**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, staff interviews, and facility policy review, the facility failed to appropriately provide assessment and interventions for the necessary care and services during a change in condition for 2 of 3 residents (Resident #3 and #6) reviewed for condition change. The facility failed to promptly identify change in respiratory condition and intervene in a timely manner for a resident with known history of chronic obstructive pulmonary disease (COPD) and respiratory failure. (Resident #6) found unresponsive with no palpable carotid or radial pulse and required emergency transport to the hospital. Resident #6 diagnosed with respiratory distress, respiratory syncytial virus (RSV) and respiratory failure with hypercapnia at hospital. Additionally, the facility failed to appropriately provide assessment and interventions for the necessary care and services following an unwitnessed fall (Resident #3). Clinical record review and interviews revealed Resident #3 had fallen on [DATE] without nursing assessment or documentation completed. On [DATE], an x-ray of left hip obtained due to Resident #3 complaints of pain, results revealed nondisplaced left sub-capital hip fracture. Resident #3 admitted to the hospital between [DATE] and [DATE] for surgical repair of left hip fracture. The facility reported a census of 36 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] at 03:00 AM on [DATE] at 10:24 AM. The facility staff removed the Immediate Jeopardy on [DATE] at 03:49 PM by implementing the following actions: 1. Education provided to all staff nurses within 24 hours or before next working shift, whichever is first on the following topics: -Documentation in real time. -When to notify the provider via phone call. -Acceptable notifications to be left in the provider binder. -Physician notification as soon as acute change is noted. 2. A review of respiratory assessment parameters and when to notify the provider completed with staff nurses, which included the development of respiratory assessment guidelines to notify the provider of any of the following that aren't resolved with interventions already in place: -Respiratory rate greater than 22 respirations/minute with complaints of shortness of breath. -Oxygen saturation less than 90%, unless otherwise specified in orders. -Acute lung sound changes, including: wheezing, rhonchi, rales, and crackles. 3. Audits of the provider binder to be completed by Director of Nursing each working day for 90 days. Findings include: 1. The admission Minimum Data Set (MDS), dated [DATE], for Resident #6 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. Diagnoses included: chronic obstructive pulmonary disease (COPD), asthma, anxiety disorder, and morbid obesity. This initial MDS revealed no shortness of breath or respiratory treatment noted upon admission. The Quarterly MDS that followed hospitalization, dated [DATE], revealed a BIMS score of 15 out of 15, indicating intact cognition. Diagnoses included: COPD, acute respiratory distress, asthma, anxiety disorder, and morbid obesity. Quarterly MDS revealed Resident #6 required oxygen therapy and had shortness of breath with exertion, when sitting at rest, and when lying flat. The Care Plan, initiated [DATE], revealed Resident #6 required oxygen therapy, and informed staff to monitor and report to the Medical Doctor (MD) for signs and symptoms of respiratory distress which included the following changes: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color ([DATE]). The Care Plan revealed that Resident #6 utilized supplemental oxygen via nasal cannula and frequently refused to wear bipap ([DATE]). The Medication Administration Record (MAR), dated [DATE], revealed the following orders in place for Resident #6: -Supplemental oxygen kept between 2 to 4 liters to maintain an oxygen saturation above 88% for COPD, started on [DATE]. -Antibiotic orders for Cefdinir 300mg twice per day for 5 days, started on [DATE] and Azithromycin 500 milligrams (mg) daily for 3 days, started on [DATE], both indicated for a lower respiratory infection. -Ventolin (albuterol sulfate) inhalation aerosol solution 108 micrograms (mcg) per actuation (act), 2 puffs inhaled orally every 4 hours as needed for shortness of breath related to COPD, initiated upon admission [DATE], had been utilized 9 times between the dates of [DATE]-[DATE], and utilized only once between the dates of [DATE]-[DATE]. -Guaifenesin liquid 100mg/5 milliliters (mL) to be given every 4 hours as needed for cough, started on [DATE], and utilized 6 times between [DATE]-[DATE]. A review of Nursing Progress Notes for Resident #6, between the dates of [DATE] to [DATE], revealed the following: a.) [DATE] at 04:51 AM: Resident #6 had increased shortness of breath, cough, and dyspnea noted. Oxygen saturation 90% on 2 liters of oxygen via nasal cannula (NC). Resident utilized inhaler and noted to have increased anxiety when nurse attempted to take inhaler out of resident's room. Lung sounds diminished and resident complained of difficulty breathing. Noted increased twitching of extremities. Resident #6 refused to wear bipap. Nursing indicated they would make a request for inhaler to be kept at bedside. b.) [DATE] at 06:38 PM: Resident #6 requested to wear bipap mask, respirations were heavy at 20 respirations per minute, audible rales noted throughout lungs. Nursing provided reassurance and one on one with Resident #6 due to increased anxiety. c.) [DATE] at 09:59 PM: Resident #6 complained of shortness of breath, nursing increased oxygen to 4 liters/NC due to oxygen saturation of 82% on 2 liter of oxygen. Lung sounds had rales noted throughout, Resident #6 continued to have frequent cough and complained of increased anxiety due to wearing bipap mask. Nurse informed resident that they would call the doctor, Resident #6 stated, Good, if I go to the Hospital, maybe I will get my Xanax (anti-anxiety medication). Nursing notified the on-call Provider and received orders for Lorazepam 0.5mg every 6 hours as needed and albuterol nebulizer every 4 hours as needed for shortness of breath, only if resident will give up her inhaler, which had been kept at bedside. d.) [DATE] at 11:32 AM: Resident #6 requested to go to the Hospital, when nursing questioned why, resident stated, I just don't feel good. Resident noted to have mouth breathing at intervals, nurse encouraged resident to breath in through nose and out through mouth. On-call Provider notified and instructed nursing to utilize the as needed anti-anxiety medication and continue to monitor. e.) [DATE] at 02:53 AM: it is noted that Resident #6 had complained of shortness of breath throughout the evening hours, vital signs included 22 respirations per minute and a temperature of 100.2 degrees Fahrenheit. Nursing reported that administration of as needed medications did not provide relief as Resident #6 continued to express increased restlessness. Nursing also noted that Resident #6 intermittently sat upright in recliner, resident's skin had been warm, dry, and dusky per norm for resident. Lung sounds had scattered congestion and an occasional moist cough continued. According to documentation, nursing provided an FYI for MD in the communication binder for evaluation upon rounds to the facility. f.) [DATE] at 03:03 AM: an addendum had been added to correct the documentation in previous note to inform that respirations had been 26 per minute, not 22 per minute as recorded and indicated that respirations were also slightly labored but subsided through the night. g.) [DATE] at 05:50 AM: Resident #6 stated, I just feel wiped out. It's the Ativan, it makes me feel drugged. Nursing noted that resident had occasional twitching of arms, an overall generalized increased weak appearance, and continued to voice that she didn't feel good. According to documentation, nursing provided an FYI for the MD and next shift nursing staff for continued monitoring. h.) [DATE] at 02:30 PM: Provider saw Resident #6 on facility rounds and ordered to obtain chest x-ray related to COPD. i.) [DATE] at 03:37 AM: Resident required increased assistance due to weakness and dyspnea with activity and expressed malaise. Nursing noted an overall general weak appearance and random involuntary twitching of extremities. Lung sounds continued to have scattered congestion and respirations slightly labored at times between 22-27 respirations per minute, temperature of 99.2 degrees Fahrenheit, pulse of 102 beats per minute, and oxygen saturation between 84-92% on 3.5 liters of oxygen/NC. According to documentation, the Provider had been aware of resident decline as resident was to have chest x-ray in waking hours, and further orders pending. Nursing noted resident monitoring and encouragement continued. j.) [DATE] at 05:44 AM: Resident #6 complained of shortness of breath, nebulizer treatment administered and oxygen saturation following treatment had been 82% on 3.5 liters of oxygen/NC. Nursing increased flow of supplemental oxygen to 4 liters per NC and oxygen saturation increased to 89%. Resident #6's respirations slightly labored but calmed after one on one and encouragement, no Provider notification documented. k.) [DATE] at 02:55 AM: Resident #6 noted to be anxious with increased shortness of breath sporadically throughout the evening hours and Resident #6 intermittently yelling out, Help me, I can't breathe. Nursing reported respirations moderately labored during these events and oxygen saturation had been between 81-88% on 3.5 liters of oxygen/NC. Nursing indicated Resident #6 utilized bipap for approximately 15 minutes, education provided with encouragement for resident to utilize bipap, resident stated, I can't do it. I can't breathe with this mask. Noted Resident #6 continued to have frequent involuntary twitches of extremities and slept in a straight upright position in recliner. Supplemental oxygen had been increased to 4 liters of oxygen/NC with oxygen saturations between 86-90%, pulse ranged from 96-118 beats per minute, and respirations between 24 to 32 per minute. According to documentation, an FYI continued to be provided on nursing communication sheet and MD binder for continued monitoring/treatment as needed. Provider had not been called at this time. l.) [DATE] at 12:31 PM: Nurse had been called to Resident #6's room by Certified Nursing Assistant (CNA) when resident stated she felt like she wasn't getting air. Noted resident slightly rocking back and forth and had pursed lip breathing. Resident #6 had stated, There must be something wrong with my oxygen concentrator, I'm not getting any air. Nursing provided education for resident to attempt to hold mouth closed and inhale through nose and exhale through mouth. Oxygen saturation 91% on 3 liters of oxygen/NC. Nurse reported resident had dusky appearance per norm, lung sounds had rhonchi heard in bilateral lower lobes and diminished sounds throughout upper lobes. Resident #6 also noted to have twitching and stated, I feel cruddy. Nurse documented they would notify the Provider. m.) [DATE] at 12:51 PM: received order from Provider to obtain labs and urinalysis. n.) [DATE] at 10:25 AM: CNA called nurse to Resident #6's room due to resident not responding. Nurse reported Resident #6 sat in recliner with head tilted down and Bipap on, resident's lips colored blue and had forced air coming out of lips which caused lips to flutter. Resident #6 not responsive to verbal stimuli or sternal rub performed. Nurse reported increasing the oxygen flow to 5 liters via NC and requested Director of Nursing (DON) to be present, noted resident's status was for full code, and unable to palpate carotid or radial pulses. DON entered room and called 911, additional staff entered to assist with placing resident on the floor to start Cardiopulmonary Resuscitation, Resident #6 then opened eyes and gasped for air, eventually became more alert and breathing became more stable. Resident #6 assisted to bed with mechanical lift, staff performed cares due to bowel incontinence that occurred during non-responsive episode and prepared resident for transport in ambulance to the Hospital. o.) [DATE] at 11:00 AM: Nurse and DON gave report and assisted Emergency Medical Technicians (EMTs) with transfer of Resident #6 to stretcher for ambulance transfer to the Hospital. The hospital History and Physical Note, dated [DATE], revealed that per EMS, facility stated patient lost consciousness twice but never lost a pulse. Patient is full code and presented with worsening shortness of breath for 2-3 days prior, and had equivocal fever. H&P informed that Resident #6 presented to outside of emergency room (ER) hypoxic and hypercapnic, worse than baseline. Resident #6 tested positive for RSV. Upon physical exam, Resident #6 had been in moderate respiratory distress with decreased breath sounds and minimal wheezing. Resident #6 assessment included admission and treatment plan for respiratory distress, RSV infection, and urinary tract infection. On [DATE] at 12:15 PM, Resident #6 reported that leading up to the recent hospitalization she had experienced coughing and trouble breathing. Resident #6 reported that she had been found passed out, but unable to recall details from the day she had transferred out to the hospital. On [DATE] at 01:20 PM, Staff D, Registered Nurse (RN), recalled that Resident #6 had respiratory infection prior to an unresponsive episode and that her baseline had been on supplemental oxygen without respiratory distress at rest. On [DATE] at 01:45 PM, Staff E, Licensed Practical Nurse (LPN), stated Resident #6's baseline had been mild respiratory distress with activity and sometimes at rest dependent upon how much the resident would get worked up or anxious. She stated Resident #6's baseline oxygen saturation usually in the 90's or upper 80's and improved with position change and or treatments. Staff E indicated that prior to hospitalization, Resident #6 started to have a new moist cough, followed by no energy, sleeping more, then continued to decline with increased cough and dyspnea for a few days before being transferred out. Staff E stated the twitching extremities had also been new. Staff E noted that Resident #6 had started antibiotics prior to transfer and that symptoms of respiratory infection never totally resolved. Staff E stated Resident #6's cough and shortness of breath had been hard to assess because the resident always had some respiratory distress. Staff E did not recall any requests from Resident #6 to go to the hospital prior to the unresponsive episode, and stated the resident did not ask her. Staff E stated she would notify the provider if Resident #6 had a change to see if something else would be ordered or notify the provider if Resident #6 wasn't getting better. On [DATE] at 04:00 PM, Staff B, LPN, stated a provider should be notified of any change in resident condition or vital signs. Staff B stated that with a decrease in oxygen saturations for a resident who required supplemental oxygen to call the provider, if after hours, nursing had a number for an on-call provider. Staff B revealed that most of the oxygen orders informed staff to keep oxygen saturations above 88% and stated that if oxygen saturation is under 88% to call the provider and stated it would not be okay to put this information in communication binder only. Staff B stated facility utilized communication binder for providers who visit the facility, that is to include non-emergent items which may include orders that the facility had already received. Staff B confirmed working during Resident #6 unresponsive episode on [DATE] and recalled that Resident #6 woke up saying she wanted CPR and to go to the Hospital. Staff B assisted CNA to prepare resident for hospital transfer. On [DATE] at 09:28 AM, Staff F, RN, confirmed responding to Resident #6's unresponsive episode on [DATE], recalled performing sternal rubs and attempting to locate pulses. Staff F called for the DON to enter resident's room, took the bipap mask off, put oxygen nasal cannula on and increased the flow of oxygen. Staff F stated staff had prepared to assist Resident #6 to the floor, to perform CPR, when resident had gasped and started to respond. Staff F stated that upon waking, Resident #6 had requested CPR and wanted to go to the hospital. Staff F stated that for oxygen saturations in the 80's it would depend on the situation and how fast saturation returned to normal for this information to be put as an FYI in communication binder for Provider. Staff F revealed that a Nurse Practitioner visited the facility twice per week and the Physician visited the facility twice per month. On [DATE] at 01:33 PM, the Nurse Practitioner (NP) for the facility, revealed the expectation that non-emergent notifications would be placed in the communication binder, gave examples such as: itchy skin, didn't sleep the greatest one night, fever resolved with Tylenol, sometimes family concerns, a fall without injury, labs if normal results unless I ask them to contact me, and pharmacy recommendations. The NP revealed the expectation that facility calls with acute respiratory changes and depending on the patient with history of COPD and chronic respiratory disease to give treatment to see if that helps, if not, or symptoms continue for 1-2 hours, NP would like to be notified. On [DATE] at 10:02 AM, the Facility Administrator stated the facility lacked policy for resident change of condition. The facility document titled, Things to be Placed in Communication Log, not dated, instructed staff to place the following non-emergent patient issues in binder: seasonal allergy symptoms, skin tears, falls without injury, insomnia, family member meeting requests, if as needed medications have been initiated, non-emergent labs, tests, or x-rays, refusal of medications or medications given for other reason, medication errors without adverse effects. The facility document titled, Call Immediately For, not dated, instructed staff to immediately call Provider for the following issues: any unstable patient, falls with injury, unstable vital signs, any new findings on imaging studies, chest pain, fever, hypoxia, heart rate greater than 110 beats per minute, shortness of breath, etc. 2. The MDS, dated [DATE], revealed a BIMS score of 13 out of 15 indicating intact cognition. Resident #3 had no impairment of upper or lower extremities and utilized walker. Resident #3 independent with bed mobility, transfers, toileting, and ambulation at time of this assessment. Diagnoses included: non-Alzheimer's dementia, anxiety disorder, fibromyalgia, hypothyroidism, and history of falling. Resident #3 received scheduled pain medication for almost constant pain. The MDS, dated [DATE], revealed Resident #3 utilized both a walker and wheelchair during the assessment period and required partial to moderate staff assistance with bed mobility, transfers, and toileting. The MDS documented Resident #3 non-ambulatory during reference dates. Diagnoses of fracture of unspecified part of neck of left femur subsequent for closed fracture with routine healing included. Resident required scheduled and as needed pain medications, and non-medication interventions for almost constant pain. The Care Plan, revised on [DATE], revealed a risk for falling related to low back pain, fibromyalgia, and history of falls. Interventions informed staff to keep personal items and frequently used items within reach ([DATE]), refer to fall intervention plan (FIP) at Nurse's Station ([DATE]) and refer to resident's care card in room ([DATE]). An Incident Report, dated [DATE], completed by the Director of Nursing (DON), documented that there was no documentation of the incident. Resident #3 interview revealed that she had fallen when attempted to get into bed and hit head on a pile of soft clothes and notified that her head had still been sore where she landed. Resident recalled yelling for help and her roommate pulled the call light. Resident #3 reported that a few CNA staff came into room and checked her out, then the nurse came to room and checked her out. The Incident Report revealed that the immediate action taken had been to obtain an order for a x-ray immediately after DON was notified of fall (3 days following fall) and resulted in post incident injury of left trochanter (hip) fracture. Review of Nursing Progress Notes that followed fall on [DATE], revealed the following entry information: a.) [DATE] at 08:38 AM: Resident received new order for anti-anxiety medication Alprazolam (Xanax) scheduled three times per day. b.) [DATE] at 04:39 PM: Provider ordered x-ray of left hip for resident complaints of increased pain. c.) [DATE] at 01:59 AM: Resident more lethargic in mood, appeared to have increased generalized weakness, and fatigued appearance. Resident stated, I'm just tired. I'm just not me anymore. d.) [DATE] at 02:29 PM: Resident self-reported a fall on [DATE] and complained of left hip pain. e.) [DATE] at 02:30 PM: Obtained x-ray as ordered for left hip 2-3 views unilateral with pelvis. f.) [DATE] at 04:00 PM: Results received from mobile x-ray for non-displaced left sub-capital hip fracture. Nursing notified Provider of results. g.) [DATE] at 04:40 PM: Resident transferred to Hospital. h.) [DATE] at 05:03 PM: Director of Nursing completed investigation, found that Resident #3 had attempted to get into bed, call light had been pulled by Resident #3's roommate and Certified Nursing Assistant (CNA) answered light. Resident #3 found on the ground near her bed. CNA notified Nurse of fall. Nurse in another resident's room performing cares instructed CNA to obtain Resident #3's vital signs. CNA assisted Resident #3 off the floor and into bed. Nurse arrived to assess the resident between 5-15 minutes following incident. i.) [DATE] at 08:10 PM: Facility notified that Resident #3 had been admitted to Hospital and scheduled to have left hip surgery. The hospital History and Physical (H&P), dated [DATE], revealed that Resident #3 presented with complaints of left hip pain since falling on Saturday ([DATE]). New left hip fracture noted on outpatient x-ray. Resident stated she fell backwards when using her walker, hit her head, has been ambulatory since fall, and progressive left sided pain without radiation. The H&P also revealed that Orthopedic Surgeon had been consulted by Emergency Department and plan for surgical intervention on Thursday ([DATE]). On [DATE] at 01:45 PM, Staff E, Licensed Practical Nurse (LPN) stated that prior to falling Resident #3 had been independent using walker throughout the facility and following the fall required assist of one staff to stand pivot transfer and ambulate short distances with wheelchair to follow. Staff E revealed the facility fall process is for nursing to assess the resident before they are moved, check vital signs, look at their skin, check range of motion, and assess for head injury. Staff E stated if acute pain is assessed with a fall, call the provider and ask about evaluation at ER, call family, notify the DON and Administrator if resident needs sent to the hospital. Staff E also stated that staff involved with a fall complete a fall packet which includes a diagram, an immediate intervention to prevent it from happening again, then discussed in all staff huddle the following day. Staff E revealed that a fall assessment and 3 day follow up assessments are completed in the Electronic Health Record. On [DATE] at 04:00 PM, Staff B, LPN, stated that when residents fall, nursing staff is expected to assess the resident as soon as notified. The nurse is to check vital signs, check skin, range of motion, assist resident to a safe position and fill out fall paperwork which involves intervention appropriate to fall, staff education, resident education, and notify the Director of Nursing, Administrator, provider, and family. Staff B informed that if a resident's BIMS is lower than 13 neuro checks are automatically initiated for an unwitnessed fall. On [DATE] at 01:33 PM, the Nurse Practitioner (NP) for the facility revealed the expectation that resident fall assessment is completed immediately and indicated that there are times residents should not be moved because this may cause more harm. The NP expected that for cognitive deficits or functional decline the provider be notified immediately of the fall or if they hit their head, have injury, or pain to be notified within the hour. The NP stated that a hip fracture could be exacerbated with movement, and gave the example that a hairline fracture could be made worse. The NP expected that nurses assess resident following a fall to document change and establish a baseline. The NP stated CNA staff could check and report vital signs. On [DATE] at 02:31 PM, Staff G, Certified Nursing Assistant (CNA), confirmed working [DATE], on the date that Resident #3 had reportedly been observed on the floor. She stated that she told another CNA to notify the nurse that Resident #3 had fallen, while Staff G waited with the resident in her room. Staff G recalled that Resident #3 had been in a kneeling position on one knee and informed that after waiting 15 minutes with Resident #3 for the nurse, had assisted resident to stand up from the floor and then lay on the bed, due to resident trying to get self up and complaints of pain in her back. Staff G reported that another CNA returned to Resident #3's room with vital signs equipment and recalled that vitals looked okay and everything seemed okay when resident laid in bed, with no more pain than usual. Staff G stated a nurse entered the room and also assessed the resident. On [DATE] at 04:36 PM, the Director of Nursing (DON), stated she had not been notified that Resident #3 fell on [DATE] until Monday [DATE] when a CNA informed her that Resident #3 had fallen over the weekend. DON revealed having concern that there was a lack of documentation related to fall and completed investigation with staff who worked, as well as Resident #3, and resident's roommate. DON revealed that the nurse had been terminated due to lack of fall documentation and revealed the expectation that the nurse would do a proper fall assessment and notify the DON. The facility document, titled Fall Checklist, not dated, instructed nursing staff to complete the following tasks when a resident falls: 1. Obtain vital signs and safely position resident 2. Complete fall huddle sheet with staff 3. Call Medical Doctor (MD), Physician's Assistant (PA), or Nurse Practitioner (NP) for EVERY fall 4. Call Power of Attorney (POA) 5. Text to Administrator, DON, and on-call nurse, if injury that requires higher level of care, the Administrator and DON must be called. 6. Complete fall investigation form 7. Initiate neurological assessment (if applicable) 8. Initiate skin sheets (if applicable) 9. Complete risk management in Electronic Health Record (EHR) 10. Add intervention to CNA intervention list 11. Complete Morse Fall Scale assessment in HER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to identify the causal factors of falls to implement appropriate interventions to prevent further falls and evaluate the current fall interventions for effectiveness for 1 (Resident #25) of 3 residents reviewed for falls. Resident #25 sustained 46 falls from 11/02/21 through 11/02/22. This failure resulted in the resident sustaining falls with injuries including a fractured right ankle on 1/10/22, a small hematoma on the back of the head on 1/15/22, and a fractured hip on 1/20/22. Resident #25 was also transported and evaluated in the emergency room on 1/31/22 for a possible refracture of the right hip and on 6/09/22 for a CT (computed tomography) scan after a fall which resulted in a hematoma to the forehead. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 1/10/22 when Resident #25 sustained a fall resulting in an ankle fracture. The Administrator and DON were notified of the IJ on 11/06/22 at 12:00 PM and provided the IJ template at 12:06 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 11/08/22 at 10:12 AM. The IJ was removed on 11/09/22 at 11:12 AM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of G that was not immediate jeopardy for F689. The facility identified a census of 42 current residents. Findings included: A copy of the facility's fall prevention policy was requested and on 11/04/22 at 11:45 AM, Nurse Consultant #1 stated they did not have a policy on falls but provided a policy titled, Completion of Incident Report, dated 8/10/18. The policy indicated, An incident report shall be initiated for any unusual incidents involving residents whether they occur at the facility or not, whether injury is apparent or not. Further review of the policy revealed Unusual incidents include but are not limited to: a. Fall: unintentional change in position coming to rest on the ground, floor or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). Continued review indicated Instructions and/or demonstrations should be given to the resident or employee to prevent future incident of a like nature, when appropriate. A review of an admission Record indicated Resident #25 had diagnoses which included late onset Alzheimer's disease, osteoarthritis, repeated falls, and history of falls. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The resident required extensive to total assistance with all activities of daily living (ADLs) except eating. The MDS indicted the resident was frequently incontinent of bowel and bladder and had two or more falls since the previous assessment on 6/14/22. A review of Resident #25's care plan, initiated 10/29/21, revealed the resident was at risk for falling with interventions which directed staff to: - Assist the resident to bed after administering anti-anxiety medications, initiated 8/02/21 - Apply non-skid socks at night, initiated 8/22/21 - Keep items off the floor and within reach, initiated 9/02/21 - Ensure proper arrangement of bedding, initiated 10/11/21 - Ensure the resident was seated when applying footwear, initiated 11/16/21 - Apply slipper socks, initiated 11/17/21 - Apply half rails times two to assist with bed mobility and repositioning, initiated 11/03/21 and revised 12/15/21 - Apply non-skid strips to the bathroom floor, initiated 12/15/21 - Give the resident cookies or snacks when they are sitting, initiated 12/17/21 - Provide a night light outside of the bathroom door, initiated 1/10/22 - Apply non-skid padding in the recliner, initiated 1/18/22 - Resident was non-ambulatory at that time, initiated 10/29/21 and revised 1/19/22 - Apply non-skid padding in the wheelchair, initiated 1/20/22 - Always keep the resident in a supervised area. The resident was only to be in their room for naps and at night, initiated 1/14/22 and revised 2/08/22 - Transfers with assistance of two and the Stand-aid (mechanical lift), initiated 10/29/21 and revised 3/07/22. - Use a fall mat, initiated 3/10/22 - Use a bolster mattress, initiated 4/01/22 - Keep the resident's wheelchair out of sight when they are in the recliner, initiated 8/09/22 - Provide the resident with an activity basket between meals, initiated 8/09/22 - Provide adequate lighting, initiated 8/09/22 - Allow the resident to rest in the recliner after dinner until bedtime, initiated 6/09/22 and revised 8/09/22. A review of a Fall Risk assessment, dated 11/2/21, indicated Resident #25 was at risk for falls, and fall interventions should be initiated. Review of Incident Reports revealed Resident #25 sustained 46 falls from 11/2/21 through 11/2/22. Based on these reports, a review of Progress Notes, and interviews, there was no evidence that the facility thoroughly investigated each fall for causal factors and there was no evidence of what interventions were in place at the time of the fall. The facility did not evaluate the current fall interventions for effectiveness. The facility did not have evidence that new appropriate interventions were put into place and that those interventions were communicated to staff. A review of Resident #25's Incident Reports and Progress Notes between 11/02/21 and 12/28/21 revealed Resident #25 had 10 falls, including four falls related to ambulating in, to, or from the bathroom. A review of the care plan revealed the only interventions put into place for the falls related to the bathroom were to put non-skid strips in the bathroom in front of the toilet after the fall on 12/15/21. The resident had a fall on 12/28/21 that occurred when the resident was ambulating between the bed and the bathroom and the tennis balls on the walker malfunctioned. The facility failed to analyze the data they had from previous falls to determine causal factors in order to implement effective interventions to prevent the resident from falling again and obtaining a serious injury. A review of a Progress Note and Incident Report, dated 1/10/22 at 5:20 AM, revealed Resident #25 had a fall in the bathroom (seen scooting out of the bathroom on their buttocks), and when assessed the resident complained of discomfort to the right ankle. The physician was contacted via fax and an order for an x-ray of the resident's right ankle was received at 6:41 AM. On 1/10/22 at 2:32 PM, the progress note indicated the resident had an x-ray of the right ankle which showed a non-displaced distal right fibular fracture. Later in the day on 1/10/22, the progress notes and incident report indicated the resident sustained a second fall at 2:45 PM and was seen scooting on the floor out of the bathroom. The facility failed to investigate the causative factors of the falls but added an intervention to place a night light outside the bathroom door. A review of Progress Notes and Incident Reports between 1/12/22 and 1/18/22 revealed Resident #25 had four falls, one on 1/12/22, two on 1/15/22, and one on 1/18/22. Review of the care plan revealed the facility developed new care plan interventions for two of the four falls. The facility failed to analyze the data they had from previous falls to determine causal factors in order to implement effective interventions to prevent the resident from falling again and obtaining another serious injury. A review of a Progress Note, dated 1/20/22, indicated Resident #25 slipped off the front of the wheelchair trying to get up, with no complaints of pain and no injuries identified at that time. The care plan was updated to include non-slip padding in the wheelchair. A review of a Progress Note, dated 1/24/22, indicated Resident #25 had increased complaints of pain, x-rays were obtained, and the resident was found to have a right hip fracture and was sent to the hospital for surgical repair of the right hip. The resident's fall care plan was not updated with any new interventions when the resident returned from the hospital. A review of the facility's Self-Report, dated 1/25/22, indicated the facility contributed the right hip fracture to the fall that occurred on 1/20/22. A review of a Progress Note, dated 1/31/22, indicated Resident #25 was found on the floor after falling from a recliner and was sent to the hospital for evaluation of the right hip. The care plan was updated to include the resident was non-ambulatory with no new interventions. A review of Progress Notes and Incident Reports between 2/07/22 and 6/09/22 revealed Resident #25 fell seven times, three times from the bed and four times from the recliner. The facility failed to analyze the data they had from previous falls to determine causal factors in order to implement effective interventions to prevent the resident from falling again and obtaining a serious injury. Review of the care plan revealed it was updated four out of the seven times the resident had fallen during this time with new interventions. A review of a Progress Note, dated 6/09/22, indicated Resident #25 fell, hitting their head, resulting in the resident having a hematoma to the left side of their forehead and a laceration to the left cheek. The resident was sent to the hospital for evaluation. The care plan was updated with an intervention for the resident to be in the recliner after dinner until bedtime. A review of Progress Notes and Incident Reports between 8/25/2022 and 11/02/22 revealed Resident #25 had 19 falls, including 14 falls from the bed. Interviews with staff (see below) revealed the resident was going over the bolsters on the bed onto the fall mat and used the half rails to assist with doing this. The facility failed to track and trend the resident's falls and identify the pattern of falls from the bed and the facility failed to identify the cause of the resident's repeated falls from the bed. A review of the care plan indicated it was updated on 8/09/22 with new interventions, but there was no documentation in the resident's record to imply new interventions had been initiated or care planned for any of the 19 falls after 8/09/22. A review of physician progress notes indicated the physician recommended one-to-one support as much as possible when the resident was seen on 1/31/22 (after the resident had fallen 17 times since November 2021). The physician repeated this again on 2/18/22, after the resident had another fall, and again on 4/19/22, after the resident had fallen four more times. There was no documented evidence the one-to-one support occurred. During an interview on 11/04/22 at 1:36 PM, Staff F, a Certified Nurse Aide (CNA), stated she had been at the facility for almost 15 years and was a CNA mentor. She stated if a resident fell, she would notify the nurse to come and check them. Once the nurse said the resident was okay, then they would use the mechanical lift to get the resident up into the bed or chair. She stated she worked with the nurses to implement new interventions. Staff F stated fall interventions in place for Resident #25 included checking on the resident frequently, a bolster bed, pool noodles, and if the resident was up in the living room, they put a non-slip pad in the chair first. She stated the resident did have a fall mat, but they removed it and put down non-skid strips because the mat was not preventing anything. Staff F stated Resident #25 was able to crawl out of the bed and go over the bolsters, but was sliding out of the bed, not falling. During an interview on 11/04/22 at 1:47 PM, Staff E, a Certified Medication Aide (CMA), stated that when a resident fell, she would make sure the resident was safe and get the nurse. She stated she had no part of implementing interventions after a fall. Staff E stated fall interventions for Resident #25 included frequent checks, a bolster mattress, low bed, fall mat, toilet use and positioning schedule, and using common knowledge, such as if the resident was tired, then lay them down or put them in a recliner. She stated they would also reposition the resident from lying to sitting, provide hydration and nourishment, and one-to-one support. Staff E stated Resident #25 would go over the bolsters on the bed, and Staff E had seen the resident slide over the bolsters with their head on the bed and their bottom over the bolster. Staff E stated the resident was able to do it when they were determined. During an interview on 11/04/22 at 2:15 PM, Nurse Consultant #1 and the Director of Nursing (DON) stated if an intervention was a one-time intervention, then it would not be care planned. Nurse Consultant #1 stated interventions were documented on the fall summary done during the Falls Committee Meeting as part of their Quality Assurance (QA) process and would not necessarily be documented on the care plan or the resident's record. Nurse Consultant #1 stated staff were notified of new or changed interventions verbally during report, by the charge nurse, or by each other, and stated if they did not know they would ask. Nurse Consultant #1 stated they could not expect the staff to remember all of Resident #25's multiple interventions. The DON stated Resident #25 did not go over the bolster but kicked them out of the way. She stated no staff had reported the resident going over the bolsters. A review of Resident #25's Fall Summary revealed the facility identified Resident #25 had fallen 45 times since 11/02/21. The summary did not identify causal factors of the falls, as the Potential Contributing Factors section was left blank. The resident's response to interventions was only documented twice out of 45 falls listed on the summary. During an interview on 11/05/22 at 1:01 PM, Staff R, a CNA, stated if a resident fell, she would make them comfortable and get the nurse and then get vital signs. She stated the staff had a huddle every day at 2:00 PM to go over any changes made after a fall. She stated fall interventions for Resident #25 included bolsters on the bed, a floor mat, to check on them often, and they had a new mattress coming. Staff R stated the bed rails were supposed to help keep the resident in the bed, but the resident used the rails to help them get over the bolsters. Staff R stated she was not aware of the pool noodle being used. She stated the bolsters on the bed clipped on the sides, but they were ordering a concave mattress to try and help keep the resident in the bed. During an interview on 11/05/22 at 2:39 PM, Staff A, a Registered Nurse (RN), stated Resident #25 had a pool noodle to help keep them in bed with the bolster, fall mat with non-skid strips under it, and the staff were to check on the resident whenever they walked by. During an interview on 11/05/22 at 2:52 PM, Staff D, a RN, stated Resident #24's fall interventions included a fall mat, low bed, activities, redirection, toilet use, skid socks, mattress bolsters, repositioning, snacks/drinks, and music. She stated the resident would put themselves on the fall mat or scoot in the bed until they fell. She stated the resident had put themselves on the floor to take a nap. Staff D stated the bolsters were to keep the resident from rolling out of bed, but the resident would go over them, so they had ordered the resident a special bed on which the bolsters were attached. She stated the resident did not use a pool noodle. Staff D stated the nurse should implement the new interventions, put it on the incident report, and include it on a progress note. She stated she did not update the care plan but did a fall risk assessment after each fall. She stated she would verbally tell the staff what the new interventions were and pass it along to the next shift. During an interview on 11/09/22 at 4:44 PM, the Administrative Assistant stated her expectation was for interventions to be implemented immediately after a fall after determining the root cause. She stated new interventions were to be placed in the communication book and then the nurse managers would review the fall in the morning meeting and add to the care plan if needed. Removal Plan: 1. On 11/06/22, the Director of Nursing and MDS Nurse with input from direct staff reviewed Resident #25's fall interventions. Potential contributing factors for previous falls were discussed. The care plan was updated on 11/06/22 with current fall interventions. New interventions were communicated to staff via a fall intervention communication form. A new fall risk assessment will be completed on every resident by a licensed nurse on 11/07/22. An audit of all resident fall interventions will be conducted by the restorative nurse and MDS nurse. The MDS Nurse in collaboration with the restorative nurse will review fall interventions for effectiveness and update resident care plans as needed. Audit will be completed 11/07/22. 2. On 11/06/22, all staff present on this date received education from the Director of Nursing on Fall Scene Investigation Report process. All other staff will receive education on the Fall Scene Investigation Report process before or during their next scheduled shift. All staff not scheduled will be educated via phone by the end of business day on 11/07/22 by the Director of Nursing. 3. The Fall Scene Investigation Report is a data collection tool used to investigate and determine the root cause of a fall. The tool guides staff to review potential contributing factors such as: alarm use, amount of assistance in effect, assistive devices, environmental factors, environmental noise, footwear, medication, medical or physical condition change, acute changes to mood or mental status, toilet use needs, and sensory impairment. The report will be completed by a licensed nurse immediately after the resident is stabilized after a fall. To do this, the charge nurse asks all the staff working in the area of the fall to meet briefly together to determine the root cause analysis (RCA) of the fall. 4. An immediate fall intervention will be implemented by the attending nurse based on the results of the Fall Scene Investigation and will be documented by the nurse on the fall intervention communication form and the resident's care plan. Restorative nurse or designee will review the communication form for completeness and accuracy and updated this form as needed after every Fall Committee Meeting. The fall intervention communication form is a communication tool for the nursing staff and will be available in a binder at the nursing station. This form includes sections for the date, resident name, and new fall intervention. This form will remain in the binder for a minimum of one month. Director of nursing or designee will remove the communication tool from the binder. The forms will be submitted to the QAPI [Quality Assurance Performance Improvement] team for review quarterly. 5. The Fall Team, consisting of the Administrator, Director of Nursing, MDS Nurse, and Restorative Nurse, will meet daily during business days to review each Fall Scene Investigation Report to monitor and review for completeness, accuracy, and appropriateness of the fall intervention/s put into place. If it is determined, after this review, that an alternative intervention needs to be implemented, the MDS or restorative nurse will update the resident's care plan and communicate the change on the fall intervention communication form. The outcome of each review will be documented on the last page of the fall scene investigation form. 6. Fall scene investigations will be submitted and reviewed quarterly by the QAPI team. This process will be reviewed for the next 4 quarters. 7. All corrections were completed on 11/07/22. 8. The immediacy of the IJ was removed on 11/07/22. Onsite Verification of Removal Plan: The IJ was removed on 11/09/22 at 11:12 AM after the survey team performed onsite verification that the Removal Plan had been implemented. The survey team verified Resident #25's care plan was updated on 11/06/22 with appropriate person-centered fall interventions and the new interventions were placed on the fall intervention communication form. A fall risk assessment for Resident #25 was completed 11/07/22. Fall risk assessments for all residents were completed on 11/07/22 which was verified by reviewing a random sample of residents. The audit of all resident fall interventions was reviewed and revealed seven residents' plans of care were updated during the audit. A review of the education related to the fall investigation process and sign-in sheets revealed all staff had been in-serviced either in person or via phone by 11/07/22. This was verified with the staff list provided by the facility compared to the education sign-in sheet. Interviews on 11/09/22 with five CNAs, one CMA, two floor nurses, the Restorative Nurse, the MDS nurse, the DON and the Administrative Assistant confirmed they received the training. Review of the Fall Scene Investigation Report process revealed it included all information identified in the Removal Plan. Review of the Fall Intervention Communication Form revealed no concerns, and the location of the binder was verified to be at the nurse's station. Interviews on 11/09/2022 with five CNAs, one CMA, two floor nurses, the Restorative Nurse, the MDS nurse, the DON and the Administrative Assistant confirmed the initiation of the new forms and the new process.