**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to revise the person-centered Comprehensive Care Plan (CCP) to include measurable objectives and timeframes to provide services that met standards as related to care plan revision by the Interdisciplinary Team (IDT) after each assessment for five (5) of nine (9) residents, Residents #1, #2, #3, #7, and #8. 1. Review of Resident #1's Comprehensive Care Plan (CCP), initiated [DATE], revealed the facility assessed the resident as at risk for falls with interventions noting the resident required staff support and assistance for toileting. However, the facility provided Resident #1 a bedside commode on [DATE], and interviews revealed the resident attempted to toilet himself/herself without the staff's assistance. Staff interviews revealed they felt Resident #1 required additional supervision. The facility failed to care plan Resident #1 for additional supervision and monitoring for accident prevention and failed to discuss the resident's risk versus (vs.) benefits if he/she sustained a fall while on his/her blood thinner medication. Therefore, on [DATE], Resident #1 experienced a fall while attempting to toilet himself/herself on the bedside commode which resulted in serious injury to the resident, subsequently, the resident died on [DATE]. 2. Review of Resident #2's Comprehensive Care Plan (CCP), initiated [DATE], revealed the facility assessed the resident as at risk for falls with a goal for the resident to be free from falls and fall-related injuries. The facility implemented interventions to keep Resident #2's bed in the lowest position and assist the resident with mobility and transfers. However, there was no documented evidence the facility discussed Resident #2's risk vs. benefit regarding accidents, should he/she experience a fall while on Plavix (medication to prevent blood clots) and care plan the resident for that risk. Additionally, the facility failed to care plan Resident #2's mental status changes which occurred as a result of a urinary tract infection (UTI) and required additional supervision and monitoring of the resident to prevent accidents. As a result of the facility's failures Resident #2 sustained a fall on [DATE], from his/her bed which was in the highest position. The fall resulted in Resident #2 sustaining a left temporal subarachnoid hemorrhage, fracture of the right temporal bone, and large right subdural hematoma. Resident #2 expired on [DATE], as a result of trauma sustained during the fall. 3. Review of Resident #3's Baseline Care Plan (BCP), dated [DATE] revealed the facility care planned the resident as at high risk for falls related to a history of falls and decreased safety awareness. The facility care planned Resident #3 for his/her activities of daily living (ADL's) which had been assessed as he/she required assist of one (1) person for his/her selfcare needs, and toileting, and two (2) person assist with mobility, and transfers related task. However, the facility failed to care plan Resident #3's risk vs. benefits, or potential for harm if the resident experienced a fall while taking his/her anticoagulant medication on admission and failed to revise the care plan for the need for additional supervision or level of assistance the resident required. Therefore, Resident #3 experienced a fall from his/her bed on [DATE], and fell again on [DATE], from his/her wheelchair hitting his/her head on the floor both times. The facility transferred Resident #3 to the hospital, where the resident was diagnosed with a severe subarachnoid hemorrhage. 4. The facility assessed Resident #7 as a high risk for falls and as taking an anticoagulant medication for his/her diagnosis of Atrial Fibrillation (A-fib). However, the facility failed to care plan Resident #7 for adverse effects of the anticoagulant if he/she experienced a fall while taking the medication which could result in serious injuries. The facility's interventions for Resident #7 included staff to assist the resident to the bathroom and check on him/her every two (2) to three (3) hours. On [DATE], at approximately 10:51 AM, Resident #7 experienced an unwitnessed fall with major injury while attempting to toilet on his/her own. Resident #7 complained of severe right hip pain, and was sent to the hospital emergency room (ER) and admitted to the hospital. Resident #7 was diagnosed with a displaced right femoral neck fracture and underwent a right hip hemiarthroplasty. Resident #7 returned to the facility on [DATE], where he/she sustained three (3) additional falls from that date to [DATE]. However, the facility failed to update Resident #7's care plan with additional interventions to address the resident's need for increased supervision or the level of assistance he/she required. 5. The facility care planned Resident #8 with interventions which included: checking on the resident every two (2) to three (3) hours and as needed, providing incontinence care as needed; ensuring the resident's bed was in the low position and his/her call light was in reach; informing the resident to ask for assistance with ambulation, and ensure he/she was wearing appropriate footwear. Resident #8 sustained four (4) falls from [DATE] to [DATE], with the one (1) on [DATE], resulting in injury to the resident. On [DATE], Resident #8 sustained a fall from his/her bed and complained of pain in his/her right elbow. The resident was sent to the ER on 05/302022 and was diagnosed with a closed fracture of the 4th and 5th metatarsal bones. However, the facility failed to revise Resident #8's care plan with additional interventions for his/her need for further supervision related to his/her noncompliance, Physician's request for the resident to have a protective weight bearing status and use of a walker, or for the Orthopedic consult scheduled for [DATE]. The facility's failure to ensure staff revised residents' Comprehensive Care Plans (CCPs) in a timely manner has caused or is likely to cause serious injury, harm, or death to residents. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices (F689); at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Care Plan Timing and Revision (F657); at 42 CFR 483.70 Administration (F835); and at 42 CFR 483.75 Quality Assurance and Performance Improvement, Quality Assurance and Performance Improvement Program/Plan, Disclosure/Good Faith Attempt (F865) all at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE]. The findings include: Review of the facility's policy titled, Care Plan Process, revised [DATE], revealed each resident's plan of care must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and social well-being. Continued review of the policy revealed residents' care plans were to incorporate identified problem areas and be reviewed and revised periodically by the Interdisciplinary Team (IDT), Director of Nursing (DON), or Registered Nurse (RN) designee. 1. Review of Resident #1's closed Electronic Medical Record (EMR) revealed, the facility admitted the resident on [DATE], with diagnoses to include Atrial Fibrillation (A-fib), Congestive Heart Failure (CHF), and a History of Myocardial Infarction. Continued review of the closed EMR revealed the facility assessed Resident #1 to be a falls risk. Review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE], and Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated intact cognition. Continued review of the MDS Assessments revealed the facility assessed Resident #1 to require extensive physical assistance of two (2) staff with his/her Activities of Daily living (ADL's) with bed mobility, transfers and walking in his/her room. Review of Resident #1's Comprehensive Care Plan (CCP) related to Activities of Daily Living (ADL's) self-care deficit, initiated on [DATE], and revised on [DATE], revealed the resident required assistance with ADL care including toileting, bathing, personal hygiene, bed mobility, and transfers. Per review, the goal was the resident would not develop any complications related to decreased ADL self-performance through the next review. Continued review revealed Resident #1's interventions included: assisting him/her to the bathroom as needed; providing incontinence care as indicated; assisting up in the wheelchair; turning, repositioning, and shifting the resident as indicated. Per review of the CCP, Resident #1 was also care planned as at risk for falls, related to deconditioning, gait and balance problems, and impaired range of motion (ROM). Review of the at risk for falls care plan revealed a goal for the resident to have a safe environment, and that included: partial bed rails up with cane rails as an enabler for mobility when in bed; gathering information on past falls and attempting to determine the root cause of a fall, ensuring his/her call light was within reach and encouraging its use, for assistance as needed. Review of the at risk for falls care plan further revealed staff were to respond promptly to all requests for assistance from the resident and anticipate and meet his/her individual needs. Continued review of Resident #1's CCP additionally revealed the facility care planned him/her on [DATE], for use of Coumadin (anticoagulant medication) due to the diagnosis of Atrial Fibrillation (A-fib). Review of the care plan revealed the interventions included; administering the anticoagulant medication as ordered; monitor for side effects and effectiveness every shift; perform a daily skin inspection and report abnormalities to the nurse; laboratory (labs) as ordered and report abnormal lab results to the Physician; and Vitamin K antidote for bleeding emergencies. Review of the Facility Investigation dated [DATE] at approximately 11:30 PM to 12:05 AM (AM marked out) for Resident #1 revealed staff had found the resident lying face down on the floor in his/her room. Per review, Resident #1 reported he/she had gotten up to use the bedside commode and fell. Continued review of the Investigation revealed Resident #1's call light had been in reach; however, had not been turned on. Further review revealed there had been no witnesses to the fall, and the BSC was listed as an environmental hazard which was present on the facility's Investigation documentation. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 4:09 PM, revealed Resident #1 used a BSC and required staff's assistance with his/her care, including using the BSC. CNA #1 stated Resident #1 would sometimes ring out to ask for assistance; however, he/she often tried to get up and do things on his/her own, such as using the BSC without calling for staffs' assistance. CNA #1 further stated staff reinforced and encouraged Resident #1 to use his/her call bell to request assistance and encouraged him/her not to get up on his/her own to prevent injury. Interview with Registered Nurse (RN) #1 on [DATE] at 1:34 PM. revealed Resident #1 required encouragement and reinforcement to use his/her call light to request assistance to use the BSC, so the staff knew to check on him/her routinely. Further interview revealed RN #1 reported staff had been trained to monitor Resident #1 for noncompliance with assistance and to ensure the BSC was in the correct position at the end of the bed. Interview with RN #3 on [DATE] at 10:50 AM, revealed she was familiar with Resident #1, and recalled the resident required assistance. She stated, however, most of the time Resident #1 got up and used the BSC on his/her own. Continued interview with RN #3 revealed she did not believe Resident #1 had been assessed as a falls risk, or that the resident had required any additional monitoring. Per RN #3, Resident #1 had only required encouragement to use his/her call light. Further interview revealed RN #3 had been aware Resident #1 was on Coumadin to prevent blood clots; however, she was not aware of any care planned interventions such as an antidote for the anticoagulant medication, or a risk vs benefit if the resident sustained a fall while on the blood thinner. Interview with RN/Unit Manager on [DATE] at 2:00 PM, revealed the facility did not increase Resident #1's supervision level to one on one (1:1) supervision due to it not being feasible with the number of staff to provide care. Further interview revealed however, it was imperative the facility addressed residents' falls and provided additional observation and supervision to protect residents from injury and ensure their safety. Interview with the Medical Director on [DATE] at 5:24 PM, revealed she had met with Resident #1 two (2) days prior to the fall incident on [DATE], and the resident had been doing well. The Medical Director stated she noted Resident #1 had some hip pain and ordered Tylenol for pain control. Per the Medical Director, she had been aware Resident #1 used a BSC to toilet and required additional support and supervision for transferring to the BSC to prevent potential injury from a fall. 2. Review of Resident #2's closed Electronic EMR revealed the facility admitted the resident on [DATE], with diagnoses which included a history of Urinary Tract Infections (UTIs). Review of Resident #2's admission MDS dated [DATE], revealed the facility assessed the resident to have a BIMS score of ten (10), which indicated moderate cognitive impairment. Continued review revealed the facility also assessed Resident #2 to require extensive physical assistance of two (2) persons for bed mobility, transfers, and locomotion on/off unit, dressing, toilet use, and personal hygiene. Review of Resident #2's CAA assessment dated [DATE], revealed the facility assessed the resident as at risk for falls due to decreased mobility and deconditioning, difficulty maintaining sitting balance, and impaired balance during transitions. Continued review revealed the assessed medication factors included antidepressants, antianxiety agents, and opioids. Review revealed the facility assessed internal risk factors for Resident #2 included neuromuscular, functional, psychiatric or cognitive issues, anxiety disorder, and depression. Additional review revealed the facility's care plan considerations related to falls were to be addressed. Review of Resident #2's Comprehensive Care Plan initiated on [DATE], revealed the facility had care planned the resident as at risk for falls related to impaired balance and mobility, and use of psychotropic medications. Continued review revealed the facility's goal for Resident #2 was for him/her to be free from falls and fall related injuries. Per review of the care plan, the facility's interventions included keeping Resident #2's bed in the lowest position, anticipating the resident's needs, assisting with his/her mobility and transfers, maintaining a clutter free environment, placing the call bell within reach and observing for any side effects of medications. Further review revealed however, no documented evidence the facility had discussed with Resident #2 the risks vs. benefits of being on an anticoagulant medication and potential for injuy related to accidents if he/she should have a fall while on the Plavix (anticoagulant medication). In addition, review also revealed no documented evidence the facility care planned Resident #2's for UTIs and resulting mental status changes, which required additional supervision and monitoring to prevent accidents. Review of the facility's Event Summary Report for Resident #2 dated and signed by the DON on [DATE], revealed at approximately 7:30 PM, the resident was found lying on the floor next to his/her bed. Continued review revealed Resident #2 returned from the ER approximately thirty (30) minutes prior to the fall and observed to have a change in mental status and behavioral symptoms. Further review revealed Resident #2 had been diagnosed with a UTI while at the ER and Intravenous (IV) antibiotics were given. Review of the facility's Investigation documentation dated [DATE], revealed no root cause analysis had been performed. Per review, the results/conclusion revealed Resident #2 had fallen out of bed after returning from the ER, and sustained another fall resulting in a head injury. Further review revealed Resident #2 was sent back to the ER. In addition, review revealed no documented evidence the facility had taken corrective action, and the Administrator's signature, dated [DATE]. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 11:50 AM, revealed Resident #2 required total assistance. Further interview revealed CNA #1 was not fully aware of Resident #2's care plan interventions specific to falls; however, she felt all residents were at risk for falls and the care plans should be reviewed and residents monitored to protect them from injury related to a fall. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 11:50 AM, revealed Resident #2 had a history of confusion at times and would push his/her bed up and down; however, would not remember why he/she pushed it, especially, if the resident had an infection or a UTI. LPN #2 stated Resident #2 required total care and had been in the ER the morning of [DATE], and diagnosed with a UTI. Continued interview with LPN #2 revealed when Resident #2 returned to the facility he/she had been experiencing confusion, and when the LPN entered the room later on, she found Resident #2 lying on the floor with a lot of blood. She stated, EMS was called and LPN #2 and the CNAs remained with the resident until emergency management services (EMS) personnel arrived. Further interview revealed the care plan was important because it told staff what care a resident needed, and how to provide that care. In addition, LPN #2 stated it was important Resident #2's care plan to have been updated based on the resident's needs and with any status changes, to include confusion and UTI's. Interview with Registered Nurse (RN) #1 on [DATE] at 3:48 PM, revealed when a resident had a change of condition, she would not revise the resident's care plan to implement additional interventions. She stated she waited until she notified the DON or MDS Coordinator and then the care plan would be revised if needed. She stated it was important for residents' care plans to be revised with any immediate changes related to falls to prevent injuries. Continued interview revealed each resident was to have a specific individualized care plan that met their assessed needs. The RN stated all staff was to be up to date with residents' care plans and review their interventions and goals routinely in order, to provide the best appropriate care and prevent potential harm or injury to a resident. RN #1 further stated the facility failed to address the change in condition for Resident #2 by updating his/her care plan upon returning to the facility from the ER on [DATE], prior to the second fall. Interview with LPN #1 on [DATE] at 10:12 AM, revealed Resident #2 returned to the facility between 7:00 PM and 7:10 PM and was anxious and agitated. Per interview, RN #1 asked LPN #1 to hang IV fluids for Resident #2 around 7:35 PM. LPN #1 stated upon entering Resident #2's room to hang the fluids, she found Resident #2 lying on the floor next to his/her bed attempting to get himself/herself up off the floor. LPN #2 revealed it was the nurses' responsibility to update residents' care plans. In addition, she stated she did not always have time to go over her residents' care plans every day. Interview further revealed however, it was important for Resident #2's care plan to have been updated based on his/her needs and condition change status including confusion and UTI's. Interview with the Unit Manager (UM) on [DATE] at 1:10 PM, revealed Resident #2 required total care and experienced delusional behaviors at times. Continued interview revealed on the day of the incident ([DATE]), Resident #2 had been experiencing increased behaviors and confusion, weakness, was requiring increased assistance, and had not been eating as well or participating in his/her care. Continued interview revealed Resident #2 was sent out to the ER for evaluation and returned to the facility later on with a diagnosis of UTI. The UM stated following Resident #2's return to the facility, he/she was found on the floor by staff. Per interview, Resident #2's bed had been in the highest position with the call light and bed control in his/her hand. The UM further stated there was no certain facility plan or procedure in place for monitoring and supervising residents; however, the nurses and CNAs were responsible for knowing their resident's needs and care, and it was the staff's responsibility to ensure the safety of residents. 3. Review of Resident #3's closed Electronic Medical Record (EMR) revealed the facility admitted the resident on [DATE], with diagnoses that included A-fib and Dementia. Continued review of the resident's closed EMR revealed Resident #3 had been admitted with confusion and being unaware of his/her surroundings. Review of Resident #3's Baseline Care Plan dated [DATE], revealed the facility noted the resident was at risk for falls related to a history of falls and decreased safety awareness. Continued review revealed the facility also noted Resident #3 had impaired range of motion and/or loss of functional movement of joint(s), required one (1) person assistance with toileting and two (2) person assistance with mobility, and transfers. Per review of the Baseline Care Plan, interventions for Resident #3 included floor mats at bedside; gather information on the resident's past falls and attempt to determine the root cause of falls; anticipate and intervene to prevent reoccurrence of falls; be sure his/her call light was within reach and encourage the resident to use it for assistance as needed. Review further revealed other interventions included: staff to respond promptly to all the resident's requests for assistance; and anticipate and meet the individual needs of the resident. Further review revealed however, no documented evidence the staff discussed and care planned the risk vs. benefits with Resident #3 the potential for harm if the resident fell while being on anticoagulants. In addition, review revealed no documented evidence Residen#3's care plan was revised to include a need for increased supervision or level of assistance needed when the resident was up in a wheelchair after he/she sustained a fall on [DATE]. Interview with Resident #3's daughter on [DATE] at 11:48 AM, revealed she and other family members told staff on the resident's admission, that he/she had confusion and a history of falls. Continued interview revealed she informed nursing staff of the need and importance of keeping a close eye on Resident #3 and to check on him/her often to keep the resident safe. Interview with Certified Nursing Assistant (CNA) #3 on [DATE] at 12:00 PM, revealed Resident #3 had been a two (2) person assist with transfers and she was aware of the resident's interventions on his/her care plan. Interview revealed however, she was not aware of additional supervision for Resident #3 to include direct 1:1 supervision of the resident while up in his/her wheelchair, after the fall on [DATE]. CNA #3 stated on the day of the incident ([DATE]) she had not had prior contact with Resident #3 before he/she experienced the fall. Further interview revealed while passing meal trays that day she heard a noise and found Resident #3 lying on the floor. CNA #3 further stated she felt it had just been a few minutes that Resident #3 was left alone without supervision at the nurse's station. Interview with Licensed Practical Nurse (LPN) #3 on [DATE] at 11:50 AM, revealed Resident #3 was to have been be up in a wheelchair in front of the nurse's station before meal trays due to his/her confusion and being a fall risk. She stated staff had been aware to keep an eye on Resident #3 due to being a new admission, and his/her history of confusion and falls. Continued interview with LPN #3 revealed on the day of the incident ([DATE]) Resident #3 had experienced increased confusion earlier that day and had been moved to the nurse's station for increased monitoring and supervision. LPN #3 stated Resident #3 had been fidgety and removing his/her clothes. Per interview, Resident #3 had been eating his/her dinner by the nurse's station while the nurse was passing medications. Interview revealed while passing medications, she heard something, and CNA #3 yelled that Resident #3 had fallen out of his/her wheelchair. LPN #3 further stated she was aware of residents' baseline care plans; however, she was unfamiliar with how to update the care plans following an incident. In addition, she stated the facility did not provide 1:1 supervision, and said, it's impossible to keep an eye on all residents twenty-four (24) hours a day seven (7) days a week. LPN #3 additionally stated staff could walk away for a second and anything could happen. Interview with Registered Nurse (RN) #4 on [DATE] at 12:15 PM, revealed Resident #3 had to be monitored closely and bolsters were to be present on both sides of his/her bed due to his/her recent fall on [DATE]. RN #4 stated Resident #3 had been moved to the nurse's station in a wheelchair earlier on the day of the incident involving the injury ([DATE]) to help the resident relax following his/her increased confusion that morning. Further interview revealed she was not certain what Resident #3's level of care or care needs had been but stated she would refer to a resident's care plan to know that information. The RN additionally stated when a resident's care plan was not followed or revised, staff could injure the resident or themselves, or could result in falls with injuries. Interview with the RN/Unit Manager (UM) on [DATE] at 2:00 PM, revealed the facility had no certain process or procedure in place for additional supervision of residents; however, staff were provided education and daily report on residents with noncompliance, falls, and mental status changes. In addition, she stated the staff were all responsible for knowing their residents and to keep an extra eye on them to ensure their safety. Further interview additionally revealed the facility had no set schedule or procedure which was enforced for monitoring to provide additional supervision of residents. 4. Review of Resident #7's admission record revealed the facility admitted the resident on [DATE], with diagnoses that included difficulty in walking and Chronic A-fib for which the resident received anticoagulation medication therapy. Review of Resident #7's Quarterly MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of seven (7), which was indicative of being severely cognitively impaired. Continued MDS review revealed the facility also assessed Resident #7 as requiring extensive assistance of two (2) person for transfers and toileting. Review of Resident #7's Comprehensive Plan of Care (CCP) initiated on [DATE], revealed the facility care planned the resident as a high risk for falls with interventions which included staff being required to assist the resident to the bathroom and check on him/her every two (2) to three (3) hours and as needed, provide incontinence care as needed, and encourage the resident to ask for assistance for ambulation. Continued review revealed additional interventions included ensuring Resident #7's bed was in the lowest position as needed; his/her call light was in reach when in bed; keeping his/her room neat and clutter free; and reminding the resident of safety awareness such as locking the brakes of his/her wheelchair prior to attempting to stand or transfer, and ensure the resident wore appropriate footwear. Continued review of the CCP revealed the facility also care planned Resident #7 for ADL's with a target date of [DATE]. Review of the ADL care plan revealed the focus was for Resident #7 to have assistance with toileting, bathing, dressing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and ambulation related to generalized weakness, and his/her diagnoses. Per review of the ADL care plan, the goals included Resident #7 maintaining his/her current level of ADL functioning without a significant decline unless he/she experienced unavoidable deterioration due to the disease process. Continued review of the ADL care plan revealed interventions which included the resident might require occasional two (2) person assist with bed mobility, transfers, and toileting and it would take more staff to provide for the resident's care. Further review revealed however, no documented evidence the facility had revised Resident #7's care plan to include an increased level of supervision related to assisting the resident with toileting after his/her fall on [DATE]. Review of Resident #7's Progress Note titled, Change in Condition dated [DATE] at 10:51 AM, revealed the resident had been found sitting on his/her bottom on the floor next to his/her bed. Per review, Resident #7 stated he/she had gotten up to use the bathroom and slipped and fell on his/her buttocks. Review revealed Resident #7 had been wearing a urine-saturated brief, hospital gown and non-skid socks at the time of the fall, with a puddle of urine observed next to the resident on the floor. Continued review revealed a skin tear was noted to Resident #7's right elbow with blood present, and the Physician was notified and new orders were obtained to include oxygen for the resident and continued monitoring of him/her. Review of the hospital Medical Records dated [DATE], revealed Resident #7 had fallen on [DATE] at the nursing home where he/she resided and was complaining of severe pain to his/her right hip area. Continued review revealed Resident #7 stated he/she had fallen from a standing position with no assistive device. Per review of the hospital medical records, observation revealed Resident #7's right elbow was bandaged, without complication and limited ROM to his/her right hip. Further review revealed Resident #7 was diagnosed with a displaced right femoral neck fracture, and the Physician's recommendation was for the resident to be transferred to a higher level of care for Orthopedic evaluation. In addition, review revealed Resident #7 underwent right hip hemiarthroplasty for a right hip fracture on [DATE], and the resident was discharged back to the facility status post mechanical fall on [DATE]. Review of Resident #7's Progress Notes dated [DATE], [DATE], and [DATE] revealed the resident also sustained falls on those dates. Review of the [DATE] Progress Note revealed Resident #7 injured his/her head, with a raised area to the left side of his/her head with tenderness to touch noted. Observation of Resident #7 on [DATE] at 10:27 AM, revealed the resident lying on his/her bed with no nonskid socks on, his/her supplemental nasal oxygen (O2) tubing lying on floor, and the call light lying on the floor under the bed. Interview with Resident #7, at the time of observation, revealed the resident was alert and stated it had been a while since staff checked on hi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices necessary to prevent accidents for five (5) of nine (9) sampled residents (Residents #1, #2, #3, #7 and #8). 1. The facility assessed Resident #1 as at risk for falls and care planned the resident to require physical assistance of two (2) staff with his/her Activities of Daily Living (ADLs) to include transfers and walking in his/her room. On [DATE], the facility provided a bedside commode for Resident #1's toileting; however Physical Therapy and Occupational Therapy assessed the resident to require Contact Guard Assistance (CGA), which indicated the resident needed one (1) to two (2) staff to have hands-on the resident's body to assist with steadying the resident. The resident's care plan revealed he/she was encouraged to press his/her call light for staff's assistance; however, interviews revealed Resident #1 often transferred from his/her bed to the bedside commode without staff's assistance. The facility failed to revise the resident's care plan to supervise/monitor for the resident's refusals to utilize his/her call light for assistance and failed to provide the resident education related to his/her risk versus benefits should the resident experience a fall while on anticoagulants, to prevent the resident from falling. On [DATE], while toileting himself/herself on the bedside commode, Resident #1 fell and sustained injuries which resulted in his/her death. 2. The facility assessed Resident #2 as at risk for falls, and initiated a care plan on [DATE], for the resident's risk. The facility's care plan for Resident #2 revealed interventions which included keeping the resident's bed in the lowest position. However, on [DATE], Resident #2 fell from his/her bed while the bed was in the highest position and sustained a large right subdural hematoma; a left temporal, subarachnoid hemorrhage; and fracture of the right temporal bone. Resident #2 expired on [DATE], due to the trauma sustained related to the fall. 3. The facility admitted Resident #3 on [DATE], with diagnoses that included Atrial Fibrillation which required anticoagulation therapy. The facility assessed Resident #3 as a high risk for falls due to a history of falls and decreased safety awareness. However, the facility failed to care plan Resident #3 for the potential for harm should the resident sustain a fall while on anticoagulant therapy. Resident #3 experienced a fall from his/her bed on [DATE], and again on [DATE], when he/she fell out of his/her wheelchair hitting his/her head on the floor. After the fall, the facility transferred Resident #3 to the hospital, where the resident was diagnosed with a severe subarachnoid hemorrhage and placed on trauma alert due to the fall. 4. The facility admitted Resident #7, on [DATE], with diagnoses that included Chronic Atrial Fibrillation, with use of anticoagulation therapy (blood thinner). The facility assessed Resident #7 to be a high risk for falls and care planned the resident for the fall risk. However, the facility failed to care plan Resident #7 for the use of blood thinner medication, and the potential for serious outcomes if he/she sustained a fall while on the medication. The facility care planned Resident #7 for staff to check on and assist the resident to the bathroom every two (2) to three (3) hours. However, on [DATE], at approximately 10:51 AM, Resident #7 experienced an unwitnessed fall with major injury while attempting to toilet on his/her own. Resident #7 was sent out to the hospital with complaints of severe right hip pain and admitted . Resident #7 was diagnosed with a displaced right femoral neck fracture and underwent a right hip hemiarthroplasty. Resident #7 returned to the facility on [DATE]. Review of the facility's Event Reports revealed the resident fell again on [DATE], [DATE], [DATE], with no injuries reported. However, following the four (4) falls there was no documented evidence the facility updated Resident #7's care plan with additional interventions, to include interventions for the need of additional supervision. 5. The facility assessed Resident #8 as a high risk for falls on admission, and to require one (1) staff person's assistance to toilet and transfer. Resident #8 sustained four (4) falls from [DATE] to [DATE]. On [DATE] at approximately 11:30 PM, staff found the resident lying on the floor by his/her bed on his/her right side. On [DATE], the resident complained of pain and an X-ray was ordered; the resident had a closed fracture of the 4th and 5th metatarsal bone. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care. F689 Free from Accidents/Hazards/Supervision/Devices; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657 Care Plan Timing and Revision; 42 CFR 483.70 Administration, F835; and 42 CFR 483.75 Quality Assurance and Performance Improvement: F865, Quality Assurance and Performance Improvement Program/Plan, Disclosure/Good Faith Attempt all at a Scope and Severity (S/S) of K'. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on [DATE], prior to exit on [DATE]. The findings include: Review of the facility's policy titled, Chapter 7: Abuse Prevention Managing Incidents and Fall, undated, revealed the following information: provide timely analysis of falls/incidents to determine possible contributing factors and/or trends; develop and implement reasonable and appropriate action plans and resident specific care plans to identify interventions reducing the potential of future falls/incidents. Further review revealed falls and incident management also included: identifying high-risk residents and ensuring complete assessment and care planning and communicating the plans to appropriate staff through orientation, in-services, staff meetings, shift report, and care planning. Review of the facility's policy titled, Falls Management, undated, revealed the Interdisciplinary Team (IDT) was to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Per review, residents were to be assessed for fall risks as part of the nursing assessment process, to include assessing and reviewing residents' risk factors for falls and injuries upon admission, with a significant change in condition, or after a fall. Policy review revealed its purpose was to reduce the risk for falls and minimize the actual occurrence of falls, address any injury, and provide care after a fall. Review revealed the facility was to implement goals and interventions with the resident/family included in the interdisciplinary plan of care (IPOC) based on individual needs. Further review revealed the facility was to communicate interventions to the caregiving team, review and revise the IPOC at subsequent IPOC meetings, and educate the resident and family as indicated. In addition, policy review revealed for fall injury prevention and after a fall staff should assess the resident and immediately implement appropriate measures to prevent injury. Review of the facility's policy titled, F869, Accident and Incident Guidelines, undated, revealed the Director of Nursing (DON) and the Interdisciplinary Team (IDT) were to review the incident/accident at the next Clinical Quality Improvement (CQI) meeting to follow up incident documentation that would occur for the next seventy-two (72) hours to ensure no latent injury surfaces. Continued review revealed Further review revealed the resident's care plan was to be addressed to ensure that any needed points of focus had measurable goals with appropriate interventions in place and the Certified Nurse Aide (CNA) Kardex (CNA care plan) were also be updated as indicated to reflect the current care plan. 1. Review of Resident #1's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses that included Congestive Heart Failure (CHF), History of Myocardial Infarction (heart attack) and Atrial Fibrillation. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was cognitively intact. Continued review of the MDS Assessment revealed Resident #1 required extensive physical assistance of two (2) staff with his/her Activities of Daily Living (ADLs) to include bed mobility, transfer and walking in room, and one (1) person limited physical assistance with other ADLs. Further review revealed the facility assessed Resident #1 to require staff's assist with weight-bearing support for the guided maneuvering of limbs or other non-weight-bearing assistance for transfers, walking in his/her room, and for toilet use. Review of the Comprehensive Care Plan dated [DATE], revealed the facility care planned Resident #1 as at risk for falls related to: deconditioning; gait and balance problems; impaired range of motion; and loss of smooth joint movement. Continued review of the falls risk care plan revealed the goal stated Resident #1 would have a safe environment and interventions which included: partial bed rails up with cane rails (a handle attached to the bed) for use in bed as an enabler for bed mobility; gather information on past falls and attempt to determine the root cause of the fall(s); anticipate and intervene to prevent (fall) recurrence; be sure call light was within reach and encourage the resident to use it for assistance as needed. Further falls care plan review revealed the interventions also included: staff to respond promptly to all requests for assistance; and to anticipate and meet the individual needs of the resident. However, the facility failed to ensure the resident was care planned for increased supervision, when the resident was known to ambulate without staff assistance and failed to care plan for the resident's risk versus benefits should the resident experience a fall while on anticoagulants (a blood thinner). Review of Resident #1's Physician's Order, dated [DATE], revealed the resident was ordered to be administered a 5 milligram (mg) tablet of Coumadin (a blood thinner), in the evening every Tuesday, Thursday, and Saturday. Review of the manufactures recommendation for the drug, last updated [DATE], revealed [residents] should avoid any activity or sport that may result in traumatic injury. Review of Resident #1's Occupational Therapy (OT) Summary dated [DATE], revealed the resident would safely perform toileting tasks using a bedside commode (BSC) with Contact Guard Assist (having staff provide one (1) to two (2) hands-on the resident's body and assist with steadying the resident to help with balance). Review of Resident #1's Physical Therapy (PT) Discharge summary dated [DATE] revealed the resident required Contact Guard Assist (CGA) when being assisted to his/her bedside commode. Review of Resident #1's Progress Note dated [DATE] at 12:05 AM, revealed the resident had sustained a serious fall and had been found face down on the floor. Continued review of the note revealed Registered Nurse (RN) #1 documented Resident #1 got up to use the bedside commode (BSC) and fell. Per review, Resident #1 had a cut above his/her eye and swelling was noted. Further review revealed the Physician, and family were notified, and EMS (Emergency Medical System) transported Resident #1 to the hospital. Review of the facility's initial investigation, dated [DATE], completed approximately forty-four (44) days after the resident's fall, revealed the facility investigated Resident #1's fall (which occurred on [DATE] and resulted in major injury to the resident) and subsequent death after Adult Protective Services (APS) notified staff of the allegation of abuse and/or neglect on [DATE]. Continued review revealed the Administrator reported the allegation to the State Survey Agency (SSA) on [DATE], conducted the investigation, and sent the five (5) day follow-up of the findings to the SSA on [DATE]. Additionally, review of the facility's investigation information revealed on [DATE] at approximately 11:30 PM to 12:05 AM, Resident #1 was found lying face down on the floor in his/her room. Per review, Resident #1 reported he/she got up out of bed to use the bedside commode and fell. Review of the investigation revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of the investigation further revealed Resident #1's call light had been in reach; however, the resident had not turned his/her call light on. In addition, review of the investigation revealed there were no witnesses to Resident #1's fall, and his/her bedside commode was listed as an environmental hazard that was present. Review of the Emergency Medical Service (EMS) Run Sheet, dated [DATE], revealed the County EMS had been contacted by the facility on [DATE], at approximately 12:01 AM for an incident that involved a fall. Continued review revealed EMS Crew #1 arrived on scene at approximately 12:25 AM and found Resident #1 lying prone (face down) on the floor, with excessive facial bleeding and his/her eyes swollen shut. Per review of the Run Sheet, EMS Crew #1 noted Resident #1 stated he/she had been trying to get to the bathroom and was on a blood thinner. Further review revealed Resident #1 was transferred to the ambulance where he/she required suctioning to clear his/her throat of blood. The resident began vomiting blood. In addition, review revealed EMS Crew #1 documented due to Resident #1's head trauma and difficulty in maintaining the resident's airway free of blood, a request for ALS (Advanced Life Support) was made to assist with care, as well as, Air Medical for flight transfer to a Level One (1) Trauma Center. Review of the trauma hospital medical records dated [DATE], revealed Resident #1 arrived at 1:49 AM, and was diagnosed with Acute Respiratory Failure with Hypoxia, Open Fracture of Facial Bone due to a Fall, Closed Odontoid (second neck vertebrae) Fracture, Epistaxis (nosebleed) due to Trauma and Fall. Further review of the hospital documentation revealed Resident #1 had been non-responsive, and was transferred to the Hospice Unit, where he/she passed away the following day, on [DATE]. Review of the Death Certificate for Resident #1 dated [DATE], revealed the resident died of Acute Post-Traumatic Respiratory Failure due to complications of Blunt Force Head and Neck Trauma due to a Fall from a Standing Position. Interview with Resident #1's roommate, Resident #10, on [DATE] at 3:56 PM, revealed the resident did not recall the incident related to Resident #1's fall. Per interview, however, Resident #10 did recall how Resident #1 would take himself/herself to the bedside commode, without the staff's assistance. Interview with Resident #10 further revealed Resident #1 would get short of breath and weak a lot of times; however, the resident would still get up on his/her own but really needed staff to assist him/her. Interview with Certified Nursing Assistant (CNA) #2 on [DATE] at 9:18 PM, revealed she had provided direct care of Resident #1 and stated the resident would call out at times requesting to be pulled up in bed. The CNA stated Resident #1 had tried to get up and go to the bedside commode by himself/herself; however, staff made a point of encouraging the resident to ask for assistance to the commode. According to CNA #2, on the night of Resident #1's fall she heard CNA #1 scream, come now, and when she got to the resident's room, she saw him/her lying halfway under his/her roommate's bed. Further interview revealed Resident #1 had blood on his/her face and on the floor by him/her. She further revealed Registered Nurse (RN) #1 and RN #3 both were at Resident #1's side taking care of the resident's injuries, applying ice packs, and taking his/her vital signs. Interview further revealed CNA #2 stated Resident #1 had a laceration to the left side of the top part of his/her eye and under his/her eye. In addition, CNA #2 stated staff could not move Resident #1 due to the unknown extent of his/her injuries and head trauma so, they placed towels down on the floor around his/her head and body. Interview with CNA #1 on [DATE] at 4:09 PM, revealed Resident #1 used a bedside commode for toileting and required staff assistance with his/her Activities of Daily Living (ADL) care. CNA #1 stated Resident #1 would sometimes ring the call bell to ask for assistance; however, the resident tried to get up and do things on his/her own, such as using the bedside commode (BSC) without assistance. Per CNA #1, staff reinforced and encouraged Resident #1 to use the call bell for assistance and encouraged the resident not to get up on his/her own. Continued interview revealed on the night Resident #1 fell, at approximately 11:00 PM CNA #1 offered to assist Resident #1 with using the BSC and to record the resident's output for the shift. She stated Resident #1 had not requested her assistance to use the bedside commode since shift change. Per interview with CNA #1, at approximately 12:00 AM to 12:05 AM, as she had started her charting in the hallway, she heard a loud noise from the area of Resident #1's room. She stated upon entering Resident #1's room, she observed the resident lying on his/her stomach on the floor, with his/her head and upper body under the roommate's bed. Further interview revealed she yelled for help and additional staff responded immediately. In addition, CNA #1 stated RN #1 immediately called for an ambulance as RN #3 provided direct care to Resident #1. Interview with Registered Nurse (RN) #1 on [DATE] at 1:34 PM, revealed she had worked at the facility for eighteen (18) years and had provided direct care of Resident #1. RN #1 stated Resident #1 required encouragement and reinforcement to use his/her call light for assistance to the bedside commode; however, not as much at night as staff knew to check on him/her routinely. Per interview, RN #1 revealed staff had been trained to monitor Resident #1 for noncompliance with assistance and to ensure the bedside commode was in the correct position at the end of his/her bed. Further interview revealed she was aware the resident was on blood thinners and often refused to press his/her call light for assistance; however, the resident was not placed on increased supervision nor did the facility discuss with the resident risk versus benefits should the resident experience a fall but should have. Continued interview, with Registered Nurse (RN) #1, on [DATE] at 1:34 PM, revealed on [DATE], at approximately 11:50 PM to 12:00 AM, while in the hallway starting her medications pass, she heard a loud noise and both she and CNA #1 went to Resident #1's room. RN #1 stated they observed Resident #1 lying on the floor on his/her stomach face down and halfway under his/her roommate's bed. Interview revealed Resident #1 had a moderate amount of blood coming from his/her nose and the resident stated, I was getting up to use the potty. Further interview revealed RN #3 and CNA #2 came to help, and they both started providing care, applying pressure and an ice pack to Resident #1's forehead laceration and to the bleeding from his/her nose. Further interview revealed RN #3 began taking vital signs and monitoring the resident while RN #1 called EMS for immediate transfer. RN #1 further stated EMS was notified at approximately 12:05 AM and made aware of Resident #1's fall and that he/she was bleeding profusely and was on Coumadin (a blood thinner medication). Interview with RN #3 on [DATE] at 10:50 AM, revealed she had been called to assist with a resident's fall (Resident #1) around 12:00 AM on [DATE]. Per interview, she was familiar with Resident #1, and that the resident required assistance; however, knew most of the time the resident got up and used the bedside commode on his/her own. RN #3 revealed Resident #1 was assessed and sent out to the hospital immediately due to the severity of his/her injuries. Continued interview revealed RN #3 did not believe Resident #1 was assessed as a falls risk, nor was any additional monitoring required. RN #3 further revealed the resident was on blood thinners and should have been educated on the risk versus benefits of experiencing a fall while on blood thinners. She stated Resident #1 only required encouragement to use his/her call light. Further interview revealed, after the fall, the RN observed Resident #1 to have facial injuries and a laceration above his/her right eye. RN #3 further stated the resident had bleeding which was coming mostly from his/her nose and nasal cavity. Interview with Emergency Medical Service (EMS) Provider #2 on [DATE] at 11:00 AM, revealed on the early morning of [DATE], he was dispatched to the facility to transport an eighty-two (82) year-old male/female due to extensive injury after a fall which included severe head trauma. EMS Provider #2 the resident had to be transferred to the local Helipad for Air Vac Medical (AVM) flight services to transfer the resident to a Level 1 Trauma Center related to his/her condition and injuries. Interview with the Director of Nursing (DON) on [DATE] at 5:20 PM, revealed residents' rights included the right to fall, and the facility had done everything it could do to prevent residents' falls. She stated Resident #1 never had a prior fall, and this was his/her first fall. Further, she stated the facility ensured the resident's safety; however, we could only do so much. Review of the facility's policy, however, revealed fall injury prevention and after a fall included staff assessment of the resident, and [staff] would immediately implement appropriate measures to prevent injury. Interviews with Certified Nursing Assistant (CNA) #1 on [DATE] at 4:09 PM; Registered Nurse (RN) #1 on [DATE] at 1:34 PM; and RN #3 on [DATE] at 10:50 AM, revealed they were aware the resident refused to utilize his/her call light to ask for assistance to toilet, when the resident required one (1) to two (2) staff to assist. Further record review revealed there was no documented evidence to support the facility care planned for the resident's increased ambulation to his/her bedside commode, without staff supervision and no documentation to support the facility discussed with the resident his/her risk versus benefits should the resident fall while on blood thinners. 2. Review of Resident #2's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses which included Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, Type II Diabetes Mellitus, Anxiety Disorder and Required Need for Assistance with Personal Care. Review of Resident #2's Admission's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of ten (10), indicating the resident was moderately cognitively impaired. Continued review revealed the facility assessed Resident #2 to require extensive assistance of two (2) plus persons for physical assistance with bed mobility, transfers, and locomotion on and off the unit, dressing, toilet use and personal hygiene. Review of Resident #2's Comprehensive Care Plan initiated [DATE], revealed the resident was at risk for falls related to impaired balance and mobility, and use of psychotropic medications. Continued review revealed Resident #2 was to be free from falls and fall-related injuries with interventions which included: keeping the resident's bed in the lowest position; anticipating the resident's needs; assisting with mobility and transfers; maintaining a clutter-free environment; placing the call bell within reach; and observing for side effects of medications. Further review of the care plan revealed no documented evidence the facility discussed with Resident #2 his/her risk versus (vs.) benefit related to accidents, should he/she have a fall while on blood thinners (Plavix). Additionally, review of the care plan revealed no documentation to support the facility care planned Resident #2 for his/her history of Urinary Tract infections (UTIs) with mental status changes, to include the resident raising his/her bed from the lowest to the highest position when he/she exhibited signs of confusion, which required additional supervision and monitoring to prevent accidents. Review of the facility's Change in Condition Assessment for Resident #2 dated [DATE] at 12:37 PM, revealed the resident's condition change was, Altered Mental Status with Behavioral Symptoms (agitation, psychosis, diarrhea, nausea, and vomiting). Per review, Resident #2 had been experiencing Altered Mental Status Behavioral Symptoms to include diarrhea with nausea and vomiting symptoms which started on [DATE]. Continued review revealed the symptoms also included: increased confusion; cussing and hitting at staff; talking with different voices and had a large amount of green bile noted from vomit. Further review revealed Resident #2's increased confusion persisted, and the Medical Provider was notified on [DATE] at 12:43 PM. Additionally review revealed an order was obtained to send Resident #2 to the emergency room (ER) for evaluation and treatment. Review of the facility's Change in Condition Assessment for Resident #2 dated [DATE] at 7:30 PM, revealed the resident sustained a fall. Review revealed Resident #2 had: bleeding; suspected serious injury (Fracture); Contusion with Wound on the face above the right eye; and altered and sudden change in level of consciousness and responsiveness. Continued review revealed the Medical Provider had been notified, and an order was obtained to send the resident to the ER for evaluation and treatment. Review of Resident #2's Progress Note dated [DATE] at 7:40 PM, signed by Licensed Practical Nurse (LPN) #1, revealed the resident had been found on the floor parallel with his/her bed, wearing a gown, brief, and with a Foley catheter in place. Review revealed Resident #2 had been incontinent of bowel at the time of the fall. Continued review revealed Resident #2 had just returned from the ER, after being evaluated for a change in behavior and cognition, approximately thirty (30) minutes prior to the incident. Further review revealed Resident #2 had been placed in his/her bed upon return from the ER, with the bed placed in the lowest position. Per review of the Note, revealed Resident #2's call light and remote were placed within reach. Further review revealed however, at the time of the resident's fall, his/her bed was found up in the highest position and the call light on the floor next to the resident. In addition, review further revealed Resident #2 had a significant amount of blood noted from a laceration above the right eye approximately ten (10) centimeters in length. Review of Resident #2's Event Summary Report, dated and signed by the Director of Nursing (DON) on [DATE], revealed at approximately 7:30 PM, the resident was found lying on the floor parallel with his/her bed. Continued review revealed Resident #2 had just returned from the ER, where he/she was evaluated for a change in mental status and behavior symptoms, approximately thirty (30) minutes prior to the fall. Further review revealed Resident #2 had been diagnosed with a UTI while at the ER visit, prior to the fall, and Intravenous (IV) antibiotics had been given to him/her. Review of the Facility Fall Investigation for Resident #2 dated [DATE], revealed the resident's bed was noted to be waist high, (in the highest position) and the call light lying next to the resident on the floor in reach; however, was not on. Continued review revealed Resident #2 had been wearing a gown, and a brief at the time of the fall. Per review, Resident #2 had blood noted from a laceration approximately ten (10) centimeters (cm) to the right side of his/her face, above the eye. Further review revealed the fall had been unwitnessed with major injuries. Additional review revealed, the required State Agencies had not been notified due to not being necessary or feasible. Continued review of the Facility Fall Investigation documentation revealed no documented evidence the facility performed a root cause analysis of Resident #2's fall. Per review, the facility noted Resident #2 fell from his/her bed after returning from the ER and sustained a head injury. Review further revealed no documentation to support the facility had taken corrective action. Review of the trauma hospital's medical record for Resident #2 dated [DATE], revealed the resident arrived at the Level 1 Trauma Center via helicopter on [DATE] at 9:25 PM, status post fall. Continued review revealed Resident #2 was reportedly found down in a large pool of blood, and there was no report of the resident striking his/her head on objects aside from the floor. Per review, Resident #2 was life-flighted (transported by helicopter) to the Trauma Center, intubated and had posturing (indicative of severe brain or spinal injury). Review revealed Resident #2's injuries included a large right Subdural Hematoma status post right craniotomy on [DATE], diffuse Subarachnoid Hemorrhage (SAH), Facial Lacerations, Right Face and Front temporal Hematoma, Right Femoral Neck Fracture, and Left Corneal Laceration status post repair on [DATE]. Further review revealed a Tracheostomy was placed on [DATE] per the family's wishes, and Resident #2 died on [DATE], due to trauma related to the fall. Review of the Autopsy Report for Resident #2 dated [DATE], revealed the preliminary diagnoses included: Blunt force injuries to the head sustained in a fall; Fracture of Right Temporal Bone; Right Temporal Extradural and Thin Subdural Hemorrhages; Left Temporal Subarachnoid Hemorrhage. Continued review of the Autopsy Report revealed Resident #2 had delayed death status post-medical intervention, and toxicology was not performed due to the duration of the hospital stay. Further review of the report revealed the focused exam information noted Resident #2 had experienced an internal bleed of the head. Interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 11:50 AM, revealed Resident #2 required total assistance and had returned from the hospital at approximately 7:10 PM on [DATE]. CNA #1 stated at approximately 7:15 PM, LPN yelled for help due to Resident #2 being found lying on the floor. Continued interview revealed CNA #1 did not witness Resident #2's fall and had not been fully aware of the resident's care plan interventions, specific to falls. Further interview revealed however, she felt all residents were at risk for falls and should be monitored and reviewed to protect the resident from injury. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 10:12 AM, revealed Resident #2 had a history of Urinary Tract Infections (UTIs) with mental status changes. She further stated the resident should have been care planned for his/her mental status changes and should have been monitored more closely. LPN #1 further revealed that on [DATE], Resident #2 was transferred to the hospital due to his/her mental status changes. She stated Resident #2 returned to the facility between 7:00 PM and 7:10 PM on [DATE], the same day,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's policy and Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's administration's failure to follow its policies in preventing falls and ensure the safety of residents assessed as at high risk for falls resulted in injury for five (5) of nine (9) sampled residents, Residents #1, #2, #3, #7 and #8. Interviews with the Administrator, Director of Nursing (DON), and Minimum Data Set (MDS) Coordinator revealed they participated in the facility's Interdisciplinary Team (IDT) meetings. However, the IDT failed to follow the facility's falls policy to include: analysis of the contributing factors that lead to residents' falls; and developing appropriate action plans specific to those residents. The IDT further failed to ensure residents assessed to be at risk for falls were care planned with necessary interventions according to their assessed needs. The facility's failure to be administered in a manner which enabled effective use of its resources has caused or is likely to cause serious harm, impairment, or death of a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 11/23/2022, and was determined to exist on 11/06/2021, in the areas of 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices (F689); at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Care Plan Timing and Revision (657); at 42 CFR 483.70 Administration (F835); and at 42 CFR 483.75 Quality Assurance and Performance Improvement, Quality Assurance and Performance Improvement Program/Plan, Disclosure/Good Faith Attempt (F865) all at a S/S of K. The facility was notified of the Immediate Jeopardy on 11/23/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 12/05/2022, with the facility alleging removal of the Immediate Jeopardy on 11/30/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 11/30/2022, prior to exit on 12/08/2022. (refer to F656, F689, and F865) The findings include: Review of the facility's Job Description for the, Administrator, undated, revealed the Administrator led and directed the overall operations of the facility in accordance with residents' needs, federal and state government regulations, and company policies to maintain quality care for residents while achieving the facility's business objectives. Per review, the Administrator's essential job duties included conducting regular rounds to ensure staff addressed residents' needs and to monitor operations of all departments. Continued review revealed the Administrator ensured adequate staffing through the development of recruitment sources, and managed turnover through appropriate selection, orientation, training and staff education. Review revealed additional roles and responsibilities of the Administrator included recognizing potential hazards and monitoring personnel to ensure safety procedures were followed. Further review revealed the Administrator ensured the understanding of and compliance with all rules regarding residents' rights. In addition, the Administrator was to work with the facility's management staff and consultants in planning all aspects of the facility's operations, including setting priorities and job assignments. Review of the facility's policy entitled, Managing Incidents and Fall, undated, revealed all residents would benefit from a safe environment and an individualized plan of care. Review of the policy revealed the facility was to provide timely analysis of falls/incidents to determine possible contributing factors and/or trends. Continued review revealed the facility was also to develop and implement reasonable and appropriate action plans and resident specific care plans in order to identify interventions which reduced the potential of future falls/incidents. Further review revealed the facility was to: identify high-risk residents; ensure complete assessment and care planning for residents; provide for analysis of underlying systems issues and develop performance improvement plans, and communicate the plans to appropriate staff through orientation, in-services, staff meetings, shift report, and care planning. Interview with Certified Nursing Assistant (CNA) # 6 on 11/21/2022 at 10:42 AM, revealed she was unaware of Resident #7's care plan, and stated she did not know the resident was a falls risk. CNA #6 revealed she should have used the [NAME] (CNAs care plan) to care for Resident #7. Additionally, she stated it was important to know residents' care plan interventions to prevent a fall because it could cause a safety concern, and added the resident could get hurt. Interview with Registered Nurse (RN) #1 on 11/01/2022 at 3:48 PM, revealed when a resident had a change of condition, she would not revise the resident's care plan to implement additional interventions. RN #1 revealed she waited until she notified the Director of Nursing (DON) or Minimum Data Set (MDS) Coordinator of resident's change in condition. Further interview revealed it was important to revise residents' care plans with immediate changes, related to falls, to prevent an injury. Interview with the Minimum Data Set (MDS) Coordinator on 11/21/2022 at 2:50 PM, revealed he was part of the IDT that went over residents' falls, the day after residents experienced a fall. He stated it was the responsibility of the direct care nurse to update/revise residents' care plans when a resident had a change of condition and/or fall. Continued interview revealed it was important for the direct care nurse to revise the residents' care plans to ensure the safety of the residents. Further interview revealed the IDT would review all interventions put in place by the direct care nurse, and monitor to ensure the interventions were effective. Interview further revealed however, he was unaware of any auditing process or tool the facility utilized to ensure care plan revisions were implemented and/or effective. Interview with the Director of Nursing (DON) on 10/26/2022 at 11:26 AM, revealed when a resident sustained a fall, nursing completed an incident report, investigated the incident and notified the guardian and Physician. She stated the Interdisciplinary Team (IDT) reviewed the incident reports for residents' falls the next morning, and reviewed the residents' care plans and interventions and implemented additional interventions if needed, to include a therapy screen if the resident was not already receiving therapy. Continued interview revealed the IDT met for three (3) days after a resident's fall to follow up and communicate any concerns. Interview further revealed seven (7) days after the fall, the IDT then collaborated and determined if the interventions implemented were working and were appropriate. Further interview revealed however, the facility's IDT did not audit residents' care plan interventions to ensure the effectiveness of the interventions. Interview with the Administrator on 11/21/2022 at 4:05 PM, revealed the facility utilized and implemented several fall resources, such as utilizing the falls risk assessment and following its falls management procedures. She stated the IDT and Medical Director were involved with developing a plan to reduce the number of residents' falls within the facility. Further interview revealed however, the facility did not audit or monitor to ensure the interventions implemented were effective. Interview with the Regional Nurse Consultant (RNC) on 12/08/2022 at 7:13 PM, revealed it was the Administrator's responsibility to watch, identify patterns, analyze, and implement changes based on the facility's findings for improvement. He stated the IDT were to collaborate and figure out what the root cause of the falls were, and then decide what action plan to initiate. Further interview revealed the RNC served as part of the team to provide education/training for all staff regarding the care plan process, function, timing, how to retrieve, and ensured the audit information was taken to share with the facility. ****The facility provided an acceptable Immediate Jeopardy Removal Plan on 12/05/2022, alleging removal of the Immediate Jeopardy on 11/30/2022. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. On 11/28/2022, corrective action(s) were accomplished for those residents found to have been affected by the same deficient practice (Resident's #1, #2, #3, #7, and #8): (a) Resident #1 no longer resided at the facility; Resident #2 no longer resided at the facility; and Resident #3 no longer resided at the facility. (b) On 11/28/2022, an audit of Resident #7's care plan was completed by the MDS Nurse related to the resident's use of anti-coagulant therapy as related to falls. Resident #7's care plan was revised on 11/27/2022, by the RN Weekend Supervisor related to the resident's current one-on-one (1:1) supervision. (c) On 11/21/2022, the Charge Nurse revised and updated Resident #8's care plan to include appropriate interventions to prevent falls related to: the resident's continued refusal to wear a mobilizer boot on his/her right lower extremity; and refusing wear of non-skid slippers. Resident #8's care plan was updated to include a new mattress being placed on his/her bed as the resident stated he/she had slid off the mattress which caused his/her fall. In addition, Resident #8 had the non-compliant care plan updated on 11/21/22, by the MDS Coordinator. (d) On 11/28/2022, the facility implemented the MDS Coordinator continuing to monitor the falls care plans and update the care plans based on the resident's Fall Risk assessments completed on admission, re-admission, with a change of condition, a fall or quarterly. 2. On 11/28/2022, an audit was conducted of residents at risk for falls, and the facility identified and implemented corrective actions for residents residing in the facility and at risk for falls with the potential to be affected by the same deficient practice: a) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit review of all residents that had falls in the last three (3) months. (b) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit of any residents identified as having two (2) or more falls, or residents who had a fall with significant injury over the last three (3) months. The audit included ensuring those falls were reviewed to ensure (as much as possible, considering the length of time since the fall), that they had been investigated and that a root cause had been defined for residents that had a fall in the last three (3) months. (c) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit to ensure appropriate assessments had been done post fall and that therapy screened the residents post fall. Additionally, the audit included ensuring the residents' care plans were revised to include any enhanced supervision and/or assistive devices needed by the resident to prevent falls/accidents. (d) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit to ensure that Action Plans had been implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. (e) On 11/28/2022, the facility implemented a corrective action for residents who had a fall to ensure those residents were reviewed in the weekly Falls Meeting until the IDT decided that the residents' falls had been managed and they were no longer at HIGH RISK for falls. In addition, some residents might remain on the Falls Meeting list indefinitely for long-term monitoring purposes and based on their Falls Risk score. All falls were to be reviewed at the next daily, Monday through Friday (M-F) morning Clinical Quality Indicator (CQI) meeting following the fall to ensure that all post fall protocols were followed. (f) Beginning 11/28/2022, the facility implemented an additional corrective action for the DON/Unit Manager to monitor all falls post fall as well as, at the Falls Meetings weekly. In addition, the Nurse Consultant for the facility would be notified either in person or remotely of any fall sustained by any resident to offer guidance and input. 3. Beginning 11/23/2022, the facility additionally implemented corrective measures to promote systemic changes that ensure the deficient practice would not recur (a) On 11/28/2022, the facility implemented a systemic schedule that all falls would be reviewed at the next daily, M-F CQI meeting following the fall at this time, it would be determined if all post fall protocols were followed. Any concerns would be addressed. (b) Beginning 11/23/2022, the Administrator/DON/UM, with input from the RNC conducted an in-service training for all staff that reviewed: the Falls Policy; what to do if you (in your role) witness a resident who had fallen; Nurses: what to do when a resident fell; why it was important to identify the root cause of a fall; what are FALL INTERVENTIONS; care plans/CNA's assignment sheets related to falls; action plans rolled out with a focus on falls; questions/answers. (c) Beginning 11/23/2022, the Administrator/DON/UM ensured staff knowledge was measured by a POST TEST performance that required 100% accuracy of the answers to pass. Any staff who failed to comply with the points of the in-service would be further educated and/or progressively disciplined as indicated. In addition, no staff would work prior to receiving the in-service after 11/28/22, this included any newly hired staff, agency staff, prn staff or any staff on any type of leave or vacation. 4. On 11/28/2022, the facility implemented a monitoring system of the corrective actions to ensure the deficient practice did not recur, (i.e., what Quality Assurance Program would be put into place and by what date the systemic changes for each deficiency would be completed). (a) Beginning 11/28/2022, the DON/Unit Manager were to review all falls at the next daily CQI meeting held M-F, to ensure that all post fall protocols were followed per policy and regulation. (b) On 11/28/2022, the daily CQI meeting was held and consisted of the Administrator, DON, UM, MDS, SSD, and Rehab Director and all residents who were at HIGH RISK for falls were to be discussed at the weekly Falls Meeting, until the IDT, decided that the residents' falls had been managed and the resident was no longer a HIGH RISK for falls. (c) On 11/28/2022, the results of the falls monitoring from the daily (M-F) CQI meetings as well as the weekly Falls Meetings were to be presented by the DON/Unit Manager at the weekly then monthly QAPI meetings. Any concerns or patterns were to be addressed and identified. (d) On 11/28/2022, if needed, an Action Plan/PIP was to be written by the QAPI Committee with input from the Regional Team. Any written Action Plan/PIP was to be monitored weekly by the Administrator until resolved. (e) On 11/28/2022, the facility also implemented a member of the Regional Team to attend the QAPI meetings either in person or remotely weekly, then monthly for three (3) months. The Regional Team members were to serve as a reference and additional oversight. The facility's QAPI Committee Members include: the Administrator, DON, ADON and/or Unit Manager, MDS Coordinator, Business Office Manager, Social Services Designee, Dietary Manager, Activities Director, Rehab Director, Maintenance Director, Housekeeping/Laundry Supervisor, RVP/RDO/RNC/MDS Consultant (might attend if present), Pharmacy Consultant/Dietician (might attend if present), and the Medical Director/Nurse Practitioner. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 11/30/2022 1. (a) Review of the facility's documentation and medical record review revealed Resident #1, Resident #2, and Resident #3 no longer resided at the facility. (b) Review of the facility's documentation and care plans revealed on 11/28/2022, an audit of Resident #7's care plan was completed by the MDS Nurse to reflect the resident's use of ant-coagulation therapy as related to falls, and the care plan had been revised on 11/27/2022, by the RN Weekend Supervisor related to resident's current one-on-one (1:1) supervision. Continued review of Resident #7's care plan revealed resident centered goals for fall prevention and interventions in place as alleged. Observation of Resident #7 on 12/07/2022 at 9:13 AM and 12/08/2022 at 2:45 PM, revealed the resident in a room across from the nursing station, resting in a low bed with neon tape on the call light and 1:1 supervision, as care planned. Interview on 12/08/2022 at 4:09 PM, with the RN Weekend Supervisor revealed she had revised and updated Resident #7's care plan on 11/27/2022, related to 1:1 supervision. (c) Review of Resident #8's care plan revealed revisions were made to include appropriate interventions to prevent falls including the resident's refusal to: wear a mobilizer boot on his/her right lower extremity and non-skid slippers, and new mattress applied to his/her bed. In addition, review of Resident #8's care plan revealed a non-compliant care plan updated on 11/21/22, by the Charge Nurse and MDS Coordinator. Observation of Resident #8 on 12/07/2022 at 09:24 AM, revealed he/she was resting in a low bed with a new mattress in place, and wearing non-skid socks. (d) Review of the facility's documentation and interview with the Unit Manager (UM) on 12/08/2022 at 09:42 AM revealed she and the MDS Coordinator reviewed and updated the falls care plans based on the residents Fall Risk assessments completed upon admission, re-admission, quarterly, change of condition, or a fall. The DON was not available for interview. 2. (a) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit review of all residents that had falls in the last three (3) months. Interview with UM for both units on 12/08/2022 at 9:42 AM revealed she and the DON and MDS conducted audits to ensure all residents had falls assessments completed in the last quarter, with any resident found to be high risk for falls receiving updates to their care plan. She further stated they also looked back 90 days to 08/22/2022 to determine that the residents who fell had correct interventions in place, consistent with the cause of the fall. The DON was not available to to interview due to illness and the MDS Coordinator was not available due to having surgery. (b) Review of the facility's documentation of residents at risk for falls and care plan audits dated 11/28/2022 through 12/06/2022, revealed the audits were completed as alleged of residents identified as having two (2) or more falls, or residents who had a fall with significant injury over the last three (3) months. Review of the facility documents additionally revealed those residents falls had been investigated and a root cause analysis had been identified with planned interventions implemented and monitored. Interview with the UM on 12/08/2022 at 09:42 AM revealed she and the MDS coordinator completed fall care plan audits including a lookback timeframe of three (3) months, from 08/22/2022. (c) Review of residents' Electronic Medical Record (EMR) review revealed assessments had been completed post fall and therapy had screened residents post fall. Continued review revealed the care plans were revised to include any enhanced supervision and/or assistive devices needed by the resident to prevent falls/accidents. (d) Review of the facility's audit tools and documentation revealed the DON, UM, and MDS Coordinator conducted a facility wide audit beginning 11/28/2022 to ensure that Action Plans were implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. Interview with the UM on 12/08/2022 at 09:42 AM revealed she, the DON and MDS Coordinator completed facility audits across the facility to ensure the action plans were implemented. (e) Interview with UM on 12/08/2022 at 9:42 AM revealed the QAPI team had been through every residents' record for fall risk and anticoagulant, and have added to care plans for bleeding risk and they process falls everyday. Further interview revealed residents who have had falls were reviewed during weekly falls meeting and continued until determined they were no longer high risk or if high risk continued, those residents would continue to be reviewed long term Interview with Administrator on 12/08/2022 at 7:33 PM revealed falls were reviewed at daily clinical meeting, with the goal of being sure the post fall protocol was followed for any fall and to be sure the care plan was updated with an intervention after a fall occurred. Interview also revealed continued monitoring for residents with high risk for falls at weekly meeting. Review of the facility's CQI meeting sign in sheet and corresponding agendas, dated 11/28/2022 through 12/02/2022, revealed the daily (M-F) meetings included discussion and review of residents' falls post fall as alleged, with the DON/Unit Manager as alleged. Interview on 12/08/2022 at 7:33 PM, with the Administrator revealed residents' care plans were revised immediately for antibiotic, skin concerns or any recent falls. The Administrator stated for the residents' comprehensive care plans, the facility utilized a tool's form, which included updated physician's orders. She further stated the managers for the unit would bring the tool to CQI to make sure the residents' care plans were revised or amended with actions discussed as needed. (f) Interview with administrator on 12/08/2022 at 7:33 PM revealed falls were reviewed at daily clinical meeting, with the goal of being sure the post fall protocol was followed for any fall and to be sure the care plan was updated with an intervention after a fall occurred. Interview further revealed the DON and UM were monitoring falls on a weekly basis for four (4 ) weeks, subsequent to that would monitor three (3) falls weekly for at least six (6) months and this would be reviewed by regional staff. Interview on 12/08/2022 at 7:13 PM, the RNC revealed he had been providing direct oversight as alleged. 3. (a) Interview on 12/08/2022 at 9:42 AM, with the UM revealed beginning 11/28/2022, during the daily (M-F) CQI meeting, falls were the designated topic with daily discussion and review to determine if all post fall protocols were followed, and all concerns were addressed. (b) Review of the facility's, In-Service Falls Education Record revealed beginning 11/23/2022, the education had been provided as alleged for all staff regarding the Falls Policy; what to do if staff witnessed a resident who had fallen; for Nurses on what they should do when a resident fell; why it was important for staff to identify the root cause of a fall; what the fall interventions were; review and update of care plans/CNA's assignment sheets related to falls; and action plans rolled out with a focus on falls. Further review revealed the Administrator, DON, and UM, with input from the RNC, conducted the in-service training for all staff. Interview on 12/08/2022 at 4:09 PM with RN #2; at 4:58 PM with LPN #1; at 4:35 PM with CNA #4, and at 6:42 PM with RN #3 and CNA #2 revealed they had been provided the education as alleged and had taken a test afterwards. (c) Review of the facility's post-tests information for the education provided for staff in all departments and the IDT team revealed all had taken the test and scored 100% as alleged. Interview on 12/08/2022 at 10:28 AM, with the HR Director revealed the education had been provided along with the POST TEST and requirement of 100% accuracy to pass the test. Continued interview revealed no staff worked prior to receiving the in-service after 11/28/2022, which included any newly hired staff, agency staff, prn (as needed) staff or any staff on any type of leave or vacation as alleged. Further interview revealed the education had been provided by the Administrator, DON, and UM with input and participation from the RNC. 4. (a) Review of the facility's CQI meeting sign in sheets and corresponding agendas, dated 11/28/2022 through 12/02/2022, revealed the daily (M-F) meeting the DON/Unit Manager reviewed and discussed the post fall protocols being followed as per policy and regulation as alleged. Review of the facility's QAPI sign-in sheet and corresponding agenda dated 11/28/2022, revealed the meeting discussion included but not limited to the facility's system wide corrective actions implemented to ensure the deficient practice did not recur and date the systemic changes for each deficiency would be completed. Review of clinical records of sampled residents and training record review revealed the trainings were consistent with the removal plan. Review of QAPI documentation revealed membership, attendance, content and goals consistent with stated intent. Additional review revealed QAPI committee consisted of the Administrator, Director of Nursing (DON), Unit Manager (UM), Minimum Data Set (MDS), Business Office Manager (BOM), Social Service Director (SSD), Dietary Manager, Directors of Activities, Rehabilitation Director, Maintenance, Housekeeping/laundry supervisor, and the Medical Director/Nurse Practitioner. Further review of QAPI revealed committee developed audit tool to track education and monitoring. Interview with the Business Office Manager (BOM) on 12/08/2022 9:25 AM revealed QAPI works to resolve problems facility wide such as safety and falls. Additional interview revealed QAPI reviewed new tools for safety and fall prevention, and also discussed the two (2) falls for IJ at the last QAPI meeting. Interview with the UM on 12/08/2022 at 9:42 AM revealed the QAPI team has been through every resident record for fall risk and use of anticoagulant, and have added to care plans for bleeding risk. Interview revealed the last QAPI was this morning and they process falls everyday. (b) Review of the facility's CQI meeting sign in sheets and corresponding agendas revealed a CQI meeting was held on 11/28/2022, as alleged with the Administrator, DON, MDS, SSD, Unit Manager (UM), and Rehab Director. Continued review revealed it was determined all residents assessed as at HIGH RISK were to be discussed in the weekly Falls Meeting until the IDT decided a resident's falls had been managed and he/she was no longer a HIGH RISK for falls. Further review of the CQI information through 12/06/2022, revealed the members continued discussion of the same topics. Interview on 12/08/2022 at 11:23 AM with the SSD; and at 11:55 AM with the Rehab Director revealed they had participated in the daily CQI meeting, starting on 11/28/2022, discussion of audit reports of residents who were at HIGH RISK for falls which was discussed at the weekly Falls Meeting. Further interview revealed the review and discussion of HIGH RISK for falls residents continued in the weekly Falls Meeting until the IDT decided the residents' falls had been managed and the residents were no longer a HIGH RISK for falls. (c) Review of the facility's QAPI meeting sign in sheets and corresponding agendas revealed beginning on 11/28/2022, revealed the DON/Unit Manager (UM) presented the results of the falls monitoring from the daily (M-F) CQI meetings and Falls Meetings to the QAPI Committee. Continued review revealed it was determined all residents assessed as at HIGH RISK were discussed in the weekly Falls Meeting until the IDT decided a resident's falls had been managed and he/she was no longer a HIGH RISK for falls. Further review of the QAPI meeting information through 12/06/2022, revealed the DON/UM continued presenting and discussing of the same topics. Interview with the UM on 12/08/2022 Interview with the Administrator on 12/08/2022 at 7:33 PM revealed the DON and UM were monitoring falls on a weekly basis for four (4) weeks, subsequent to that would monitor three (3) falls weekly for at least six (6) months and would be reviewed by regional staff. (d) Review of the facility's audit tools revealed the DON/UM/MDS Coordinator conducted a facility wide audit beginning 11/28/2022 to ensure that Action Plans were implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. Interview on 12/08/022 at 7:33 PM, with the Administrator revealed results of the falls audit/monitoring were being reviewed in the CQI meetings as well as the weekly Falls Meetings, and if an Action Plan/PIP was needed the QAPI Committee would write it with input from the Regional Team. The Administrator further stated she would participate in the development of any written Action Plan/PIP, and monitor it until it was determined to be resolved. (e) Interview on 12/08/022 at 7:33 PM, with the Administrator revealed the facility's QAPI Committee members included herself, the DON, ADON and/or Unit Manager, MDS Coordinator, Business Office Manager, Social Services Designee, Dietary Manager, Activities Director, Rehab Director, Maintenance Director, Housekeeping and Laundry Supervisor. Continued interview revealed others who might attend if present in the facility at the time of the meeting were: the RVP, RDO, RNC, MDS Consultant, Pharmacy Consultant, Dietician, and Medical Director and/or Nurse Practitioner. Further interview revealed a member of the Regional Team had attended the QAPI Committee meetings either in person or remotely on a weekly basis. The Administrator further revealed the Regional Team's participation would decrease to every three (3) months, as determined by them, to provide additional oversight and serve as a reference for the facility. Interview on 12/08/2022 at 7:13 PM, with the Regional Nurse Consultant (RNC) revealed beginning 11/28/2022, he had been attending the facility's QAPI Committee meetings weekly either in person by remotely to provide direct oversight and act as a reference for the facility. Interview on 12/02/2022 at 6:18 PM, with the Medical Director revealed the facility held a QAPI meeting on 11/28/2022, and continued the meetings weekly. Per the Medical Director, she attended in person or remotely with the facility by phone for the QAPI Committee meetings. Continued interview revealed however, there were times when she was tied to activity at the hospital and could not attend the QAPI meetings. The Medical Director stated if she was unable to attend the meetings in person or remotely, she went over the actions discussed and taken by the QAPI Committee. Further interview revealed the facility's QAPI Committee would continue meeting weekly and move to monthly as determined by the need. In addition, the Medical Director stated during the QAPI Committee meetings there was discussion of falls and incidents, identification of the root cause, review of any removal plan, and ongoing monitoring.

Based on observation, interview, record review, and review of the facility's policy, investigations, and documentation, it was determined the facility failed to implement their Quality Assurance Performance Improvement (QAPI) program to ensure the identification of opportunities for improvement in the care and services provided to residents. The facility's QAPI process failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards of quality of care regarding performance improvement measures were sustained. As a result the facility's QAPI program failed to develop, implement, and monitor to identify issues with supervision of residents in prevention of falls. (Refer to F657, F689, and F835) The facility's QAPI program's failures allowed forty-one (41) falls to be sustained by its residents during a five (5) month look back period, with two (2) of the residents' falls resulting in death, Resident #1 and Resident #2. In addition, three (3) of the residents' falls resulted in injuries to the residents, Residents #3, #7, and #8. The facility's failure to ensure the implementation of its QAPI process has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 11/23/2022, and was determined to exist on 11/06/2021, in the areas of 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices (F689); at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Care Plan Timing and Revision (F657); at 42 CFR 483.70 Administration (F835); and at 42 CFR 483.75 Quality Assurance and Performance Improvement, Quality Assurance and Performance Improvement Program/Plan, Disclosure/Good Faith Attempt (F865) all at a Scope and Severity (S/S) of K'. The facility was notified of the Immediate Jeopardy on 11/23/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 12/05/2022, with the facility alleging removal of the Immediate Jeopardy on 11/30/2022. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on 11/30/2022, prior to exit on 12/08/2022. The findings include: Review of the facility's policy titled, Quality Assurance and Improvement, undated, revealed the facility's QAPI program represented the facility's commitment to continuous quality improvement. Per policy review, the QAPI program ensured a systemic performance evaluation, problem analysis, and implementation of improvement strategies to achieve performance goals. Continued review revealed the QAPI committee's oversight responsibilities included: annual review of the facility's QAPI program; the establishment of Performance Improvement Projects (PIP) subcommittees; ensure the subcommittees had adequate resources to conduct their projects; submit findings of performance improvement (PI) projects to the chairperson which was to include a summary of QAPI project activities and findings; utilize facility data to identify opportunities to improve the facility's systems and care. Further review revealed the data might include: grievance logs; medical record reviews; skilled care claims; falls and pressure ulcer logs; treatment logs; staffing trends; incident and accident reports; and quality measures and survey outcomes. Review of the facility's, Job Description for the Administrator, undated, revealed the Administrator was responsible for the facility's Quality Assurance (QA) Program. Further review revealed the Administrator was to identify and participate in the process improvement initiatives which would improve the residents' experience, enhance workflow, and/or improve the work environment. Review of the facility's Quality Assurance (QA) Committee meeting documentation revealed meetings had been held on at least a monthly basis. Continued review revealed the QA Committee attendees included, but were not limited to the Administrator, the Medical Director, and the Director of Nursing (DON). Interview with the MDS Coordinator on 11/21/2022 at 2:50 PM, revealed he was part of the facility's QA team that met monthly regarding the facility's PI processes. He stated the QA Committee discussed the number of resident falls and the root cause of the falls. Further interview revealed the Administrator led the QA meetings and nursing notes were often reviewed. The MDS Coordinator further stated however, the facility had no system in place to audit or monitor the progress or effectiveness of the discussed interventions for fall prevention. Interview with the Medical Director on 12/08/2022 at 6:13 PM, revealed she was notified of falls which occurred in her own residents, and for other residents experiencing falls, she went over the details of those falls during the QAPI meetings. Per the Medical Director, the QAPI Committee discussed the root cause of falls and implemented strategies to prevent falls and reduce the impact of injury. Further interview revealed however, she felt the care had been provided for residents, but not documented as fully as needed to be. The Medical Director further stated she felt good about the overall care of residents after having issues identified during the survey investigation, and also felt there had been improved documentation, and communication in response to the new processes now implemented. Interview with the Director of Nursing (DON) on 11/17/2022 at 5:19 PM, revealed she attended the facility's monthly QAPI meetings and was an active participant of the QA Committee. Per interview, she was also involved in the facility's Clinical Morning Meetings which occurred Monday through Friday. The DON stated she conducted ongoing rounds in the facility to monitor for QA issues, and for regulatory compliance for all nursing practices and protocols. Continued interview revealed she worked closely with the Administrator for guidance and support related to clinical QA. According to the DON, the current falls of residents were discussed by the QA Committee; however, did not recall if any look back of all the falls was discussed. Further interview revealed the DON also did not recall if an audit of care plans was discussed to validate appropriate interventions had been implemented related to identifying the root cause of the fall. The DON further stated the QA Committee had not identified any concerns with the clinical systems in the facility. In addition, she stated she provided support for the facility's staff and ensured the safety and well-being of residents to promote quality of care. Interview with the Administrator on 11/21/2022 at 4:05 PM, revealed the facility's QAPI Committee met monthly, and discussed any clinical concerns brought to the QAPI Committee meetings. The Administrator revealed it was her responsibility to ensure all facility processes established by its Governing Body were maintained, including the facility's Quality Assessment and Assurance (QAA) and QAPI programs. Continued interview revealed the facility discussed the number of falls in the QAPI Committee meetings, and the DON and Medical Director were involved with that. She stated a Performance Improvement Plan (PIP) had been developed to decrease the number of resident falls within the facility, and the overall falls within the facility had decreased as a result. However, review of the facility's falls incident reports with the Administrator and SSA Surveyor revealed the number of falls within the facility increased over the last five (5) month review period. Further interview revealed the facility did not have a system in place to audit or monitor the effectiveness of the PIP implemented. Interview with the Regional Nurse Consultant (RNC) on 12/08/2022 at 7:13 PM, revealed the QAPI plan implemented should intervene and assist the facility in establishing relevant guidelines and policies for falls, fall assessments, care planning and implementation of action plans for falls. The RNC revealed the QAPI plan also assisted with root cause analysis, performance improvement plan and action plans. Continued interview revealed the facility's QAPI assisted with developing the goals and how to track response. Per interview, the RNC's duties included communication of the facility's QAPI actions to regional staff, and the Governing Body. According to the RNC, the facility's new QAPI process resulting from the outcome of the identified deficient practice was improved identification of issues during a weekly meeting which allowed for less time to pass between taking extra steps and being effective for residents's safety. Per the RNC, it was the Administrator's responsibility to watch, identify patterns, analyze, and implement changes based on the findings. He stated the IDT were to collaborate and figure out what the root cause of the falls was, and then decide what action plan to initiate. Further interview revealed the RNC served as part of the team to provide education/training for all staff regarding the care plan process, function, timing, how to retrieve, and ensured the audit information was taken to the facility's QAPI meeting every week and continued at the monthly QAPI meetings. ****The facility provided an acceptable Immediate Jeopardy Removal Plan on 12/05/2022, alleging removal of the Immediate Jeopardy on 11/30/2022. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. On 11/28/2022, corrective action(s) were accomplished for those residents found to have been affected by the same deficient practice (Resident's #1, #2, #3, #7, and #8): (a) Resident #1 no longer resided at the facility; Resident #2 no longer resided at the facility; and Resident #3 no longer resided at the facility. (b) On 11/28/2022, an audit of Resident #7's care plan was completed by the MDS Nurse related to the resident's use of anti-coagulant therapy as related to falls. Resident #7's care plan was revised on 11/27/2022, by the RN Weekend Supervisor related to the resident's current one-on-one (1:1) supervision. (c) On 11/21/2022, the Charge Nurse revised and updated Resident #8's care plan to include appropriate interventions to prevent falls related to: the resident's continued refusal to wear a mobilizer boot on his/her right lower extremity; and refusing wear of non-skid slippers. Resident #8's care plan was updated to include a new mattress being placed on his/her bed as the resident stated he/she had slid off the mattress which caused his/her fall. In addition, Resident #8 had the non-compliant care plan updated on 11/21/22, by the MDS Coordinator. (d) On 11/28/2022, the facility implemented the MDS Coordinator continuing to monitor the falls care plans and update the care plans based on the resident's Fall Risk assessments completed on admission, re-admission, with a change of condition, a fall or quarterly. 2. On 11/28/2022, an audit was conducted of residents at risk for falls, and the facility identified and implemented corrective actions for residents residing in the facility and at risk for falls with the potential to be affected by the same deficient practice: a) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit review of all residents that had falls in the last three (3) months. (b) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit of any residents identified as having two (2) or more falls, or residents who had a fall with significant injury over the last three (3) months. The audit included ensuring those falls were reviewed to ensure (as much as possible, considering the length of time since the fall), that they had been investigated and that a root cause had been defined for residents that had a fall in the last three (3) months. (c) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit to ensure appropriate assessments had been done post fall and that therapy screened the residents post fall. Additionally, the audit included ensuring the residents' care plans were revised to include any enhanced supervision and/or assistive devices needed by the resident to prevent falls/accidents. (d) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit to ensure that Action Plans had been implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. (e) On 11/28/2022, the facility implemented a corrective action for residents who had a fall to ensure those residents were reviewed in the weekly Falls Meeting until the IDT decided that the residents' falls had been managed and they were no longer at HIGH RISK for falls. In addition, some residents might remain on the Falls Meeting list indefinitely for long-term monitoring purposes and based on their Falls Risk score. All falls were to be reviewed at the next daily, Monday through Friday (M-F) morning Clinical Quality Indicator (CQI) meeting following the fall to ensure that all post fall protocols were followed. (f) Beginning 11/28/2022, the facility implemented an additional corrective action for the DON/Unit Manager to monitor all falls post fall as well as, at the Falls Meetings weekly. In addition, the Nurse Consultant for the facility would be notified either in person or remotely of any fall sustained by any resident to offer guidance and input. 3. Beginning 11/23/2022, the facility additionally implemented corrective measures to promote systemic changes that ensure the deficient practice would not recur (a) On 11/28/2022, the facility implemented a systemic schedule that all falls would be reviewed at the next daily, M-F CQI meeting following the fall at this time, it would be determined if all post fall protocols were followed. Any concerns would be addressed. (b) Beginning 11/23/2022, the Administrator/DON/UM, with input from the RNC conducted an in-service training for all staff that reviewed: the Falls Policy; what to do if you (in your role) witness a resident who had fallen; Nurses: what to do when a resident fell; why it was important to identify the root cause of a fall; what are FALL INTERVENTIONS; care plans/CNA's assignment sheets related to falls; action plans rolled out with a focus on falls; questions/answers. (c) Beginning 11/23/2022, the Administrator/DON/UM ensured staff knowledge was measured by a POST TEST performance that required 100% accuracy of the answers to pass. Any staff who failed to comply with the points of the in-service would be further educated and/or progressively disciplined as indicated. In addition, no staff would work prior to receiving the in-service after 11/28/22, this included any newly hired staff, agency staff, prn staff or any staff on any type of leave or vacation. 4. On 11/28/2022, the facility implemented a monitoring system of the corrective actions to ensure the deficient practice did not recur, (i.e., what Quality Assurance Program would be put into place and by what date the systemic changes for each deficiency would be completed). (a) Beginning 11/28/2022, the DON/Unit Manager were to review all falls at the next daily CQI meeting held M-F, to ensure that all post fall protocols were followed per policy and regulation. (b) On 11/28/2022, the daily CQI meeting was held and consisted of the Administrator, DON, UM, MDS, SSD, and Rehab Director and all residents who were at HIGH RISK for falls were to be discussed at the weekly Falls Meeting, until the IDT, decided that the residents' falls had been managed and the resident was no longer a HIGH RISK for falls. (c) On 11/28/2022, the results of the falls monitoring from the daily (M-F) CQI meetings as well as the weekly Falls Meetings were to be presented by the DON/Unit Manager at the weekly then monthly QAPI meetings. Any concerns or patterns were to be addressed and identified. (d) On 11/28/2022, if needed, an Action Plan/PIP was to be written by the QAPI Committee with input from the Regional Team. Any written Action Plan/PIP was to be monitored weekly by the Administrator until resolved. (e) On 11/28/2022, the facility also implemented a member of the Regional Team to attend the QAPI meetings either in person or remotely weekly, then monthly for three (3) months. The Regional Team members were to serve as a reference and additional oversight. The facility's QAPI Committee Members include: the Administrator, DON, ADON and/or Unit Manager, MDS Coordinator, Business Office Manager, Social Services Designee, Dietary Manager, Activities Director, Rehab Director, Maintenance Director, Housekeeping/Laundry Supervisor, RVP/RDO/RNC/MDS Consultant (might attend if present), Pharmacy Consultant/Dietician (might attend if present), and the Medical Director/Nurse Practitioner. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 11/30/2022 1. (a) Review of the facility's documentation and medical record review revealed Resident #1, Resident #2, and Resident #3 no longer resided at the facility. (b) Review of the facility's documentation and care plans revealed on 11/28/2022, an audit of Resident #7's care plan was completed by the MDS Nurse to reflect the resident's use of ant-coagulation therapy as related to falls, and the care plan had been revised on 11/27/2022, by the RN Weekend Supervisor related to resident's current one-on-one (1:1) supervision. Continued review of Resident #7's care plan revealed resident centered goals for fall prevention and interventions in place as alleged. Observation of Resident #7 on 12/07/2022 at 9:13 AM and 12/08/2022 at 2:45 PM, revealed the resident in a room across from the nursing station, resting in a low bed with neon tape on the call light and 1:1 supervision, as care planned. Interview on 12/08/2022 at 4:09 PM, with the RN Weekend Supervisor revealed she had revised and updated Resident #7's care plan on 11/27/2022, related to 1:1 supervision. (c) Review of Resident #8's care plan revealed revisions were made to include appropriate interventions to prevent falls including the resident's refusal to: wear a mobilizer boot on his/her right lower extremity and non-skid slippers, and new mattress applied to his/her bed. In addition, review of Resident #8's care plan revealed a non-compliant care plan updated on 11/21/22, by the Charge Nurse and MDS Coordinator. Observation of Resident #8 on 12/07/2022 at 09:24 AM, revealed he/she was resting in a low bed with a new mattress in place, and wearing non-skid socks. (d) Review of the facility's documentation and interview with the Unit Manager (UM) on 12/08/2022 at 09:42 AM revealed she and the MDS Coordinator reviewed and updated the falls care plans based on the residents Fall Risk assessments completed upon admission, re-admission, quarterly, change of condition, or a fall. The DON was not available for interview. 2. (a) On 11/28/2022, the DON/UM/MDS Coordinator conducted a facility wide audit review of all residents that had falls in the last three (3) months. Interview with UM for both units on 12/08/2022 at 9:42 AM revealed she and the DON and MDS conducted audits to ensure all residents had falls assessments completed in the last quarter, with any resident found to be high risk for falls receiving updates to their care plan. She further stated they also looked back 90 days to 08/22/2022 to determine that the residents who fell had correct interventions in place, consistent with the cause of the fall. The DON was not available to to interview due to illness and the MDS Coordinator was not available due to having surgery. (b) Review of the facility's documentation of residents at risk for falls and care plan audits dated 11/28/2022 through 12/06/2022, revealed the audits were completed as alleged of residents identified as having two (2) or more falls, or residents who had a fall with significant injury over the last three (3) months. Review of the facility documents additionally revealed those residents falls had been investigated and a root cause analysis had been identified with planned interventions implemented and monitored. Interview with the UM on 12/08/2022 at 09:42 AM revealed she and the MDS coordinator completed fall care plan audits including a lookback timeframe of three (3) months, from 08/22/2022. (c) Review of residents' Electronic Medical Record (EMR) review revealed assessments had been completed post fall and therapy had screened residents post fall. Continued review revealed the care plans were revised to include any enhanced supervision and/or assistive devices needed by the resident to prevent falls/accidents. (d) Review of the facility's audit tools and documentation revealed the DON, UM, and MDS Coordinator conducted a facility wide audit beginning 11/28/2022 to ensure that Action Plans were implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. Interview with the UM on 12/08/2022 at 09:42 AM revealed she, the DON and MDS Coordinator completed facility audits across the facility to ensure the action plans were implemented. (e) Interview with UM on 12/08/2022 at 9:42 AM revealed the QAPI team had been through every residents' record for fall risk and anticoagulant, and have added to care plans for bleeding risk and they process falls everyday. Further interview revealed residents who have had falls were reviewed during weekly falls meeting and continued until determined they were no longer high risk or if high risk continued, those residents would continue to be reviewed long term Interview with Administrator on 12/08/2022 at 7:33 PM revealed falls were reviewed at daily clinical meeting, with the goal of being sure the post fall protocol was followed for any fall and to be sure the care plan was updated with an intervention after a fall occurred. Interview also revealed continued monitoring for residents with high risk for falls at weekly meeting. Review of the facility's CQI meeting sign in sheet and corresponding agendas, dated 11/28/2022 through 12/02/2022, revealed the daily (M-F) meetings included discussion and review of residents' falls post fall as alleged, with the DON/Unit Manager as alleged. Interview on 12/08/2022 at 7:33 PM, with the Administrator revealed residents' care plans were revised immediately for antibiotic, skin concerns or any recent falls. The Administrator stated for the residents' comprehensive care plans, the facility utilized a tool's form, which included updated physician's orders. She further stated the managers for the unit would bring the tool to CQI to make sure the residents' care plans were revised or amended with actions discussed as needed. (f) Interview with administrator on 12/08/2022 at 7:33 PM revealed falls were reviewed at daily clinical meeting, with the goal of being sure the post fall protocol was followed for any fall and to be sure the care plan was updated with an intervention after a fall occurred. Interview further revealed the DON and UM were monitoring falls on a weekly basis for four (4 ) weeks, subsequent to that would monitor three (3) falls weekly for at least six (6) months and this would be reviewed by regional staff. Interview on 12/08/2022 at 7:13 PM, the RNC revealed he had been providing direct oversight as alleged. 3. (a) Interview on 12/08/2022 at 9:42 AM, with the UM revealed beginning 11/28/2022, during the daily (M-F) CQI meeting, falls were the designated topic with daily discussion and review to determine if all post fall protocols were followed, and all concerns were addressed. (b) Review of the facility's, In-Service Falls Education Record revealed beginning 11/23/2022, the education had been provided as alleged for all staff regarding the Falls Policy; what to do if staff witnessed a resident who had fallen; for Nurses on what they should do when a resident fell; why it was important for staff to identify the root cause of a fall; what the fall interventions were; review and update of care plans/CNA's assignment sheets related to falls; and action plans rolled out with a focus on falls. Further review revealed the Administrator, DON, and UM, with input from the RNC, conducted the in-service training for all staff. Interview on 12/08/2022 at 4:09 PM with RN #2; at 4:58 PM with LPN #1; at 4:35 PM with CNA #4, and at 6:42 PM with RN #3 and CNA #2 revealed they had been provided the education as alleged and had taken a test afterwards. (c) Review of the facility's post-tests information for the education provided for staff in all departments and the IDT team revealed all had taken the test and scored 100% as alleged. Interview on 12/08/2022 at 10:28 AM, with the HR Director revealed the education had been provided along with the POST TEST and requirement of 100% accuracy to pass the test. Continued interview revealed no staff worked prior to receiving the in-service after 11/28/2022, which included any newly hired staff, agency staff, prn (as needed) staff or any staff on any type of leave or vacation as alleged. Further interview revealed the education had been provided by the Administrator, DON, and UM with input and participation from the RNC. 4. (a) Review of the facility's CQI meeting sign in sheets and corresponding agendas, dated 11/28/2022 through 12/02/2022, revealed the daily (M-F) meeting the DON/Unit Manager reviewed and discussed the post fall protocols being followed as per policy and regulation as alleged. Review of the facility's QAPI sign-in sheet and corresponding agenda dated 11/28/2022, revealed the meeting discussion included but not limited to the facility's system wide corrective actions implemented to ensure the deficient practice did not recur and date the systemic changes for each deficiency would be completed. Review of clinical records of sampled residents and training record review revealed the trainings were consistent with the removal plan. Review of QAPI documentation revealed membership, attendance, content and goals consistent with stated intent. Additional review revealed QAPI committee consisted of the Administrator, Director of Nursing (DON), Unit Manager (UM), Minimum Data Set (MDS), Business Office Manager (BOM), Social Service Director (SSD), Dietary Manager, Directors of Activities, Rehabilitation Director, Maintenance, Housekeeping/laundry supervisor, and the Medical Director/Nurse Practitioner. Further review of QAPI revealed committee developed audit tool to track education and monitoring. Interview with the Business Office Manager (BOM) on 12/08/2022 9:25 AM revealed QAPI works to resolve problems facility wide such as safety and falls. Additional interview revealed QAPI reviewed new tools for safety and fall prevention, and also discussed the two (2) falls for IJ at the last QAPI meeting. Interview with the UM on 12/08/2022 at 9:42 AM revealed the QAPI team has been through every resident record for fall risk and use of anticoagulant, and have added to care plans for bleeding risk. Interview revealed the last QAPI was this morning and they process falls everyday. (b) Review of the facility's CQI meeting sign in sheets and corresponding agendas revealed a CQI meeting was held on 11/28/2022, as alleged with the Administrator, DON, MDS, SSD, Unit Manager (UM), and Rehab Director. Continued review revealed it was determined all residents assessed as at HIGH RISK were to be discussed in the weekly Falls Meeting until the IDT decided a resident's falls had been managed and he/she was no longer a HIGH RISK for falls. Further review of the CQI information through 12/06/2022, revealed the members continued discussion of the same topics. Interview on 12/08/2022 at 11:23 AM with the SSD; and at 11:55 AM with the Rehab Director revealed they had participated in the daily CQI meeting, starting on 11/28/2022, discussion of audit reports of residents who were at HIGH RISK for falls which was discussed at the weekly Falls Meeting. Further interview revealed the review and discussion of HIGH RISK for falls residents continued in the weekly Falls Meeting until the IDT decided the residents' falls had been managed and the residents were no longer a HIGH RISK for falls. (c) Review of the facility's QAPI meeting sign in sheets and corresponding agendas revealed beginning on 11/28/2022, revealed the DON/Unit Manager (UM) presented the results of the falls monitoring from the daily (M-F) CQI meetings and Falls Meetings to the QAPI Committee. Continued review revealed it was determined all residents assessed as at HIGH RISK were discussed in the weekly Falls Meeting until the IDT decided a resident's falls had been managed and he/she was no longer a HIGH RISK for falls. Further review of the QAPI meeting information through 12/06/2022, revealed the DON/UM continued presenting and discussing of the same topics. Interview with the UM on 12/08/2022 Interview with the Administrator on 12/08/2022 at 7:33 PM revealed the DON and UM were monitoring falls on a weekly basis for four (4) weeks, subsequent to that would monitor three (3) falls weekly for at least six (6) months and would be reviewed by regional staff. (d) Review of the facility's audit tools revealed the DON/UM/MDS Coordinator conducted a facility wide audit beginning 11/28/2022 to ensure that Action Plans were implemented to address falls as indicated post significant falls with injury, and that patterns or trends were identified. Interview on 12/08/022 at 7:33 PM, with the Administrator revealed results of the falls audit/monitoring were being reviewed in the CQI meetings as well as the weekly Falls Meetings, and if an Action Plan/PIP was needed the QAPI Committee would write it with input from the Regional Team. The Administrator further stated she would participate in the development of any written Action Plan/PIP, and monitor it until it was determined to be resolved. (e) Interview on 12/08/022 at 7:33 PM, with the Administrator revealed the facility's QAPI Committee members included herself, the DON, ADON and/or Unit Manager, MDS Coordinator, Business Office Manager, Social Services Designee, Dietary Manager, Activities Director, Rehab Director, Maintenance Director, Housekeeping and Laundry Supervisor. Continued interview revealed others who might attend if present in the facility at the time of the meeting were: the RVP, RDO, RNC, MDS Consultant, Pharmacy Consultant, Dietician, and Medical Director and/or Nurse Practitioner. Further interview revealed a member of the Regional Team had attended the QAPI Committee meetings either in person or remotely on a weekly basis. The Administrator further revealed the Regional Team's participation would decrease to every three (3) months, as determined by them, to provide additional oversight and serve as a reference for the facility. Interview on 12/08/2022 at 7:13 PM, with the Regional Nurse Consultant (RNC) revealed beginning 11/28/2022, he had been attending the facility's QAPI Committee meetings weekly either in person by remotely to provide direct oversight and act as a reference for the facility. Interview on 12/02/2022 at 6:18 PM, with the Medical Director revealed the facility held a QAPI meeting on 11/28/2022, and continued the meetings weekly. Per the Medical Director, she attended in person or remotely with the facility by phone for the QAPI Committee meetings. Continued interview revealed however, there were times when she was tied to activity at the hospital and could not attend the QAPI meetings. The Medical Director stated if she was unable to attend the meetings in person or remotely, she went over the actions discussed and taken by the QAPI Committee. Further interview revealed the facility's QAPI Committee would continue meeting weekly and move to monthly as determined by the need. In addition, the Medical Director stated during the QAPI Committee meetings there was