATE] and was assessed to be at risk for falls. On 2/5/22 and 5/14/22 the resident sustained a fall resulting respectively in a fractured hip and wrist and acute head injury. Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right hip fracture. On 1/10/22 the resident sustained a fall resulting in a dislocation of the right hip prosthesis. Resident #292 was admitted to the facility on [DATE]. The resident was assessed to be at risk for falls. On 6/11/22 the resident was sent to an acute care hospital after he was found on the floor with a head wound actively bleeding, requiring staples. Resident #27 was admitted to the facility on [DATE]. Resident #27 was assessed to be at risk for falls. Resident #27 sustained 12 unwitnessed falls from 2/9/22 through 5/23/22. Resident #192 was admitted to the facility on [DATE] with a history of falls with injury. Resident #192 sustained eight unwitnessed falls, including four falls on 5/31/22. The facility's failure to implement systemic interventions to prevent avoidable falls and fall related serious injuries resulted in noncompliance at the Immediate Jeopardy level starting on 4/20/22. On 7/30/22 at 6:29 p.m., the Administrator was informed of the determination of ongoing Immediate Jeopardy and provided the Immediate Jeopardy templates. The findings included: Cross reference: F835 and F867. The facility's fall policy revised 2/18/22 noted the facility, perform a post fall assessment to determine the root cause of the fall. Gather assessment data from the patient, staff members, and any witnesses to the fall. Review the events that proceeded the fall and contributing factors. After a fall, complete a detailed incident report to help track the frequency of the patient's fall so that the facility can implement prevention measures with high-risk patients. 1. On 7/24/22 at 2:54 p.m., Review of the clinical record for Resident #85 showed an admission date of 10/29/20 with diagnoses of End Stage Renal Disease, and anemia. Upon admission, Resident #85 was assessed to be at risk for falls and a care plan developed. The care plan for falls initiated on 10/31/20 noted the resident was at risk for falls due to history of falls, impaired balance, poor coordination, and unsteady gait. The goal was to minimize risk for falls. The interventions included to encourage to transfer and change positions slowly, have commonly used articles within easy reach, provide assistance to transfer, reinforce, re-educate and remind patient of the need to call for assistance and use call light. The Annual Minimum Data Set (MDS) assessment with a target date of 11/17/21 noted Resident #85 was cognitively intact. The discharge from therapy MDS with an assessment reference date of 11/26/21 noted Resident #85 required supervision or touching assistance (Helper provides verbal cues or touching/steadying assistance) for walking as resident completes activity. The progress note dated 1/28/22 at 11:36 a.m., noted, Staff reports that resident states that while reaching for a stuffed animal resident sat herself on the floor . The note did not describe the location of the fall. Review of the incident report created on 2/1/22 (4 days after the fall) at 11:18 a.m., showed on 1/28/22 at 11:00 a.m., Staff reports that resident states that she was reaching for a stuffed animal and sat herself on the floor. The investigation report did not contain any witness statements, or a review of the events that proceeded the fall and contributing factors. The incident investigation did not document if the fall interventions were in place at the time of the incident or interventions implemented to prevent recurrence. The progress note dated 2/5/22 at 4:19 p.m., noted, CNA went into residents [sic] room and noted that she was lying on the floor in front of the foot of the bed. When nurse went in she was sitting on her buttocks with knees slightly bent, on the floor at the foot of her bed . The nurse documented she assisted the resident to a standing position. Resident #85 could barely bear any weight on her left leg and complained of pain. The resident was sent to the hospital for evaluation and treatment. The incident and investigation report dated 2/5/22 at 3:57 p.m. did not document people interviewed during the investigation, a timeline of critical events, actions taken during the investigation, or a conclusion. The hospital record dated 2/5/22 noted Resident #85 said she came out of her room to walk down the hallway to check on someone who sounds like they were crying, she tripped and fell, she could not bear weight afterwards, and she hit her head. The resident was diagnosed with a left femoral neck fracture (part of the thigh bone), left wrist fracture, left facial abrasion and contusion. Resident #85 returned to the facility on 2/9/22. Resident #85 received Physical, and Occupational Therapy. The care plan was not updated to include preventive measures to prevent recurrence of falls. The progress note dated 3/28/22 at 10:18 a.m., noted, Resident with a fall on 3/26/22. IDT (Interdisciplinary team) reviewed fall care plan and risk factors with interventions added. The incident report created on 3/28/22 at 8:36 a.m., (Two days after the fall) noted Date of incident: 3/26/22 2:00 PM. The housekeeper notified the nurse someone is on the floor. The writer observed the resident sitting on the floor in front of her wheelchair. On 3/28/22 at 10:55 a.m., the nurse documented, She [Resident #85] is able to tell the nurse she fell and how it happened. The note did not document the content of the interview with the resident. On 3/28/22 the care plan was updated to Provide resident with rest periods after meals/throughout the day as needed/desired. The investigative report dated 3/28/22 (two days after the fall of 3/26/22) was incomplete and did not document the content of the interview with the resident to determine the root cause of the incident and ensure the interventions listed on the care plan were appropriate to prevent recurrence of avoidable falls and fall related serious injuries. On 3/31/22 at 9:59 a.m. a progress note documented, Resident with a fall on 3/30/22. IDT reviewed fall care plan and risk factors with intervention added. The incident report created on 3/31/22 at 9:35 a.m. noted, Date of incident 3/30/22 at 12:00 p.m. Resident was observed sitting on floor in front of wheelchair. Resident stated she was attempting to get up on her own. Call light within reach and not activated, gripper socks [anti-skid socks] in place. Wheelchair locks engaged and bed in low position. On 3/31/22 the care plan was updated to assist and encourage resident to have her lunch meal in the Dining Room. The investigation report was not completed. It did not include a root cause analysis to determine if the intervention added to the care plan was appropriate to prevent further avoidable falls. On 5/14/22 at 10:20 a.m., an incident report noted Resident #85 was observed on the floor laying on her right side in front of the wheelchair and the air conditioner. The resident was awake and alert and stated, I slid off the w/c (wheelchair). The investigation report was not completed. The resident was sent to the hospital for evaluation and returned with a diagnosis of acute head injury. The care plan was updated on 5/16/22 (two days after the fall with serious injury) to include a Dycem (anti slip material) to the wheelchair seat. On 7/26/22 at 2:23 p.m., the Assistant Director of Nursing (ADON) said it is the facility process to complete a fall investigation. The ADON said Resident # 85 was independent prior to her fall of 2/5/22 and has not been able to ambulate on her own since sustaining those injuries. On 7/26/22 at 4:06 p.m., the Minimum Data Set (MDS) Registered Nurse Staff D said that prior to fall of 2/5/22, Resident #85 required supervision to independence with all functional status. As of last MDS assessment completed on 7/1/22, the resident has declined and requires extensive assistant with all functional mobility and is no longer ambulatory. RN Staff D said despite therapy, Resident #85 has not regained her prior level of function. On 7/26/22 at 2:54 p.m., the Rehabilitation Director said Resident #85 received therapy after her fall with major injuries on 2/5/22. The resident was discharged from therapy on 7/1/22 at a maximum assist to dependent with some functions. 2. Resident #292 was admitted to the facility on [DATE]. The admission MDS assessment with a target date of 6/16/22 noted the resident had severe cognitive impairment. Resident #292 required extensive physical assistance of one person for bed mobility and extensive assistance of two persons for transfer (how resident moves to or from bed, chair, wheelchair, standing position). The diagnoses included traumatic brain injury. The resident's vision was highly impaired and did not wear corrective lenses. The care plan created on 6/13/22 noted the resident was at risk for falls due to a history of falls, recent falls with head injury, poor safety awareness, new environment, and weakness. On 6/11/22 the facility noted in an incident report, Resident observed lying on the floor with a head wound actively bleeding. He had been placed in w/c [wheelchair] 5 min (minutes) prior d/t (due to) climbing OOB (Out of bed). Resident #292 was sent out to the hospital and returned on 6/13/22 with staples to his head and a diagnosis of unspecified falls. The care plan updated on 6/13/22 noted to, assist with and encourage use of non-skid footwear, non-skid socks in and out of bed. The investigation report was not completed. It did not include a root cause analysis to determine if the intervention added to the care plan was appropriate to prevent further avoidable falls. On 6/14/22 at 12:40 p.m., the facility noted in an incident report, Pt [patient] fell next to bathroom door ambulating without assistive device. The nurse completing the incident report noted the resident sustained a skin tear to the right hand. The care plan was updated on 6/14/22 to assist the resident with toileting and/or provide incontinence care upon rising, before/after meals, at bedtime and as needed. One on one care/observation with staff as needed/indicated. The investigation report for the fall of 6/14/22 was not completed. It did not include an investigation, conclusion to determine the root cause of the incident to ensure the interventions were appropriate to prevent further avoidable falls. On 7/29/22 at 3:00 p.m., the Administrator and the Director of Nursing (DON) said the interdisciplinary team IDT reviewed the falls every morning and afternoon, Mondays through Fridays through the Eagle Room process. The Eagle Room process consists of a check list to ensure the following areas were completed after a fall: Neurological checks, Medication review, Notification of MD and family, electronic incident report, Investigation complete, reportable, fall evaluation completed, Pain evaluation completed, Referral or new intervention, Calcium and Vitamin D protocol, root cause (IDT) management document, care plan and task list (updated). The DON could not provide additional information indicating an investigation to determine root cause of the falls. 6. On 7/24/22 at 10:33 a.m., Resident # 20 said she was rolled out of bed by a Certified Nursing Assistant (CNA) who was changing her. She said she told the CNA she was too close to the edge of the bed, but the CNA did it anyway. Resident #20 said she fell off the edge of the bed and landed face down on the floor. Resident #20 said she sustained a broken nose from the fall. Review of the MDS with the ARD of 1/21/22 indicated Resident #20 required the assistance of 2 staff when she fell out of bed on 1/22/22 while being assisted by one CNA. Review of the care plans for Resident #20 revealed the intervention requiring 2 staff at all times for Activities of Daily Living (ADLs) which includes toileting needs, was not updated until 2/17/22. Review of the progress notes for Resident #20 revealed a progress note on 1/22/2022 indicating resident #20 had a fall at the facility and transported by Emergency Medical Services (EMS) to the hospital. The hospital discharge records dated 1/23/22 indicated Resident #20's nose was fractured at the facility where she fell out of bed. The incident report dated 1/22/22 for Resident #20's fall included witness statements from five CNAs who were not in the room at the time of the incident and one CNA in the room assisting the resident. On 7/27/22 at 3:56 p.m., the MDS coordinator responsible for assessing Resident #20 verified the 7-day look back for the MDS with assessment reference date of 1/21/22 indicated Resident #20 required two staff for bed mobility and toileting. On 7/26/22 at 4:09 p.m., the Director of Nursing (DON) confirmed there was only one CNA in the room helping Resident #20 at the time she fell. He said he provided training two days later on 1/24/22. The DON said if the staff were in the facility on that day he provided the training, he would have trained them however, it was not mandatory. Review of the staff training revealed only one CNA who was present when Resident #20 fell received the training. On 7/28/22 at 11:03 a.m., Resident #20 said staff continue to help her using only one staff. Resident #20 said last week one CNA changed her in bed. The CNA told Resident #20 someone would come to assist, but the other CNA never showed up. Resident #20 said the CNA started and completed the toileting task by herself. Review of the CNA toileting documentation for Resident #20 from 6/30/22 through 7/29/22 indicated Resident #20 was toileted by staff 66 times. Twenty-three times out of 66 times Resident #20 was toileted by one person. Review of the grievances revealed Resident #20 complained on 5/19/22 staff can never find two CNAs to help with her care and has to wait. The DON's documented response to the resident was there may be a short wait time due to staff caring for other residents. The resolution of concern was discussed needs and expectations. Will provide education to staff on communication with residents on wait times. The DON unable to produce training documentation. On 7/29/22 at 4:26 p.m., the DON said he does not monitor how many staff assist resident #20 with Bed Mobility and Toileting. He said he is only checking for the red and green marks. 7. Review of the medical record revealed Resident #392 was admitted to the facility on [DATE] at 5:30 p.m. She was [AGE] years old, and her BIMS score was 7, indicating severe cognitive impairment. Her diagnoses included pneumonia, fracture, and dementia. Resident #392 had a peripherally inserted central catheter at the time of admission for intravenous antibiotics. Her medication orders included an antipsychotic, Quetiapine Fumarate 25mg, at bedtime. Resident #392 required extensive assistance of two staff members for transfers from bed to wheelchair, from bed to standing, and for toileting needs. Review of the nursing progress notes for Resident #392 revealed a late entry on 5/19/22 at 3:52 a.m. indicating Resident #392 had a fall prior to admission. Resident #392 was quoted to say, When I fall, I fall real good. Review of the progress notes revealed a second progress note on 5/19/22 at 4:02 a.m. indicating Resident #392 fell in her room at the facility. She was found on the floor, sustained a bump to the back of the head, and was transported to the hospital. Review of the Fall Care Plan for Resident #392 revealed interventions: Use of non-skid footwear, bed in low position, encourage slow transfer, commonly used articles within easy reach, provide assist to transfer and ambulate as needed, and reinforce need to call for assistance. The care plan did not include specific resident-centered interventions to minimize the risk of falls for Resident #392. Review of the facility Incident Report for Resident #392's fall listed the incident date and time as 5/19/22 at 10:49 a.m. The time resident was taken to the hospital was the same. The dates contradicted the hospital records, which revealed Resident #392 was admitted on [DATE] at 4:33 a.m. and discharged on 5/19/22 at 8:09 a.m. Review of the Investigation Report for #392's fall included a blank investigation report (3 pages) and blank witness statement (2 pages). Review of the progress note dated 5/19/22 at 2:18 p.m. indicated Resident #392's risk factors for falls were discussed with the Inter-Disciplinary Team and (Care Plan) interventions added. On 7/28/22 at 9:09 a.m., the DON said resident falls are discussed daily in the Eagle Room Morning Meetings. The DON provided the Eagle Room [NAME] Paper (HCR-MC-0200_F Date: 02/2019) with Resident #392 listed in the bottom 3rd of the paper. The DON could not provide additional information indicating an investigation to determine root cause of the fall was determined with actions the facility would take to prevent another fall for the resident. There were no witness statements from Resident #392, the staff, or staff training. 4. Clinical record review showed Resident #193 was admitted to the facility on [DATE] following a fall and fracture requiring right hip surgery. The admission Minimum Data Set (MDS) assessment with a target date of 1/13/22 noted Resident #193 scored 13 on the brief interview for mental status indicative of intact cognition. Resident #193 required extensive physical assistance of one person for bed mobility, transfer, and walking. The care plan initiated on 1/7/22 noted Resident #193 was at risk for falls due to weakness, recent fall with fractures. The goal was to minimize the risk for falls. The interventions included to have commonly used articles within reach, provide assistance for transfer and ambulation as needed, reinforce the need to call for assistance. A care plan progress note dated 1/11/22 documented Resident #193 sustained a fall on 1/10/22. The interdisciplinary team reviewed the fall care plan and risk factors with interventions added. The incident report created on 1/11/22 noted Resident #193 sustained a fall on 1/10/22 at 10:21 p.m., Resident noted on floor, laying on right side, on her back. Right leg bent behind her and complaining of pain 10 (A pain score of 10 on a numerical pain scale from 0 to 10 indicates the worse possible pain). Resident #193 was sent to the hospital for evaluation and treatment. The incident report showed no documentation of an investigation date, no documents reviewed, people interviewed, timeline of critical events, or actions taken during or after the investigation. A fall assessment dated [DATE] at 9:10 p.m. showed Resident #193 had difficulty maintaining a standing position and had impaired balance. The fall assessment showed Resident #193 had joint pain and cognitive impairment. The fall assessments showed no environmental factors to the fall. The form showed a care plan was initiated or revised. There was no additional comments or observations documented on the form. A progress note dated 1/11/22 at 4:43 a.m. showed Resident #193 returned from the hospital with a dislocated right hip prosthesis. On 1/11/22 the Care Plan was updated for the resident to be encouraged to wear nonskid footwear and non-skid socks in and out of bed, and for the bed to be in a low position. There was no documentation as to why these interventions were put in place. On 7/27/22 at 4:29 p.m., the DON verified Resident #193 was interviewable. The DON said since there was no documentation of attempts to interview Resident #193 regarding the cause of the fall, he would not be able to determine the cause of the fall. 5. Resident #192 was admitted to the facility on [DATE] with history of falls with injury. The admission MDS with a target date of 4/16/22 showed Resident #192's cognition was impaired. The resident required extensive physical assistance of two persons for bed mobility and transfers. A care plan initiated on 4/10/22 showed Resident #192 was a fall risk due to recent falls with fractures and surgery, weakness, cognitive impairment, and poor safety awareness. Review of incident report dated 4/29/22 at 11:10 a.m. for Resident #192 showed on 4/27/22 at 2:15 a.m., the nurse documented she was called to the resident's room by the Certified Nursing Assistant. The resident was observed lying on the floor besides the bed on the left side. The nurse documented she reminded the resident to use the call light and not get up unassisted. The fall evaluation dated 4/27/22 at 2:15 a.m., noted Resident #192 had impaired balance during transition, had impulsivity or poor safety awareness. The care plan for falls was updated to include to assist and encourage use of non-skid footwear, non-skid socks in and out of bed, bed in low position. There was no investigation to determine the root cause of the incident to ensure the interventions were appropriate to prevent further avoidable falls. Review of the incident report dated 5/3/22 showed on 5/3/22 at 11:10 a.m., Resident #192 was observed lying on the floor beside the bed. Bed was low to the floor upon discovery. The resident complained of severe back pain. The resident was sent out to the hospital via emergency medical services. The change in condition progress note dated 5/3/22 noted the resident returned from the hospital. A progress note created on 5/3/22 at 8:28 a.m. shows the MDS Coordinator documented Resident #192 returned from the hospital and that she would be monitored for a significant change for 14 days. The care plan was updated on 5/4/22 to include assist and encourage to be up in chair and ready for breakfast. There was no investigation to determine the root cause of the incident to ensure the interventions were appropriate to prevent further avoidable falls. On 5/16/22 after a fall the care plan was updated to implement use of preventative device: Bed pillows to help resident recognize edge of bed. Review of the incident report created on 5/31/22 showed on 5/30/22 at 11:30 p.m., the resident was found, sitting on floor. Unwitnessed fall. There was no documented investigation to determine the root cause of the incident. There was no documentation if the previous fall interventions were in place at the time of the fall. Review of the incident report dated 5/31/22 showed on 5/31/22 at 8:30 a.m., Resident #192 was observed on the floor besides her wheelchair in the café. She stated she was looking for her ID and slid out of her chair. There was no immediate intervention to prevent the resident from sliding out of her wheelchair. On 5/31/22 an incident report documented on 5/31/22 at 11:30 a.m., the resident was observed sitting on the floor beside her bed. She continues to report that she slid out of bed looking for her ID. There was no documentation if the previous interventions to prevent the resident from rolling out of bed were in place. There was no immediate intervention to prevent recurrence. On 5/31/22 at 3:30 p.m., an incident report documented Resident #192 was observed sitting on the floor between her wheelchair and over bed table. She slid out of the chair trying to pick up a puzzle piece. There was no investigation or immediate intervention to prevent recurrence. On 5/31/22 at 4:17 p.m., an incident report documented, Resident observed sitting on the floor beside her bed. She continues to report that she sled [sic] out of bed looking for her ID. There was no investigation or immediate interventions documented to prevent further avoidable falls and potential fall related injuries. All incident reports showed no investigation, and no actions taken for the resident's falls, no documented root cause of each incident. The resident was assessed for falls on 4/27/22, 5/14/22, and twice on 5/30/22. The four fall assessments completed by the facility show Resident #192 had an impaired balance. Resident #192 was taking cardiac medications, and narcotic analgesics. 3. On 7/28/22 review of Resident #27's medical record revealed he was admitted to the facility on [DATE]. The admission assessment dated [DATE] assessed Resident #27 to have a BIMS score of 11, a score between 8 to 12 means a person was assessed with moderately impaired cognition for daily decision making. Resident #27 admitting diagnoses included anxiety disorder, unspecified cerebral infarction, cognitive communication deficit, and a history of repeated falls. Further review of Resident #27's medical record revealed a fall care plan created on 2/4/2022 stating Resident #27 was at risk for falls due to weakness, confusion, poor safety awareness, resident placed himself on the floor and would slide out of bed and chair. The facility's goal for falls is the facility would minimize the risk of injury related to falls and decrease the number of falls, with a target date of 9/03/2022. The fall care plan interventions stated they would assist and encourage the resident to be up and out of bed and room daily for supervised activities and dining (4/25/2022), assist Resident #27 with toileting, and/or provide incontinence care upon rising, before/after meals and bedtime (3/11/2022), assist with and encourage the use of non-skid footwear (4/20/2022), bed in low position (2/14/2022), Dycem/anti-slip material to wheelchair seat (2/14/2022), encourage resident to be up in chair daily for breakfast (2/28/2022), encourage resident to attend supervised activity (4/08/2022), encourage to transfer and change position slowly (2/17/2022), follow-up with psychiatric Nurse Practitioner (NP) post 4/16/22 fall (4/18/2022), have commonly used articles within easy reach (2/04/2022), implement use of preventative devices for falls (5/24/2022), medication review with physician, NP and pharmacy consultant (4/18/22), monitor positioning while in bed to ensure safety and reposition as needed in bed (5/06/2022), provide assist to transfer and ambulate as needed (2/04/2022), provide stuffed animal while up in wheelchair and in bed for comfort and happiness (4/01/2022), psychiatric service consult related to sliding out of bed and chair behaviors (2/17/2022), reinforce need to call for assistance (2/04/2022), reinforce wheelchair safety as needed (2/27/2022), and the use of a STOP sign to help prompt/cue Resident #27 to call for assistance related to frequent falls (3/07/2022). A review of Resident #27's Incident Report and Investigation Report forms revealed Resident #27 from his admission on [DATE] to 5/23/22 had 12 unwitnessed falls with no major injury. The incident Report created on 2/9/2022 stated Resident #27 was sitting on the floor in front of his wheelchair during lunchtime on 2/09/2022 at 1:00 p.m. with no injuries. The incident and investigation report dated 2/09/2022 said they took his vital signs, did a full assessment, and started neurological (neuro) checks. The incident and investigation report dated 2/09/2022 did not document the facility staff they interviewed during the investigation, timeline of critical events, actions taken during the investigation, or conclusion of their investigation. The incident Report created on 2/11/2022 stated Resident #27 was observed on the floor next to his bed on 2/10/2022 at 11:30 p.m. with no injuries. The incident and investigation report dated 2/11/2022 said they put Resident #17 back to bed, took his vital signs, and started neuro checks. The incident and investigation form did not document the name of the staff interviewed during the investigation, timeline of critical events, actions taken during the investigation, or conclusion of their investigation. The incident Report created on 2/16/2022 stated Resident #27 was observed next to his bed on 2/16/2022 at 6:15 p.m. with no injuries. The incident report stated Resident #27 told the nurse he rolled out of bed. The incident report investigation stated resident was wearing his non-skid socks, the bed was in a low position, the bedside table with fluid was in reach of Resident #27, and Resident #27 was last seen by nursing staff at 5:45 p.m. The incident and investigation report dated 2/16/2022 did not document the name of the staff interviewed during the investigation, the timeline of critical events, and the conclusion of their investigation. The incident report created on 2/23/2022 stated Resident #27 was observed on the floor next to his bed on 2/23/2022 at 6:32 a.m. with his pillow and blanket, with no injuries. The investigation revealed Resident #27's nurse said Resident #27 had yelled out multiple times during the shift, and when the nurse went into his room the resident was on the floor with his pillow and blanket covering him. Resident #27 told the nurse he placed himself on the floor. The investigation said the nurse did neuro checks, a full assessment, vital signs, and assisted the resident back into bed. The incident and investigation report dated 2/23/2022 did not document the name of the staff interviewed during the investigation, and the conclusion of their investigation. The incident report created on 2/27/2022 stated Resident #27 was observed on the floor next to his bed on 2/27/2022 at 5:45 a.m., with no injuries. The investigation stated Resident #27's nurse said they observed Resident #27 was on the floor next to his bed without injuries. She assisted Resident #27 back to bed, did a full assessment, and started five minutes neuro checks. She further said she had seen Resident #27 five minutes earlier in his bed resting quietly at 5:40 a.m. The incident and investigation report dated 2/27/2022 did not document the name of the staff interviewed during the investigation, and the conclusion of their investigation. The incident report created on 3/05/2022 stated Resident #27 was observed on the floor next to his bed on 3/05/2022 at 10:00 a.m., with no injuries. The investigation revealed Resident #27's nurse said she was notified by Resident #27's certified nursing assistant he was on the floor next to his bed without injuries. The resident was unable to state what happened but said he was not in pain. The nurse did a set of vital signs, initiated neuro checks, and put Resident #27 back to bed. The incident and investigation form did not document the staff interviewed during the investigation, the timeline of critical events, or the conclusion of their investigation. The incident report created on 3/10/2022 stated Resident #27 was observed on the floor during hourly rounds next to his bed on 3/10/2022 at 8:30 p.m., with no injuries. The investigation revealed Resident #27's certified nursing assistant said during her hourly rounds she found Resident #27 on the ground. Resident #27's nurse said they assisted Resident #27 back to bed, initiated neuro checks, started vital signs, and gave Resident #27 Tylenol for generalized pain. The investigation revealed Resident #27 had non-skid socks on, his call light was in reach, and the bedside table with fluids was in reach. The incident report said Resident #27 was unable to state what [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interview the facility administration failed to use its resources effectively to ensure consistent and ongoing implementation of effective measures to prevent avoidable falls and fall related injuries. Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right hip fracture. On 1/10/22 the resident sustained a fall resulting in dislocation of the right hip prosthesis. On 1/22/22 Resident #20 sustained a nasal bone fracture when she was improperly turned in bed and fell. Resident #85 sustained multiple falls at the facility on 1/28/22, 2/5/22, 3/26/22, 3/30/22 and 5/14/22. On 2/5/22 Resident #85 was diagnosed with a left femoral neck, and left wrist fracture, left facial abrasion and contusion. On 5/14/22 Resident #85 was sent to the hospital after the fall and diagnosed with an acute head injury. On 2/20/22 the facility developed a performance improvement plan to address the increase in falls and fall related injuries. The facility administration failed to ensure implementation, and monitoring of the approaches in the performance improvement plan to minimize the risk of falls and fall related injuries. The failure of the facility's administration to implement and monitor effective fall preventive measures resulted in noncompliance at the Immediate Jeopardy level starting on 4/20/22. The Administrator was informed to the determination of ongoing Immediate Jeopardy on 7/30/22 at 6:29 p.m. and provided the Immediate Jeopardy templates. The findings included: Cross reference to F689 and F867. Review of the Administrator's job description signed on 5/10/19 revealed the Administrator, . Manages all business-related activity the HCR (Health Care and Retirement Corporation) Manorcare vision and supporting strategies and assures that . high-quality provider of health services is maintained . follows established safety policies and procedures. Ensures potential safety/health hazards are eliminated . Directs the staff to provide high quality in daily care which meets/exceeds all internal/external standards. The Director of Nursing Job Description signed on 6/21/21 showed the Director of Nursing is responsible to, . Follow established safety policies and procedures . Communicates care delivery trends, issues and opportunities to administration, medical director, and the quality assurance committee. Anticipates customer's needs and works to minimize potential problems. Establishes and manages goals and objects for the nursing department through analysis and strategic planning consistent with the company's mission. Promotes nursing process and critical thinking in nursing care delivery . Participates in clinical risk identification, strategy planning, and risk reduction. Ensures and evaluates systems to plan, promote, develop, assess, interpret, validate, and evaluated the implementation of clinical programs, policies and procedures and forms. Ensures personnel are adequately educated to care for acute events, chronic illnesses of the frail elderly, cognitive impairment, end of life . The facility's incident log showed a total of 157 falls from January 1,2022 through July 22, 2022. Review of a sample of 10 residents with falls and fall related serious injuries revealed four residents sustained serious injuries (broken bones) and one resident sustained a head laceration. Two residents sustained multiple falls without documentation of an investigation to prevent reoccurrence. Review of the Performance Improvement Project (PIP) titled Falls Management dated 2/2/22 noted the overall goal of the improvement project was to reduce the trends of falls and falls with major injury. The target end date was April 20, 2022. The summary of the findings of the root cause analysis noted a Knowledge deficit related to the process steps for identification of resident falls risks, interventions and systems to minimize fall risks while promoting quality of care. The measures included: 1 The facility will identify a subcommittee related to falls management reduction. The team consisted of two nurses, one therapist, two CNAs (Certified Nursing Assistants) and one leadership team member preference would be Activities Director. The committee will be tasked to review all current residents who have had more than three falls in 90 days or one major fall with injury. Discuss for each: Any with possible sleep deprivation/up frequently during night/awake most of the night. On February 28, 2022, the DON documented increased rounding/observation education provide to all nursing staff with refresher on fall, documentation, interventions and preventions. On March 18, 2022, the DON documented Ongoing review during Eagle Room standup and stand-down. Falls decreased and interventions in place. Monitoring of results of interventions completed. On March 29, 2022, the DON documented Medication review and causes associated with recent falls and correlation of effectiveness of interventions since PIP initiation. The result of the intervention was documented as In progress. 2 The Administrator/Designee will educate the interdisciplinary team and set expectations for the review of falls during Eagle Room and the completion of the Eagle Room QA (Quality Assurance) tool. On 2/28/2022, the DON documented education provided on fall interventions and preventions with implementation of increased rounding and monitoring by all nursing staff. On 3/29/22 the DON documented ongoing reminders and plan for fall documentation review. New falls added to monitoring list for IDT review of causes and preventions. The result of the intervention was documented as Successful. 3 The DON/Designee will educate CNAs and licensed nurses on post fall process review utilizing the FYI (For Your Information) post fall evaluation. On 2/28/22 the DON documented education provided to all nursing staff at mandatory meeting/education on 2/23, 2/24 and 2/25. On 3/18/22 the DON documented reminders to all staff based on situation and likelihood of falls or recurrent falls. Staff continue to monitor and implement fall preventions and interventions. On 3/29/22 the DON documented ongoing education and re-evaluation of fall risks including new admissions. Early prevention and rounding remain priority. The result of the intervention was documented as Successful. 4. The DON/Designee will educate licensed nurses on initial evaluation of residents past history or experiences of falls. Completing the admission/readmission screen with accuracy. On 3/18/22 the DON documented ongoing education and re-evaluation of fall risks including new admissions. Early prevention and rounding remain priority. The result of the intervention was Successful. The DON/Designee will educate licensed nurses on completing incident reports timely (Incident reports will be in incident report management by the end of the shift the incident occurred providing an accurate tracking process). On 3/29/22 the DON documented Monitoring of incident reports, review of preventions in place and new interventions added. The result of the intervention was Successful. The facility QAPI (Quality Assurance and Performance Improvement) team will conduct a trend review of falls to identify residents with falls and falls with major injury utilizing the Eagle Room QA tool to identify areas that are not completed weekly for four weeks then monthly for two months. On 7/29/22 at 2:19 p.m. The DON said the PIP was to last 30 days and the time counted during the PIP for the falls was from 3/1/22 to 3/31/22. The DON stated he thought there was a 50% reduction in falls during that period. He said he noticed the biggest trend was he thought there were more falls on the weekend. He counted the falls over the weekend on each Monday and noticed more falls occurred on the weekend than during the week. The DON verified there was no documentation in QAPI or the PIP regarding the trending of weekend falls. The DON verified there was no documented intervention put in place to reduce falls on the weekend. He stated the intervention put in place were activities were more involved in giving residents stuffed animals to calm them. The DON said he implement increased rounding for both him and the staff caring for the residents. The DON said there was no policy or minimum requirements for how often the staff were to round or when they were to round. The DON said he asked the staff to round more frequently. On 4/20/22 at the end of the PIP the DON said he spoke to staff regarding increased rounding and told them to keep up the increased rounding. No other interventions were put in place due to the PIP. The DON said he had educated all staff on expectations of completing incident reports and fall protocols. He said he did one to one education verbally back and forth. He said he could not remember at the time any nurse he had spoken to or educated. The DON said there was no post fall education he just used the incident reports he said he had copies in an education book, but it was not a fill out form, just informative. He said he would have to look for additional documentation for education. On 7/29/22 at 2:39 p.m., and on 7/29/22 at 3:29 p.m., the DON said he did not have any additional documentation of education provided to the licensed nurses or CNAs related to the interventions listed in the performance improvement plan for falls. On 7/29/22 at 2:30 p.m., the Administrator said there was no documentation of education of the interdisciplinary team and the set expectations for the review of falls. The Administrator and the DON said they could not provide documentation of subcommittee meetings with review of residents with multiple falls or major injury. The DON said the meetings were held in the Eagle room daily and the only documentation they could provide was the Eagle room tool and the MDS Coordinator's documentation of interventions put in place after each fall was reviewed that same day. The facility provided documentation 32 staff members were educated on March 3, 2022. The topic was falls, falls prevention and incident reporting. Fall management initiatives which included post fall evaluation, vital signs, mental status, and assessment, and medication. There was no documentation the five Registered Nurses employed at the facility were educated. Seven of 18 Licensed Practical Nurses (LPNs) were educated. Eight of 32 Certified Nursing Assistants received the education. An active employee list provided by the facility showed on 3/3/22 five RNs, 13 LPNs, and 30 CNAs were listed on the active roster. On 7/29/22 at 3:00 p.m., the Administrator and the DON said the interdisciplinary team (IDT) reviewed the falls every morning and afternoon, Mondays through Fridays through the Eagle Room process. The Eagle Room process consists of a check list to ensure the following areas were completed after a fall: Neurological checks, Medication review, Notification of physician and family, electronic incident report, Investigation complete, reportable, fall evaluation completed, Pain evaluation completed, Referral or new intervention, Calcium and Vitamin D protocol, root cause IDT management document, care plan and task list (updated). A sample of 10 residents with falls from March 2022 through 7/28/2022 showed: Resident #293 sustained a fall on 3/24/22. There was no incident report completed. The resident reported he fell and sat on the floor. Review of the Eagle room process shows interventions circled in red. The DON said they added the interventions but did not update the Eagle Room tool. Resident #294 sustained an unwitnessed fall in the bathroom on 3/30/22. An incident report was initiated but was incomplete. The Eagle Room tool was not updated. Resident #295 sustained a fall on 6/15/22. The resident suffered head trauma. An incident report started but lacked an investigation of the fall. No new interventions were noted in the care plan at that time. The Eagle Room tool was checked as completed. Resident#296 sustained a witnessed fall on 4/19/22 at the nurse's station. An incident report initiated but not completed. The Eagle Room tool was checked as completed. Resident #85 was observed on the floor on 5/14/22. The resident reported she slid off the wheelchair. The incident report was initiated but not completed. Care plan updated with an intervention. The Eagle Room process checked off as completed. Resident #146 sustained a fall on 6/22/22. She was observed on the floor in front of her wheelchair at the nurse's station. An incident report was initiated but not completed. The care plan was updated. The Eagle Room tool was checked off as completed. Resident #26 was observed on the floor on 7/3/22. An Investigation was initiated but not complete. There was no update to the fall care plan noted. The Eagle room tool was checked off as completed. Resident #6 was observed on the floor on 7/3/22. An incident report was partially completed and did not include an investigation of the fall. The Care plan was updated with an intervention. The Eagle Room tool was checked off as being completed. On 7/24/22 at 10:33 a.m., Resident #20 said she was rolled out of bed by a Certified Nursing Assistant (CNA) who was changing her. She said she told the CNA she was too close to the edge of the bed, but the CNA did it anyway. Resident #20 said she fell off the edge of the bed and landed face down on the floor. Resident #20 said she sustained a broken nose from the fall. On 7/29/22 at 2:29 p.m. the DON said he had no documentation of rounding on residents or any auditing for resident falls he completed. The DON said the only intervention put in place during the time of the PIP was he increased his rounding of residents and he asked the staff to increase rounding of residents. He said he did not have documentation of the rounds he or the staff completed. He did not have documentation of which residents they increased rounds for or how often the staff was to round. The DON said he did not have documentation he reviewed the results of the rounds to evaluate the effectiveness of the intervention. The Administrator who was present during the interview said there were no minimum standards for rounding at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to prevention of avoidable falls and fall related serious injuries. On 1/22/22 Resident #20 sustained a nasal bone fracture when she was improperly turned in bed and fell. Resident #193 was admitted to the facility on [DATE] after a fall, and repair of right hip fracture. On 1/10/22 the resident sustained a fall resulting in dislocation of the right hip prosthesis. Resident #85 sustained multiple falls at the facility on 1/28/22, 2/5/22, 3/26/22, 3/30/22 and 5/14/22. On 2/5/22 Resident #85 sustained a fall, was sent to the hospital and diagnosed with a left femoral neck fracture, left wrist fracture, left facial abrasion and contusion. On 5/14/22 Resident #85 was sent to the hospital after the fall and diagnosed with an acute head injury. Resident #292 was admitted to the facility on [DATE]. The resident was assessed to be at risk for falls. On 6/11/22 the resident was sent to an acute care hospital after he was found on the floor with a head wound actively bleeding, requiring staples. On 2/20/22 the facility developed a performance improvement plan to address the increase in falls and fall related injuries. The facility failed to ensure implementation, and monitoring of the approaches in the performance improvement plan to minimize the risk of falls and fall related injuries. The facility failure to implement effective corrective actions and monitor results, created a likelihood other residents suffer from falls resulting in serious harm, and resulted in noncompliance at the Immediate Jeopardy level starting on 4/20/22. The Administrator was informed to the determination of ongoing Immediate Jeopardy on 7/30/22 at 6:29 p.m. and provided the Immediate Jeopardy templates. The findings included: Cross reference to F689 and F835. Review of the facility's QAPI (Quality Assurance and Performance Improvement) plan with an effective date of May 16, 2022, noted, . The purpose of QAPI is to take a pro-active approach to continually improve the quality of care we provide . Eagle Room is a twice daily interdisciplinary care and service management process that functions as an on-going ad-hoc (for this situation) meeting of the center's QAPI Committee with a primary focus on clinical care and services . The scope of QAPI program encompasses all types and segments of care and services that impact clinical care. These include . patient safety .Aspects of service and care are measured against established performance goals and key measures are monitored and trended on a quarterly and/or annual basis . The Administrator, as the chair of the QAPI Committee, is responsible and accountable for ensuring that the QAPI program . is defined, implemented, maintained and addresses identified priorities . corrective actions address gaps in systems and are evaluated for effectiveness . The QAPI committee is responsible and accountable for . ensuring corrective actions are effective . analyzing QAPI program performance to identify and follow up on areas of concern or opportunities for improvement .The QAPI plan addresses the elements of systematic analysis and systemic action through the use of the following processes and systems: root cause analysis, use of a continuous cycle to evaluate the effectiveness of performance improvement initiatives, communication of performance improvement project efforts . On 7/29/22 at 2:39 p.m., the Administrator said the company's corporate office directed them to develop a performance improvement plan (PIP) since they had identified an increase in falls at different facilities. The Administrator said the PIP was initiated at the facility on 2/20/22 and lasted until 4/20/22. Review of the Performance Improvement Plan(PIP) titled Falls Management dated 2/2/22 noted the overall goal of the improvement project was to reduce the trends of falls and falls with major injury. The target end date was April 20, 2022. The summary of the findings of the root cause analysis noted a Knowledge deficit related to the process steps for identification of resident falls risks, interventions and systems to minimize fall risks while promoting quality of care. The measures included: 1. The facility will identify a subcommittee related to falls management reduction. The team consisted of two nurses, one therapist, two CNAs (Certified Nursing Assistants) and one leadership team member preference would be Activities Director. The committee will be tasked to review all current residents who have had more than three falls in 90 days or one major fall with injury. Discuss for each: Any with possible sleep deprivation/up frequently during night/awake most of the night. On March 29, 2022, the DON documented Medication review and causes associated with recent falls and correlation of effectiveness of interventions since PIP initiation. The result of the intervention was documented as In progress. 2. The Administrator/Designee will educate the interdisciplinary team and set expectations for the review of falls during Eagle Room and the completion of the Eagle Room QA (Quality Assurance) tool. On 2/28/2022, the DON documented education provided on fall interventions and preventions with implementation of increased rounding and monitoring by all nursing staff. On 3/29/22 the DON documented ongoing reminders and plan for fall documentation review. New falls added to monitoring list for IDT review of causes and preventions. The result of the interventions was documented as Successful. 3. The DON/Designee will educate CNAs and licensed nurses on post fall process review utilizing the FYI (For Your Information) post fall evaluation. On 2/28/22 the DON documented education provided to all nursing staff at mandatory meeting/education on 2/23, 2/24 and 2/25. On 3/18/22 the DON documented reminders to all staff based on situation and likelihood of falls or recurrent falls. Staff continue to monitor and implement fall preventions and interventions. On 3/29/22 the DON documented ongoing education and re-evaluation of fall risks including new admissions. Early prevention and rounding remain priority. The result of the interventions was documented as Successful. 4. The DON/Designee will educate licensed nurses on initial evaluation of residents past history or experiences of falls. Completing the admission/readmission screen with accuracy. On 3/18/22 the DON documented ongoing education and re-evaluation of fall risks including new admissions. Early prevention and rounding remain priority. The result of the interventions was Successful. The DON/Designee will educate licensed nurses on completing incident reports timely (Incident reports will be in incident report management by the end of the shift the incident occurred providing an accurate tracking process). On 3/29/22 the DON documented Monitoring of incident reports, review of preventions in place and new interventions added. The result of the intervention was Successful. The facility QAPI (Quality Assurance and Performance Improvement) team will conduct a trend review of falls to identify residents with falls and falls with major injury utilizing the Eagle Room QA tool to identify areas that are not completed weekly for four weeks then monthly for two months. The facility's incident log showed a total of 157 falls from January 1,2022 through July 22, 2022. Review of a sample of 10 residents with falls and fall related serious injuries revealed four residents sustained serious injuries (broken bones) and one resident sustained a head laceration. Two residents sustained multiple falls without documentation of an investigation to prevent recurrence. On 7/29/22 at 2:39 p.m. the Administrator said there was no documentation a trend review of falls in the building during the time of the PIP. On 7/29/22 at 2:19 p.m. The DON said the PIP was to last 30 days from 3/1/22 to 3/31/22. The DON stated he thought there was a 50% reduction in falls during that period. He said he noticed the biggest trend was that there were more falls on the weekend. Each Monday he counted the falls over the weekend and noticed more falls occurred on the weekend than during the week. The DON said there was no documentation in QAPI or the PIP regarding the trending of weekend falls. The DON said there was no documented intervention put in place to reduce falls on the weekend. He said the intervention put in place were activities was more involved and we tried to give stuffed animals for them it calms them. The DON said he also directed the direct care staff to increase their rounds. He also increased his rounds. The DON said there was no policy or minimum requirements for when and how often the staff were to round. He asked the staff to round more frequently. The DON said on 4/20/22 at the end of the PIP he told staff to keep up the increased rounding. No other interventions related to the PIP were put into place. The DON said did one to one education verbally back and forth and educated all staff on expectations for completing incident reports and fall protocols. He said he could not remember which nurses he spoke to or educated. The DON said there was no post fall education, he just used copies of incident reports which he kept in an education book. The education was just informative but not a fill out form. He said he would have to look for additional documentation for education. On 7/29/22 at 2:39 p.m., and on 7/29/22 at 3:29 p.m., the DON said he did not have any additional documentation of education provided to the licensed nurses or CNAs related to the interventions listed in the performance improvement plan for falls. Review of Quality Assurance and Performance Improvement Committee Meeting (QAPICM) dated 2/18/22 documents a PIP was in place for falls. The QAPICM minutes dated 3/11/22 shows a fall PIP was in progress and was due to be completed on 3/31/22. The The QAPI Committee Summary Findings dated March reads, Fall PIP updated 2/28/22 Please see attached Tracking and Trending. A Floor plan with red dots of the first and second floor, A graph of the regional number of falls dated 2/28/22, and documentation of 6 falls Resident #27 had during the month of February form 2/9/22 to 2/27/22 are noted at this time. The QAPICM minutes dated 4/8/22 show audits were being conducted for falls. There was no further QAPICM minutes regarding falls after 4/8/22. A form titled Abaqis shows the PIP had a target end date of 4/20/22. The goal of the PIP is documented as a less than 5% reduction in falls. The DON documented on the PIP form on three dates, 2/28/22, 3/18/22, and 3/29/22. On 2/28/22 the DON documented, Audits continue of recent falls indication adherence to previous fall interventions in place. On 3/18/22 the DON documented Monitoring for effectiveness . Repeated falls associated with one resident and has improved fall likelihood and occurrences. None to report at this time. Ongoing review during Eagle Room standup and stand down . Falls decreased and interventions in place. Monitoring or results of interventions completed .Reminders to staff based on situation and likelihood of falls or recurrent falls. Staff continue to monitor and implement fall prevention interventions .Completed initial and ongoing .Great success with anticipation of exceeding goal of 50% reductions in falls. Monitoring ER tool shows 7 falls since implementation of PIP and increased monitoring, Audits, and education. 2 of the current falls are from the same residents for a total of 6 residents with 7 falls in 19 days . Conclusions Was PIP successful? Yes Final notes Fall reduction was greater than 50% during the last 30 days Increased Monitoring and early detection of fall risks at the time of admission has decreased falls and the risk of falls. Several of the falls counted in this PIP were the same resident with repeated falls. Resident fall risks were greatly increased due to resident confusion which has increased since admission. Resident has been placed at the nursing station during the day and while awake to increase integration and monitoring. The Medical Director on 7/30/22 at 5:30 p.m. said, I have had had discussion with the administrator about incomplete incident reports and making sure they were completing the incident reports and notifying the physicians about any falls. The physician was asked if these discussions were in QAPI, she said it was when she had seen things were missed was when she had had these discussions with the administrator. The Medical Director was asked about staffing issues at the facility, she said, Overall, we do discuss staffing because the past year has been very difficult. They try to fill in the staffing with minimum as required. The pandemic has impacted staffing as well. We need to work more as a team have a more team approach into these issues. The physician said at other facilities there had been fall committees. The Medical Director was asked if she was aware of a fall committee at the facility, she said she was not aware of the facility having a fall committee during the last year.