**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility's policy Falls Management, the facility failed to prevent accidents for one of 11 sampled residents (R) (R13) which resulted in a fall with a major injury. On 11/19/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 12/17/2024 at 12:15 pm. The noncompliance related to the IJ was identified to have existed on 11/1/2024. An Acceptable Removal Plan was received on 12/18/2024. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 12/19/2024. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of facility staff's conformance with the facility's policies and procedures governing accident hazards. Findings included: A review of the policy titled Falls Management dated 12/29/2023 revealed an episode where a patient lost balance and would have fallen if not for staff intervention is a fall. The presence or absence of a resultant injury is not a factor in the definition of a fall. When a patient is found on the floor, the center is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred. A review of R13's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE]. Further review revealed that R13 had five falls since admission [DATE], 9/29/2022, 12/2/2022, 6/29/2023, and 11/1/2024.) A review of R13's hospital discharge record revealed she was hospitalized from [DATE] to 11/7/2024 due to a fall with a major injury that resulted in a right forehead/frontal scalp laceration with soft tissue hematoma; moderate chronic microvascular ischemic changes; left thalamic and right pontine lacunar infarcts; an acute nondisplaced oblique fracture involving the anterior inferior corner of C2; cervical spondylosis with moderate spinal canal narrowing at C5-6 and C6-7. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R13 presented with a Brief Interview for Mental Status (BIMS) score assessment of 15, indicating no cognitive impairment, and that R13 had impairment on one side to her lower extremity. A review of the Care Plan, with the revised date of 11/19/2024 revealed that R13 had a history of falls and would demonstrate the ability to use assistive devices safely and consistently during the review. A review of the facility nursing progress note dated 1/12/2024 revealed that R13 stated that she was having problems sitting on the wheelchair cushion. It was noted that the writer observed the resident sitting up in her wheelchair and sliding forward. It was documented that the writer examined the wheelchair cushion and there were no defects observed; the physical therapist was notified of the resident status/sliding forward when sitting properly; a physical therapy referral was ordered to assess and treat. A review of the Event Initial Note dated 11/1/2024 revealed that R13 was observed in the hallway being escorted by the Activities Director to an activity via her wheelchair. Staff noted that the wheelchair suddenly stopped, and the resident fell forward to the floor and hit her head/face. Further review of the Event Initial Note revealed that R13 was alert and was bleeding from a laceration on the head. A review of the Discharge Instructions dated 11/7/2024 from the acute care hospital revealed that R13 was discharged with an order for Bacitracin twice a day to the laceration and to follow up with a stroke and neurosurgeon. During an observation on 11/19/2024 at 11:43 am, R13 was observed in bed. She had a black-like line in the center of her forehead. During an interview with R13, she stated that she fell while being transported by the Activities Director (AD). R13 confirmed Certified Nursing Assistant (CNA) WW called AD for something, but the AD stopped short and R13 fell out of the wheelchair and hit her head. R13 stated that she was in the hospital for eight days. During an interview on 11/21/2024 at 12:20 pm, R13 stated that she got her stitches removed and her head was sore. During an interview on 11/21/2024 at 3:19 pm, the DON confirmed she was not employed when R13 experienced the fall with a major injury. She confirmed that the AD explained to her that she was transporting R13 and was not touching the wheelchair when R13 fell. The DON mentioned that R13 was doing something to her shoes and another resident called the AD and that's when R13 fell. During an interview on 11/21/2024 at 3:25 pm, the Resident Assessment Instrument (RAI) Director LL stated that R13 explained to her that she was being pushed to an activity when someone called the AD. She stated that the AD stopped short and R13 fell out of the wheelchair. During a phone interview on 11/21/2024 at 3:42 pm, the previous DON (DON SS) stated that she spoke with R13 right after the event. She stated that R13 explained to her that she was being pushed to activities and asked the staff to stop so she could fix her shoes. She stated that R13 said when she bent down to fix the Velcro strip on her shoe, she fell forward. During an interview on 11/21/2024 at 4:02 pm with the AD, she confirmed she was escorting R13 to bible study when another resident called for help. She stated that she left R13 in the wheelchair in the hallway to answer the other resident, however, when she returned to R13, she noticed the resident tumbling forward onto the floor. The AD mentioned she was told by R13's daughter, that she might have been trying to tie her shoes. The AD mentioned she didn't remember seeing anyone in the hall, but the CNA and staff came after the fall to assist. During an interview on 11/21/2024 at 4:56 pm, the Administrator revealed she has been in the position for two years. She stated that she did not complete an investigation into the fall resulting in a major injury for R13, but she did the AD what happened. The Administrator mentioned she did not interview any of the other staff that day but trusted that the former DON was doing what needed to be done. During an interview on 11/22/2024 at 10:42 am, R13 stated that when she fell on [DATE], it knocked her out a little. R13 confirmed she was sitting completely in the wheelchair and holding onto the armrest during the transport, but the AD stopped short, and the cushion came out of the chair, and she fell to the floor. R13 stated that before the fall, she used to get up and was able to perform her Activities of Daily Living (ADL) care but now she cannot. During an interview on 11/22/2024 at 10:57 am, the Director of Rehabilitation UU confirmed R13 has an order for rehab that she received late Tuesday afternoon (11/19/2024) and the evaluation is pending. She revealed that she just learned about R13's fall on 11/20/2024. During an interview on 11/22/2024 at 11:12 am Occupational Therapist (OT) VV mentioned she heard of R13's fall when a CNA told her she was having more trouble with performing her ADL care independently and was not getting up as much since falling on 11/1/2024. OT VV confirmed that the therapy referral was received on 11/19/2024. During an interview on 11/22/2024 at 11:39 am, the DON explained the recent investigation concluded that the AD witnessed the fall that R13 had on 11/1/2024. DON mentioned AD reported that another resident called her and asked what time bible study was. The chair was not locked, and the resident fell forward. The DON emphasized that R13 was alert and oriented before the fall but has become confused since the fall. The facility implemented the following actions to remove the IJ: 1. On 11/19/2024, a therapy screen was done for R13 by the Physical Therapist. On 11/22/2024, a Physical Therapy assessment was completed for R13. On 11/22/2024, the Social Worker completed a behavioral assessment. No changes were identified for R13. On 12/3/2024, a care plan conference was held with R13 and her (family) with the Social Worker, the RAI Registered Nurse (RN), the Licensed Practical Nurse (LPN), the Restorative Nurse, the Dietary Manager, the Charge Nurse LPN, the CNA. R13 stated she had no problems or concerns. On 12/6/2024, Speech Therapy completed an assessment for R13. On 12/17/2024, the Occupational Therapy department evaluated R13 for positioning and wheelchair review. A 16x18 inch cushion was placed in the wheelchair providing more even support to hips and the footrests were exchanged for more appropriate length allowing Bilateral Lower Extremity flexibility. On 12/17/2024, the Registered Dietitian assessment was done for R13 weight loss, with a new order for a nutritional supplement (one carton by mouth q day was ordered. Continue weekly weight. Speech Therapy to evaluate and treat. No recommendation currently. On 12/17/2024, a Medical Doctor assessed R13, with no concerns noted at that time. On 12/17/2024, the Psych Physician conducted an evaluation post-fall for R3, no recommendation at this time. The plan of care was reviewed and updated on 11/1/2024 and 11/8/2024 by a licensed practical nurse, and on 12/17/2024 by an RN for R13. 2. The DON who conducted the original investigation on 11/1/2024 is no longer employed; she resigned on 11/7/2024. Newly hired DON as of 11/11/2024 began a new root cause analysis on 11/19/2024. The root cause was completed for R13 on 11/22/2024. 3. On 12/17/2024, an ad hoc Quality Assurance Process Improvement (QAPI) and performance improvement plan (PIP) was developed and initiated. The meeting discussion included plan development and citations. In attendance at the meeting were the Division [NAME] President, Administrator, Division Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI nurses, Wound Care Nurse, Environmental Services Director, AD, health information manager Environmental/ laundry supervisor, admission Nurse, HR Partner Service, Scheduler, for the accident. The existing Fall Management policies and concluded no revisions were needed. 4. From 12/17/2024 through 12/18/2024, the Division [NAME] President and Divisional Nurse provided education to the Administrator, DON, and Social Worker on the job description, roles and responsibilities, and duties to ensure the safety of all residents. Education provided on the falls management policy included that nurses should observe and interview the patient and/or witnesses to determine the possible cause of the fall and complete the Initial Event in the EMR to capture the investigation of the fall and assessment of the patient and how to use the QAPI tool The 5 Whys and that nursing is to complete therapy referral in EMR upon admission/readmission and post-fall as indicated. Nurses are to follow up with therapy to ensure a timely review of referrals (within 72 hours). Therapy to complete an assessment post-fall as indicated to include completion of an evaluation of the wheelchair to determine if the wheelchair was appropriate for the patient. Resident transport safety to prevent falls/injuries. Nursing and social services to follow up and assess patients for psychosocial harm post-fall to determine if behavioral health services are needed. (Patient exhibiting any signs/symptoms of anxiety such as restlessness, nausea, elevated heart rate, difficulty sleeping). If the patient is noted to exhibit signs of anxiety, nursing to assess the patient and report to the provider as indicated. The Administrator, the DON, and the Social Worker received education. 5. Corrective action for other residents having the potential to be affected by the same deficient practice: All residents who reside in the facility who are transported and have had a fall have the potential to be affected by the alleged deficiency. 6. Systemic changes are made to ensure that the deficient practice will not recur. On 12/18/2024 oversight was provided by the Divisional Nurses (DN) to ensure the DON completed a root cause analysis of residents with falls within the past 30 days. On 12/18/2024 oversight by DN to ensure that 8 of 8 therapy referrals were completed by the RAI coordinator was completed. On 12/18/2024 an oversight by DN of Social Worker to confirm that eight or eight social visits were completed to ensure no evidence was noted of further treatment psychosocial harm post fall, including weight loss, increased anxiety, or further decline. One of eight patients identified with weight loss post-fall was reviewed by a Regional Dietitian on 12/17/2024. On 12/18/2024 DVP and DN made observational rounds to supervise the Administrator, DON, and Social Director of the day-to-day operations to include adhering to the falls policy and that oversight was being provided by the administration to ensure patients were being transported safely. DN attended the clinical meeting to ensure that falls were being reviewed per the guideline to include performing a root cause analysis and 72-hour observations were completed to include observation of signs of psychosocial harm. DVP and DN confirmed that education had been completed with staff for falls and safety transportation. 7. Quality Assurance plans to monitor facility performance to ensure corrections are achieved and are permanent. A quality improvement data collection Grid 3 tool was developed and initiated by the Administrator and is being utilized daily to monitor the implementation of the POC. The DON or Assistant DON will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this POC will be validated by the DVP and /or DN and submitted daily to the QAPI committee for review and further follow-up. The quality improvement data collection grid will continue until the QAPI committee deems it is no longer necessary. 8. All corrective actions were completed on 12/18/2024. The facility alleges that the IJ was removed on 12/19/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the Therapy Referral dated 11/19/2024 documented that a therapy screening was completed. A review of the Physical Therapy Certification document with a completion date of 11/22/2024. A review of the Behavioral Assessment V3.0 was completed by the Social Worker) on 11/22/2024. There were no new behaviors at that time. A review of the Care Plan Conference V2.0 was updated as her annual conference on 12/3/2024. Conference notes state R13 is interested in seeing the counselor). A review of the Speech/Language Pathology Certification assessment was completed on 12/6/2024. A review of the Occupational Therapy Daily Note dated 12/17/2024 documented R13 was seen for positioning and wheelchair review. A cushion 16 x 18 was placed in wheelchair providing more support to hips and the footrests were exchanged to appropriate length was completed. A review of the RD Nutritional Assessment V4.0 dated 12/17/2024 documented a significant change due to recent weight loss along with new orders. A review of the GA MedGroup Assessment dated 12/17/2024 was completed related to post-fall. Further review of the document revealed that continue to follow with psychiatric services. A review of the Psychiatric Diagnosis Evaluation revealed that R13 was seen on 12/17/2024 and an evaluation was conducted. A review of the Care plan dated 11/1/2024, 11/19/2024, 12/17/2024, and 12/18/2024 was updated for the focus to falls or near falls. A review of the Care plan dated 11/19/2024 was updated to focus on Fall Risk. 2. Review of the previous Director of Nursing resignation letter dated 11/7/2024. A review of the current offer letter for the DON position is dated 11/11/2024 as the hire date. A review of the Root Cause Analysis was completed on 11/22/2024. 3. A review of the audit tool titled Utilization Wheelchair and Safe Transfer/Transport dated 11/21/2024 revealed residents were questions about the safety in the building, if they felt if staff were pushing them fast, and any staffing concerns. No concerns with the review. 4. A review of the Ad hoc QAPI and PIP dated 12/17/2024 revealed Division vice president, Administrator, Division nurse, Director of nursing, licensed nurse, Medical director, Social Service, Financial controller, Maintenance director, Resident assessment instrument nurses, Wound care nurse, Environmental services director, Activity director, health information manager Environmental/ laundry supervisor, admission nurse, Human Resources Partner service, and scheduler were all in attendance for the meeting. 5. A review of the document titled Job description, roles, and responsibilities was signed off by the Administrator, DON, Division Nurse, and Social Worker on 12/17/2024. 6. A review of the in-service education titled F689 Free of Accident Hazards/Supervision/Devices dated 12/17/2024 and 12/18/2024 documented that 99 staff signatures were signed off on being educated. A review of the in-service education titled Anxiety/Post Fall/ Safe Transfer dated 12/17/2024 and 12/18/2024 documented that 99 staff signatures were signed off on being educated. 7. Confirmed by observations on 12/20/2024. 8. A review of the residents who had a fall within 30 days was completed. Eight residents identified that had a fall. A review of eight identified residents for psychiatric assessment, weight loss, root cause analysis, and therapy related to recent falls in the facility were reviewed and determined to be completed on 12/17/2024 and 12/18/2024. A review of Grid 1 titled, Review of fall from 11/18/2024 to 12/18/2024 was identified and completed for residents who had fallen. 9. A review of the Quality Improvement Data Collection Grid 3 dated 12/19/2024 documented audits indicated for psychological assessments, post falls, therapy referrals, root cause, weight loss, or decline were completed on residents that were identified as recent falls (eight of eight residents) within the last 30 days. The interview on 12/20/2024 at 1:56 pm revealed DON is responsible for Grid 2 and the Administrator comes behind her and checks to see if it is completed. Then the Administrator goes to check Grid 3. The Division nurse and the Division [NAME] President Nurse check behind the administrator to collect accurate data. DON confirmed that Grid 3 and Grid 2 are being audited daily. The target date will be daily for four weeks; then twice a week for four weeks; and then weekly for four weeks. 10. It was verified that the corrective actions were completed by 12/18/2024 and the immediate jeopardy was removed on 12/19/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the Administrator and Director of Nursing (DON) Job Description, the facility's Administration failed to address concerns with the facility's Fall Management and Transportation of Patients procedures; and failed to ensure that one of 11 sampled residents (R) (R13) was free from accident hazards related to transporting within the facility. Further, the administration failed to ensure that a therapy assessment and psychosocial harm assessment were completed for R13 post-fall and that staff were educated on safely transporting residents in the facility. On 11/19/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 12/17/2024 at 12:15 pm. The noncompliance related to the IJ was identified to have existed on 11/1/2024. An Acceptable Removal Plan was received on 12/18/2024. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 12/19/2024. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of facility staff's conformance with the facility's policies and procedures governing accident hazards. Findings included: A review of the Administrator Job Description revised February 2022, revealed the Administrator is responsible for directing the day-to-day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Regional [NAME] President, to provide appropriate care for our patients. A review of the Director of Nursing Job Description revised March 2021 revealed that the DON is responsible for planning, organizing, developing, and directing the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as directed by the Administrator and/or the Medical Director, to provide appropriate care. A review of R13's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE]. Further review of Progress Notes revealed that R13 had five falls in the facility: 9/28/2022, 9/29/2022, 12/2/2022, 6/29/2023, and 11/1/2024. On 11/1/2024, R13 was sent out to an acute care hospital and was admitted there from 11/1/2024 to 11/8/2024 due to a fall with a major injury. A review of the hospital records dated 11/8/2024 revealed that R13 was discharged from the acute care hospital with the diagnoses of seven sutures and fractures with diagnoses of cervical (C) 2, endplate fracture, right frontal scalp laceration, cervical spondylosis with a moderate spinal canal with narrowing at C5-6. The fall resulted in a right forehead/frontal scalp laceration with soft tissue hematoma, moderate chronic microvascular ischemic changes, left thalamic and right pontine lacunar infarcts, and acute nondisplaced oblique fracture involving the anterior inferior corner of C2. During an interview on 11/21/2024 at 4:56 pm, the Administrator revealed she has been in the position for two years and that the former DON resigned from the facility on 11/7/2024. The new DON was hired on 11/11/2024. The administrator confirmed that she did not complete a full investigation or a root cause analysis of the 11/1/2024 fall for R13 because the former DON told her it was not a reportable incident. She stated that she asked the Activities Director (AD) what happened but confirmed that she did not interview any other staff working on the day of the incident. The facility implemented the following actions to remove the IJ: 1. On 11/19/2024, a therapy screen was done for R13 by the Physical Therapist. On 11/22/2024, a Physical Therapy assessment was completed for R13. On 11/22/2024, the Social Worker completed a behavioral assessment. No changes were identified for R13. On 12/3/2024, a care plan conference was held with R13 and her (family) with the Social Worker, Registered Nurse (RN), Licensed Practical Nurse (LPN), Restorative Nurse, Dietary Manager, Charge Nurse LPN, and CNA. R13 stated she had no problems or concerns. On 12/6/2024, Speech Therapy completed an assessment for R13. On 12/17/2024, the Occupational Therapy department evaluated R13 for positioning and wheelchair review. A 16x18 inch cushion was placed in the wheelchair providing more even support to hips and the footrests were exchanged for more appropriate length allowing Bilateral Lower Extremity flexibility. On 12/17/2024, the Registered Dietitian assessment was done for R13 weight loss, with a new order for a nutritional supplement (one carton by mouth every day was ordered. Continue weekly weight. Speech Therapy to evaluate and treat. No recommendation currently. On 12/17/2024, a Medical Doctor assessed R13, with no concerns noted at that time. On 12/17/2024, the Psych Physician conducted an evaluation post-fall for R3, no recommendation at this time. The plan of care was reviewed and updated on 11/1/2024 and 11/8/2024 by an LPN, and on 12/17/2024 by an RN for R13. 2. The DON who conducted the original investigation on 11/1/2024 is no longer employed; she resigned on 11/7/2024. Newly hired DON as of 11/11/2024 began a new root cause analysis on 11/19/2024. The root cause was completed for R13 on 11/22/2024. 3. On 12/17/2024, an ad hoc Quality Assurance Process Improvement (QAPI) and performance improvement plan (PIP) was developed and initiated. The meeting discussion included plan development and citations. In attendance at the meeting were the Division [NAME] President, Administrator, Divisional Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI nurses, Wound Care Nurse, Environmental Services Director, AD, health information manager Environmental/ laundry supervisor, admission Nurse, HR Partner Service, Scheduler, for the accident. The existing Fall Management policies and concluded no revisions were needed. 4. On 12/17/2024 Division [NAME] President and Divisional Nurse provided education to the Administrator, DON, and on 12/18/2024 the Social worker on job description, roles and responsibilities, and duties to ensure the safety of all residents. Education provided on the falls management policy included that nurses should observe and interview the patient and/or witnesses to determine the possible cause of the fall and complete the Initial Event in the EHR (Electronic Health Record) to capture the investigation of the fall and assessment of the patient and how to use the QAPI tool The 5 Whys and that nursing is to complete therapy referral in EHR upon admission/readmission and post-fall as indicated. Nursing to follow up with therapy to ensure timely review of referral (within 72 hours). Therapy to complete an assessment post-fall as indicated to include completion of an evaluation of the wheelchair to determine if the wheelchair was appropriate for the patient. Resident transport safety to prevent falls/injuries. Nursing and social services to follow up and assess patients for psychosocial harm post-fall to determine if behavioral health services are needed. (Patient exhibiting any signs/symptoms of anxiety such as restlessness, nausea, elevated heart rate, difficulty sleeping). If the patient is noted to exhibit signs of anxiety, nursing to assess the patient and report to the provider as indicated. The administrator, DON, and Social Worker received the education. 5. On 12/18/2024, oversight was provided by the Divisional Nurse to ensure the DON completed a root cause analysis of residents with falls within the past 30 days. On 12/18/2024 oversight by the Divisional Nurse to ensure that eight of eight therapy referrals were completed by RAI coordinator was completed. On 12/18/2024 oversight by Divisional Nurse of Social Worker to confirm that eight of eight social visits were completed to ensure no evidence was noted of further treatment psychosocial harm post fall, to include weight loss, increased anxiety, or further decline. One of eight patients identified with weight loss post-fall was reviewed by the Regional Dietitian on 12/17/2024. 6. On 12/18/2024, the Division [NAME] President and the Divisional Nurse made observational rounds to supervise the administrator, DON, and Social Worker of the day-to-day operations including adhering to the falls policy and that oversight was being provided by the administration to ensure patients were being transported safely. The Divisional Nurse attended the clinical meeting to ensure that falls were being reviewed per the guideline to include performing a root cause analysis and 72-hour observations were completed to include observation of signs of psychosocial harm. The Division [NAME] President and the Divisional Nurse confirmed that education had been completed with staff for falls and safety transportation. 7. Quality Assurance Plans to monitor facility performance to ensure corrections are achieved and are permanent. A quality improvement data collection grid 3 tool was developed and initiated by the Administrator and is being utilized daily to monitor the implementation of the Plan of Correction. The DON or Assistant DON will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this plan of correction will be validated by the Division [NAME] President and /or Divisional Nurse and submitted daily to the QAPI committee for review and further follow-up. The quality improvement data collection grid will continue until the QAPI committee deems it is no longer necessary. 8. All corrective actions were completed on 12/18/2024. The facility alleges that the IJ was removed on 12/19/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of R13 electronic health records dated 11/19/2024 revealed A review of the Therapy Referral dated 11/19/2024 documented a therapy screening was completed. A review of the Physical Therapy Certification documents a completion date of 11/22/2024. A review of the Behavioral Assessment V3.0 was completed by the Social Worker on 11/22/2024. There were no new behavioral concerns at that time. A review of the Care Plan Conference V2.0 was updated as her annual conference on 12/3/2024. The conference notes stated that R13 was interested in seeing the counselor. It was verified that a referral was sent for counseling services as requested at the care plan conference. A review of the Speech/Language Pathology Certification assessment was completed on 12/6/2024. A review of the Occupational Therapy Daily Note dated 12/17/2024 documented R13 was seen for positioning and wheelchair review. A cushion 16 x 18 was placed in wheelchair providing more support to the hips and the footrests were exchanged to appropriate length was completed. A review of the Registered Dietician Nutritional Assessment V4.0 dated 12/17/2024 documented a significant change due to recent weight loss along with new orders being completed. A review of the (name of company) Assessment dated 12/17/2024 was completed related to post-fall. Further review of the document revealed that continue to follow with psychiatric services. A review of the Psychiatric Diagnosis Evaluation revealed that R13 was seen on 12/17/2024 and an evaluation was conducted. A review of the Care plan dated 11/1/2024, 11/19/2024, 12/17/2024, and 12/18/2024 was updated for the focus to falls or near falls. A review of the Care plan dated 11/19/2024 was updated for the focus on Fall Risk. 2. A review of evidence revealed in the previous DON resignation letter dated 11/7/2024. A review of the current offer letter for the DON position is dated 11/11/2024 as the hire date. A review of the Root Cause Analysis was completed on 11/22/2024. 3. A review of evidence revealed the Ad hoc QAPI and PIP dated 12/17/2024 revealed the Division [NAME] President, Administrator, Divisional Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI Nurses, Wound Care Nurse, Environmental Services Director, Activity Director, Health Information Manager, Environmental/ Laundry Supervisor, admission Nurse, Human Resources Partner Service, and Scheduler were all in attendance for the meeting. 4. A review of the Job description, roles, and responsibilities was signed off on by the Administrator, DON, Division Nurse, and Division [NAME] President on 12/17/2024. During an interview conducted on 12/20/2024 at 4:33 pm, the Administrator, DON NN, and Social Worker II confirmed in-service received along with Performance Assessment Review (PAR), Quality Assurance, and Performance Improvement (QAPI) meetings completed. All participants revealed during the PAR meetings weight loss, falls, behaviors, and new admissions with behaviors. All participants confirmed they are responsible for PAR meetings along with the charge nurse, Minimum Data Set (MDS) coordinator, Dietary Manager, ADON, and sometimes therapist. All participants revealed in QAPI meetings regarding falls the root cause, psychosocial, weight loss decline, therapy referrals, and plans in place with the Administrator will be reviewed with DON, and all falls are included. 5. A review of evidence revealed the review of the audit tool titled Utilization Wheelchair and Safe Transfer/Transport dated 11/21/2024 revealed residents were questions about the safety in the building, if they felt if staff were pushing them fast, and any staffing concerns. No concerns with the review. Interviews were conducted on 12/20/2024 with five cognitively intake residents who were transported with assistance in a wheelchair: (R6 interviewed at 11:50 am, R34 interviewed at 11:33 am, R36 interviewed at 11:30 am, R58 interviewed at 11:56 am, and R243 interviewed at 11:38 am) They all confirmed they received wheelchair assistance, and were transported at an adequate pace, they feel safe during transport and have no concerns. 6. A review of Evidence revealed the 5 Whys for the root cause analysis was completed on 11/22/2024. A review of eight identified residents for psychiatric assessment, weight loss, root cause analysis, and therapy related to recent falls in the facility was reviewed and determined to be completed on 12/17/2024 and 12/18/2024. Observation on 12/19/2024 at 1:56 pm revealed Activities Director (AD) TT wheeling a resident down the hall appropriately with no signs of complications; using both hands on the wheelchair handle. Meanwhile transporting at a slow pace. Observation on 12/19/2024 at 2:37 pm revealed Occupational Therapist (OT) VV transporting the resident in a wheelchair with foot pedals with no signs of complications. A review of the in-service education titled F835 Administration - Root cause of accident post falls follow up dated 12/17/2024 and 12/18/2024 documented that 99 staff signatures were signed off on being educated. Interviews were conducted and verified as having been educated: on 12/19/2024, Nurse BB was interviewed at 1:40 pm, three Certified Medical Assistants (CMA's) were interviewed on 12/19/2024 (CMA PPP at 3:30 pm; CMA HHH at 2:30 pm; CMA III at 2:26 pm) Six Certified Nursing Assistant (CNA's) was interviewed on 12/19/2024 (CNA OOO at 3:25 pm; CNA KKK at 2:23 pm; CNA JJJ at 2:19 pm; CNA LLL at 2:09 pm; CNA EE at 1:52 pm; CNA WW at 1:45 pm; Maintenance Director NNN interviewed at 2:46 pm; admission Coordinator QQ was interviewed at 2:43 pm; Assistant DON of Nursing MMM was interviewed at 2:00 pm. Interviews were conducted and verified as having been educated: on 12/20/2024 with Administrative Assistant SSS at 9:48 am; Resident Assessment Instrument (RAI) Director LL interviewed at 9:55 am; Agency Nurse Practitioner (NP) QQQ interviewed at 9:59 am; Healthcare Navigator RRR interviewed at 10:03 am. 7. A review of the Quality Improvement Data Collection Grid 3 dated 12/18/2024 documented audits indicated for validation of audit completion was done by the DON/ADON for psychosocial assessment, post-falls, therapy referrals, root cause analysis, weight loss or decline from falls. An interview on 12/20/2024 at 1:56 pm revealed DON is responsible for Grid 2 and the Administrator comes behind her and checks to see if it is completed. Then the Administrator goes to check the Grid The Divisional Nurse and the Division [NAME] President Nurse check behind the administrator to collect accurate data. DON confirmed that Grid 3 and Grid 2 are being audited daily. The target date will be daily for four weeks. Then twice a week for four weeks; then weekly for four weeks. 8. It was verified that the corrective actions were completed by 12/18/2024 and the immediate jeopardy was removed on 12/19/2024.