Based on observation, interview, record review, facility document and policy review, it was determined the facility failed to ensure residents' comprehensive care plans were developed and implemented for one (1) of six (6) sampled residents (Resident #7). The facility assessed Resident #7 to be a risk for elopement and care planned him/her for the risk with interventions which included: to distract from wandering by being offered pleasant diversions which included: structured activities, food, conversation, television, or a book. On 05/16/2023, the resident was observed to push on the exit door handle and press the door code box to exit the facility. The resident was provided a Wandergaurd at that time; however, the resident's person-centered care plan failed to address the resident pressing the code box and/or provide increased supervision or monitoring for the safety of the resident. Therefore, on 07/15/2023 at 6:40 PM, Resident #7 was able to exit the facility undetected by staff, by entering the code observed by a staff member who entered the code for the resident's viewing. The resident was unsupervised for approximately five (5) minutes. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 08/31/2023, alleging removal of the Immediate Jeopardy on 07/22/2023, prior to the State Survey Agency's (SSA's) investigation. The SSA validated the facility's IJ Removal Plan, on 09/07/2023, and determined the deficient practice was corrected as alleged on 07/22/2023, prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, dated 01/13/2018, revealed the purpose of the Comprehensive Care Plan was to ensure the resident or resident representative was included in all aspects of person-centered care planning which included the provision of services to enable the resident to live with dignity and supported the resident's goals, choices, and preferences. Continued review revealed a comprehensive care plan was to be developed for each resident within twenty-one (21) days and no more than seven (7) days after the completion of the Minimum Data Set (MDS) Assessment. Per review, the comprehensive care plan must be prepared with input from the facility's Interdisciplinary Team (IDT). Further review revealed care plans were to be reviewed and updated when there had been a significant change in the resident's condition; when the desired outcome was not met; when the resident was readmitted to the facility; and reviewed and revised at least quarterly. Review further revealed the subsequent care plan meetings were to be documented in the care conference notes by Social Services or his/her designee. Review of facility policy titled, Elopement Management Program, dated 12/26/2016, revealed the facility's Elopement Risk Management Program's purpose was to provide the resident with an environment that remained as free from accidents and hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Continued review revealed in order to identify residents at risk for elopement, an assessment was performed before and during the admission process, daily, weekly, and quarterly according to the MDS Assessment schedule or as needed (PRN) based on the observation and evaluation of the resident. Review revealed the IDT developed an individualized care plan to prevent elopement for which the nurse determined the resident's risk factors. Per review, the nurse was to document the intervention on the resident's care plan, and communicate the new interventions to staff members providing care shift-to-shift. Further review revealed the entire IDT must ensure all planned interventions were carried out as written in the care plan and communicated the care plan to the resident's family. Review further revealed the IDT was to review and educate the resident, family, or responsible party about the individualized interventions put in place to ensure the resident's safety. In addition, the care plan was to be reviewed for effectiveness, and the resident monitored daily for any new behaviors and changes in existing behaviors so appropriate interventions could begin as soon as possible. Record review revealed the facility admitted Resident #7, on 02/01/2023, with diagnoses that included Vascular Dementia, Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction without Residual Deficits, and Encephalopathy, Unspecified. Review of Resident #7's Quarterly MDS Assessment, dated 06/09/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), which indicated he/she was severely cognitively impaired. Review of the Progress Note, dated 05/12/2023, revealed Resident #7 had been assessed as an elopement risk due to his/her diagnosis of Dementia, history of being impulsive, ability to ambulate and self-propel in a wheelchair within the building and his/her hovering around exits. Review further revealed a Wander Guard was placed on Resident #7. Review of Resident #7's Elopement Care Plan revealed it was initiated on 05/12/2023, with interventions which included interventions implemented on 05/16/2023: to distract the resident from wandering by offering pleasant diversions, structured activities, a book, conversation, television, or food, Continued review revealed additional interventions to monitor the resident for fatigue and weight loss, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, and applying a wandering device to his/her ankle and check the placement and function. Further review of the record revealed however, no documented evidence Resident #7 was care planned for increased supervision, even though the facility assessed him/her to be at risk for elopement on 05/12/2023. Review of the Progress Note dated 05/16/2023, revealed Resident #7 had been observed at an exit door pushing on the handle and pressing the door code box. Continued review revealed however, no documented evidence to support the facility updated Resident #7's care plan with increased supervision and/or monitoring of the resident at the code box, to ensure his/her safety. Review of the Facility's Investigation revealed on 07/15/2023, a staff member punched the door code in to allow someone to exit, and Resident #7 watched the staff member enter the code to the door. Continued review revealed after watching the staff member punch in the code, Resident #7 punched in the code and exited the facility without staff supervision. Review further revealed Resident #7 was found by a staff member sitting outside, for approximately five (5) minutes, by the fence thirty-four (34) feet from the facility's front entrance. In a telephone interview, on 08/30/2023 at 8:11 PM, LPN #17 stated she had been the previous 300 Hall Unit Manager. She stated Resident #7 would dress daily and appeared not to look like a resident at times, so she did not trust the resident not to try and elope. She stated that was why she decided to make him/her an elopement risk. LPN #17 stated the process on care plans was for her to email the MDS Nurse and tell her what she had done, and the MDS Nurse was ultimately responsible for updating the care plans with input from the IDT team. She stated it was always a big deal if they did the care plans and the MDS Nurse did not. The LPN stated she could update a baseline care plan; however, the MDS Nurse had the responsibility to ensure the care plans were updated. She stated on 5/12/2023, she entered the progress note, received a Physician's order for a undergird device which she was to place on Resident #7. LPN #17 further stated she initiated the elopement care plan for Resident #7 then sent the MDS Nurse an email telling her what she had done, so the resident's care plan could be modified and updated. In an interview on 08/29/2023 at 2:00 PM, the MDS Nurse stated resident care plans were reviewed quarterly and whenever an assessment occurred. She stated the care plan could be reviewed more frequently if a resident was being monitored due to being at risk for conditions such as infections, falls, etc., and checked to see if the interventions which had been chosen needed updating. The MDS Nurse stated Social Services would update residents' elopement care plan because they assessed for mood and behaviors. She stated residents were assessed for elopement every quarter or whenever a resident displayed behaviors. The MDS Nurse stated any nurse could add an intervention to the care plan after discussing the matter with the Director of Nursing (DON) and the Executive Director (ED). She further stated the responsibility for updating the care plan after a resident displayed exit-seeking behaviors fell to whoever was working at the time the behaviors occurred. In an interview on 09/07/2023 at 8:43 AM, the DON stated the nurse on duty was responsible for updating a resident's care plan if an event occurred during their shift. In an interview on 09/07/2023 at 10:18 AM, the ED stated care plans were updated as needed. She stated the facility's process for updating care plans was for the floor nurse to initiate a conference call with her, the DON, the Nursing Supervisor on duty and/or the Regional Corporate Nurse Consultant at the time of the incident. The ED stated during that call they discussed the situation and came up with interventions. She stated someone on the conference call was assigned to update the resident's care plan and she or the Regional Nurse Consultant would confirm that the care plan had been updated. The ED further stated the charge nurse on duty was ultimately responsible for making sure the care plans were updated at the time of the event. The facility alleged it had taken the following actions: 1. Corrective Action for Resident #7 who had been affected by the deficient practice for F 689: Resident #7 was wearing tan jogging pants, a T-shirt, and shoes at the time he/she was found outside of the facility. Continued review revealed the weather was 82.4 degrees, wind was at three (3) miles per hour (mph), with 79% humidity, according to the website local conditions.com at 7:00 PM for the facility's location. 2. Corrective action included a head-to-toe skin assessment of Resident #7 that was completed with no injury noted. Further review revealed the action also included a check of Resident #7's Wander Guard alert bracelet to ensure it was in place to his/her right ankle on 07/15/2023. 3. Corrective action for Resident #7 included Resident #7 being placed on one to one (1:1) supervision on 07/15/2023, and his/her care plan updated to reflect the increased supervision by the Registered Nurse (RN). No further care plan revisions were completed as the resident remained 1:1 with facility staff at all times and was to do so for the remainder of time he/she resided in the facility or was no longer able to be independently mobile. 4. Corrective action also included notification of Resident #7's Physician (MD) and responsible party (RP) on 07/15/2023. 5. Further corrective action (for Resident #7) included a new BIMS assessment and St. Louis University Mental Status (SLUMS) assessment which was a test for Dementia that measured aspects of cognition on a scale from 0-30, given to Resident #7 by the Speech Therapist on 07/16/2023. A score of 0-30 indicated Dementia. 6. Corrective action included a new elopement assessment completed on Resident #7 on 07/15/2023, which identified him/her as at risk for elopement. 7. Further corrective action included a head count of facility residents performed by each unit nurse on 7/15/2023. All residents residing in the facility were accounted for and present. 8. Corrective action also included the residents residing in the facility that have been identified as risk for elopement had wander guards in place. Wander Guards were checked for functioning and placement by the charge nurses on 07/15/2023. 9. Corrective action included door codes changed by the Plant Operations (Ops) Director on 07/15/2023. Key pad covers were ordered and placed by the Plant Ops Director on the two (2) main exit doors on 07/21/2023. 10. Further corrective action included checking all doors and windows in the facility by Plant Ops Director on 7/15/2023 to ensure all doors/windows were locked, secured, and that delayed egress was functioning properly. 11. Corrective action also included all current residents being reassessed for elopement potential by the DON, Unit Manager, Infection Control/Risk Manager, Wound Nurse, MDS Coordinators and charge nurse starting on 07/15/2023 and completed on 07/16/2023. 12. Corrective action included all residents currently residing in the facility that had been identified at risk for elopement had care plans reviewed or implemented to reflect current needs of the residents on 07/16/2023 by the MDS Nurse and/or Regional Nurse. 13. Further corrective action included a review of the elopement binders for accuracy by the Social Services Director (SSD) on 07/16/2023. 14. Corrective action included a thirty (30) day look back in the electronic medical record operating system, point click care (PCC), on all events that had occurred in the facility and 24-hour report for exit seeking behavior; this was started on 07/15/2023 and competed on 07/16/2023. 15. Corrective action included the DON, Unit Manager, Assistant Director of Nursing (ADON), MDS Coordinators and Regional Nurse Consultant completing a thirty (30) day look back of nurses' notes for exit seeking behaviors and/or elopements with wandering behavior identified on residents in the facility currently identified as at risk for elopement. This was started on 07/15/2023 and completed on 07/16/2023. 16. Corrective action included providing education to Administrative staff on 07/16/2023 by the Nurse Consultant on the policies for implementing and following care plans. Care Plan Policy and Procedure education was to include the following: Elopement/wandering care plan interventions, creating, reviewing, implementing, and following the care plan and updating care plan with changes in condition. All staff receiving education could not return to work until the education was provided, post-test administered related to elopement policy and procedures and 100% score obtained. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. That process continued until all managers obtained a 100% score on post-test. All post-tests were reviewed for compliance by the Nurse Consultant. 17. Corrective action also included re-educating facility staff to include as necessary (PRN) and Agency as well as licensed nurses and nurse aides, dietary, therapy, housekeeping and administrative staff on following policies and procedures to include elopement, missing resident, safety and supervision, accident and incident, behavior management and care planning, resident rights, Dementia, abuse and neglect, facility administration, Quality Assurance and Process Improvement (QAPI), and the Change of Condition policy and procedure per the IDT team, and communicating these specific interventions to all relevant staff which was started on 07/15/2023 and was completed for all current staff which included taking a post-test and scoring 100%, on the current working schedule by 07/21/2023. Staff not on the current schedule will receive education and be required to take a post-test and score 100%, before being permitted to work starting on 7/21/2023. 18. Corrective action included covering the exit door keypads to the main entrance and exit doors for the facility that would prevent residents or visitors from visualizing the key pad when code was being entered. 19. Further corrective action included starting on 07/15/2023, all doors were to be continued to be checked for proper function daily to ensure the delayed egress was functioning properly and the alarms were audible to alert staff, by members of the IDT team. 20. Corrective action included an elopement drill that was completed on 07/16/2023 by the Plant Operations manager. Elopement drills were to be conducted twice a day on day and night/ shifts, for one (1) week and weekly for four (4) weeks by Administrator, DON, or Department Head Managers. Then were to be conducted quarterly, thereafter. 21. Corrective action included the DON, RM, Wound Nurse, MDS or Regional Nurse were to monitor all residents, as well as new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decrease to Monday through Friday for three (3) months to determine if there were any new exit seeking behaviors and to ensure appropriate interventions have been implemented to ensure the safety of the residents. 22. Corrective action also included beginning on 07/16/2023, the following was to be reviewed daily by a member or members of the IDT team: Events in Risk Management, Clinical Summary 24-hour report, review new and readmissions for elopement assessments and updated care plans and elopement book as needed, Nurses notes, new or worsening exit seeking and/or wandering behavior tracking, care plan interventions for any identified new or worsening exit seeking and/or wandering behavior and Medication Administration Record (MAR) monitoring. 23. Corrective action included beginning on 07/16/2023, an elopement test that included questions regarding our policies on elopement, Dementia, QAPI, abuse reporting, change of condition, care plans, accidents and incidents, and safety and supervision. The testing was to be completed by employees and the employee must make a 100%, if not they must be re-educated and re-tested until 100% obtained. Staff not working on 07/17/2023 were to be educated upon return to work and a post test administered. 24. Corrective action included a nurse from the regional team or corporate office and/or the [NAME] President (VP) of Operations being available on site or by phone starting 07/15/2023. A member of the regional team was providing regional oversight from 7/15/2023 until immediacy was lifted either in person or by phone to ensure continued compliance with audits established by QAPI Committee. 25. Corrective action included a QAPI meeting conducted on 07/16/2023 to discuss the pending deficiencies with F656 in regards to care planning. QAPI was to continue to be ongoing weekly for four (4) weeks and the DON was to report the findings of all audits to QA. An immediate action plan was implemented and discussed to ensure compliance and any changes needed to the facilities plan were completed. The State Survey Agency validated the facility had taken the alleged actions: 1. In interview on 08/24/2023 at 10:52 AM, SRNA #17 stated on 07/15/2023 around 6:30 PM or so, she found Resident #7 sitting outside of the facility at the end of the sidewalk beside the fence after she clocked out of work for her shift. She stated she along with the nightshift nursing supervisor and another SRNA, brought Resident #7 back inside the facility and returned him/her to his/her unit. In an interview on 08/24/2023 at 1:55 PM, SRNA #16 stated she worked the evening shift on the night of Resident #7's elopement incident 07/15/2023. She stated she provided 1:1 supervision for Resident #7 after the elopement incident until the end of her shift on 07/16/2023 at 6:30 AM. 2. Record review of Resident #7's progress note dated 07/15/2023, revealed Resident #7 had a head to toe skin assessment performed by LPN #5 and his/her Wander Guard bracelet was removed and replaced with a new one. In an interview on 08/24/2023 at 9:05 AM, LPN #5 stated once Resident #7 was brought back to the 300 unit, she performed a head to toe skin assessment of him/her. She further stated she also checked Resident #7's Wander Guard bracelet and replaced it with a new one. 3. Review of Resident #7's care plan revealed the resident had been care planned for 1:1 supervision on 07/15/2023. In interview on 08/24/2023 at 1:55 PM, SRNA #16 stated she provided 1:1 supervision for Resident #7 on 07/15/2023, after the elopement incident until the end of her shift on 07/16/2023 at 6:30 AM. Observation of Resident #7 from 08/22/2023 through 09/07/2023, revealed Resident #7 currently remained on 1:1 supervision. 4. Review of Resident #7's progress noted dated 07/15/2023, revealed Resident #7's MD and RP were notified of the elopement event on 07/15/2023 at 6:45 PM. In an interview on 08/24/2023 at 9:05 AM, LPN #5 stated she contacted Resident #7's MD and RP to notify them of the elopement event on 07/15/2023. 5. Record review revealed a SLUMS Assessment had been completed for Resident #7 on 07/16/2023, by the Director of Rehab/Speech Therapy. Continued review revealed Resident #7 was assessed to have SLUMS Assessment score of twenty (20) out of thirty (30) on the SLUMS scale, which indicated he/she had Dementia (a SLUMS score of one [1] to twenty [20] indicated Dementia). In interview on 09/07/2023 at 12:12 PM, the Director of Rehab/Speech Therapy revealed she completed the SLUMS Assessment of Resident #7 on 07/16/2023. 6. Review of Resident #7 progress note dated 07/15/2023 revealed an elopement risk assessment was completed of the resident by LPN #5. In interview on 08/24/2023 at 9:05 AM, LPN #5 stated she performed a new elopement risk assessment on Resident #7 immediately after the elopement event on 07/15/2023. 7. In a telephone interview with the Weekend Nightshift Nursing Supervisor on 09/07/2023 at 3:28 PM, she stated, she along with each unit charge nurse, performed a head count of all residents in the facility, and each resident was accounted for. Review of the facility's Elopement Binder revealed all residents that resided in the faciltiy were accounted for by nursing staff on 07/15/2023. 8. In a telephone interview on 09/07/2023 at 3:28 PM, the Weekend Nightshift Nursing Supervisor stated she also performed the placement and function checks on the Wander Guard bracelets for all residents at risk for elopement on 07/15/2023. Observation on 08/25/2023 at 11:25 AM, revealed Unit Manager #1 demonstrated the testing and function of Resident #7's Wanderguard Bracelet, which was observed to be functioning properly. 9. In an interview on 08/22/2023 at 9:25 AM, the facility's Maintenance Director stated he changed the door keypad codes and placed covers over the keypads by 07/21/2023. Observation of the facility's exit doors on 09/01/2023 at 4:00 PM, revealed covers over all the egress doors keypads as alleged. 10. In continued interview on 08/22/2023 at 9:25 AM, the facility Maintenance Director stated he checked all the facility's doors and windows on 7/15/2023 to ensure all doors/windows were locked, secured, and the delayed egress was functioning properly. 11. In interview on 08/24/2023 at 9:05 AM, LPN #5 stated she assisted in performing the new elopement assessment risks on all residents along with the other unit charge nurses, MDS Nurse, and the Regional Nurse Consultant onsite after the elopement incident on 07/15/2023 through 07/16/2023. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated the completion of the new elopement assessment risks of all residents had been conducted and the results of the assessments were located in the Elopement Binders. Review of facility's F656 Care Plan Binder on 09/07/2023 at 1:30 PM revealed residents had been reassessed for elopement. 12. In an interview with the facility MDS Nurse on 08/29/2023 at 2:00 PM, she stated she reviewed and updated the care plans for all residents deemed at risk for elopement on 07/16/2023. 13. In an interview on 09/07/2023 at 9:49 AM, the Social Services (SS) Assistant stated she, along with the Social Services Director, updated the elopement binders and care plans on 07/16/2023. She stated they updated the list of residents at risk for elopement and placed the new updated copies in all areas. The SS Assistant further stated they reviewed the elopement binders monthly to ensure that they were up to date. On 08/30/2023 at 10:30 AM, the SSA Surveyor went to each unit in the facility and located the Orange Elopement Binder at each nurses' station behind the desk. 14. In a telephone interview with Regional Corporate Nurse Consultant #1 on 09/01/2023 at 9:03 AM, she stated she performed audits of all nurses notes, 24 hour reports and documentation, and checked for other potential residents that were at risk for exit seeking behavior from 07/15/2023 to 07/16/2023. 15. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she completed a thirty (30) day audit from 07/15/2023 to 07/16/2023, of the nurses notes for residents at risk for elopement to see if there were any exit seeking behaviors documented. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation present of the thirty (30) day audit no other exit seeking behaviors were documented. 16. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she provided education regarding care plans to the administrative staff on 07/15/2023 and administered post tests to them. She stated that all staff made 100% scores and if they had not the staff member was reducated and had to retake the posttest until 100% was achieved. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation of all staff education and their post tests. 17. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she provided elopement education to facility staff along with Regional Corporate Nurse Consultant#1 beginning on 07/15/2023 and administered post tests to them. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation noting all staffs' education and posttests. In interview on 08/31/2023 at 4:10 PM and 4:15 PM with RN #3; and at 4:30 PM with LPN #16 revealed they stated they received education on elopement. In interview on 09/06/2023 at 10:20 AM, Staff Developement Coordinator/Infection Preventionist stated he received the education and took the post tests. In interview on 09/01/2023 at 2:20 PM, Dietary Aide #1 stated she received the education and had taken a post test on elopement. 18. Observation of the facility front door and staff exit door on 08/22/2023 revealed the keypads were covered with a plastic privacy cover to obstruct viewing of the code being entered. In an interview on 08/22/2023 at 9:25 AM, the Maintenance Director stated he installed the covers to the door keypads shortly after the elopement event on 07/15/2023. 19. In an interview with the Maintenance Director on 08/22/2023 at 9:25 AM, he stated the exit doors were checked daily for proper functioning and returned demonstration of how the doors function at that time. He stated he and the ED, DON and some nurses performed the checks. In interview on 09/01/2023 at 9:03 AM, Regional Nurse Consultant #1 and at Executive Director both stated they assisted with checking the exit doors starting on 07/15/2023, and the door checks were continuing to be performed. 20. In an interview on 08/22/2023 at 9:25 AM, the Maintenance Director stated he conducted the elopement drills for facility staff on 08/16/2023. The Maintenance Director stated the elopement drills were conducted twice a day, and occurred at least once on each shift for four (4) weeks after the event, then the drills were conducted weekly and PRN. In interview on 09/07/2023 at 8:43 AM, the DON stated she the elopement drills were being conducted as required. In an interview on 09/07/2023 at 10:18 AM, the ED stated the elopement drills had been conducted as required. Review of Elopement Binder on 09/06/2023 revealed elopement drills were being conducted on each shift starting 07/16/2023 for next four (4) weeks. Interview on 08/24/2023 at 10:52 AM, with SRNA #17; on 08/25/2023 at 8:55 AM with SRNA #15; and on 08/25/2023 at 8:50 AM with LPN #6 they all stated they participated in elopement drills and the education provided. 21. In an interview on 08/29/2023 at 2:00 PM, the MDS Nurse stated she along with Regional Corporate Nurse Consultants #1 and #2 had been providing monitoring of residents for exit seeking behaviors. In an additional interview on 09/01/2023 at 9:03 AM, Regional Nurse Consultant #1 stated she audited nurse notes, 24 hr reports and all other pertinent documentation and checked other potential residents that might be at risk for elopement. Observations during the SSA onsite survey 08/22/2023 through 09/07/2023, revealed staff were observed rounding each hallway and performing every fifteen (15) minute checks of all residents at risk for elopement. 22. In an interview 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she audited nurses' notes, and 24 hour reports. In interview on 09/01/2023 at 9:42 AM, the Social Services (SS) Assistant and Social Services Director stated they put the elopement binders together, and updated them and the residents' elopement care plans as needed. 23. In interview on 08/31/2023 at 4:10 PM, with RN #3; at 4:30 PM, with LPN #16; and at 4:15 PM, with LPN #10 they all stated they were provided education on facility policies to include the following: change of condition, elopement, Dementia, QAPI, abuse reporting, care plans, accidents and incidents, and safety and supervision. They all stated they were educated by the Regional Nurse Consultant. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she had provided elopement education to facility staff. 24. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she along with Regional Corporate Nurse Consultant #2 and the VP of Operations had all either been in the building or available by telephone to provide oversight and ensure audits were performed, since the elopement incident on 07/15/2023. 25. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she attended QAPI meetings along with the facility's IDT team on 07/16/2023 and the facility had held QAPI meetings weekly since then. In an interview on 09/01/2023 at 10:43 AM, the MDS Nurse stated she updated the care plans for newly identified elopement risk residents on 07/16/2023 and has participated in QAPI. In an interview on 09/07/2023 at 8:43 AM, the DON stated she performed elopement audits and she also checks and audits of the medication carts. She further stated she attended the IDT meetings Monday-Friday, held twice a day. The DON additionally stated she reported her audit findings in the QAPI meetings. In a telephone interview on 09/06/2023 at 3:27 PM, the facility's Medical Director stated he had been made aware of the deficiencies and was participating in the QAPI meetings, which he attended in person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of facility documents and policy, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of six (6) sampled residents assessed as an elopement risk (Resident #7). The facility assessed Resident #7 as at risk for elopement and care planned the resident to be distracted from wandering by being offered pleasant diversions, structured activities, food, conversation, television, or a book. However, the resident was able to exit the facility undetected by staff on 07/15/2023 at 6:40 PM, based on a review of the facility's Final Investigation Report. The resident was found located outside the building unsupervised for approximately five (5) minutes. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 08/31/2023, alleging removal of the Immediate Jeopardy on 07/22/2023, prior to the State Survey Agency's (SSA's) investigation. The SSA validated the facility's IJ Removal Plan, on 09/07/2023, and determined the deficient practice was corrected as alleged on 07/22/2023, prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility policy titled, Increased Supervision, undated, revealed its purpose was to ensure necessary supervision was provided and continued through the interdisciplinary team (IDT) assessment. Per policy review, the IDT was to consult with the attending Physician, resident, and/or responsible party prior to removing the increased supervision. Continued review of the policy revealed Increased Supervision referred to the supervision of the resident by staff to prevent opportunities for the resident to harm themselves or others. Further review revealed staff assigned to conduct increased supervision were to complete monitoring forms and provide adequate supervision to mitigate incident risk. Review of the facility policy titled, Elopement Management Program, dated 12/26/2016, revealed the Elopement Risk Management Program's purpose was to provide residents with an environment that remained as free from accidents and hazards as possible, and received adequate supervision and assistance devices to prevent accidents. Per policy review, in order to identify residents at risk for elopement, an assessment was performed before and during the admission process, daily, weekly, and quarterly according to the Minimum Data Set (MDS) Assessment schedule or as needed (PRN). Continued review revealed based on the observation and evaluations performed of the resident, the IDT developed an individualized care plan to prevent elopement. Review revealed the nurse determined the resident's risk factors and documented interventions on the resident's care plan. Per review the licensed nurse also communicated the new interventions to the staff members who provided care shift-to-shift. Review of the policy revealed an Elopement Binder was to be kept at each nurses' station and at the receptionist's desk, which contained an elopement risk identification form on residents at risk for elopement. According to review of the policy, care plans were to be reviewed for effectiveness, and the resident was to be monitored daily for any new behaviors and changes in existing behaviors so appropriate interventions could begin as soon as possible. Further review revealed maintenance was to test and document that exit doors were secured and that alarms or electronic locks/keypads functioned as designed. Review further revealed the licensed nurse on every shift was to check the placement and function of the resident's electronic alarm devices and document the results on the resident's Treatment Administration Record (TAR). Review revealed if the electronic device did not function the licensed nurse was to immediately replace it with an operational device and communicate the changes via shift-to-shift report. In addition, the policy review revealed if a resident was identified to be at risk for elopement, an exit-seeking tracking form was to be implemented. Review further revealed when the IDT determined the resident was no longer at risk for elopement, treatment goals and approaches could be removed from the resident's care plan, a team member was to note the date of discontinuance on the resident's Care Plan and was to write a short narrative in the interdisciplinary notes indicating the rationale for the decision. Review of facility policy titled, Golden Alert, undated, revealed when the door alarm was sounding, someone must go to the door that was alarming and do an outside perimeter check, and if no resident was observed outside, the person responding was to go back inside and deactivate the alarm. Continued review revealed staff were to page Golden Alert- which alerted the units to conduct a head count of all residents, and if all residents were accounted for then they were to page, All Clear. Further review revealed if a resident was considered missing, staff was to immediately page Golden Alert and announce the resident's room number, which alerted all staff there was a missing resident. Additionally, the review revealed staff were to follow the facility's elopement guidelines located in the elopement binder. Review of Resident #7's medical record revealed the facility admitted him/her on 02/01/2023, with diagnoses including: Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction without Residual Deficits, Vascular Dementia and Encephalopathy, Unspecified. Review of Resident #7'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 five (5) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #7's Elopement Assessment Risk, dated 05/12/2023, revealed the facility assessed the resident as being at risk for elopement based on his/her ability to self-propel in a wheelchair independently. Continued review revealed Resident #7 was an elopement risk also due to: being ambulatory; his/her diagnosis of Dementia; history of wandering or hovering near exits; and history of being impulsive. Review of the Progress Note, dated 05/12/2023, revealed Resident #7 had been assessed to be an elopement risk due to his/her ability to ambulate and self-propel in a wheelchair within the building and hovering around exits. Further review of the Progress Note revealed an Undergird bracelet (a monitoring device which alarmed monitored doors and alerted staff) was applied to Resident #7. Review of the Progress Note, dated 05/16/2023, revealed Resident #7 was observed at an exit door pushing on the handle and pressing the door code box. Continued review revealed no documented evidence the facility provided increased supervision and/or monitoring of Resident #7 at the code box, to ensure his/her safety. Review of the Facility's Investigation, dated 07/15/2023 revealed on that date, Resident #7 entered the code to the door at the front entrance exit door after watching a staff member punch in the code on the key pad. Continued review revealed Resident #7 exited the facility without staffs' supervision, and was found by a staff member sitting outside, approximately five (5) minutes after exiting the facility, by the fence thirty-four (34) feet from the facility's front entrance. Further review revealed the facility based the timeframe of the resident's being found on staff interviews. Review of the facility's Final Investigation dated 07/21/2023 revealed on 07/15/2023, the [NAME] President (VP) of Clinical Operations interviewed Resident #7 at 7:30 PM, and the resident stated he/she was going to check on his/her truck. Continued review revealed when the VP of Clinical Operations asked Resident #7 how he/she got out of the facility, the resident stated I watched them punch the code in. Further review of the investigation revealed Resident #7 had been able to recall two (2) of the five (5) digit code sequence for the door at the time of the interview. Per the DON's written statement in the facility's Final Investigation documentation dated 07/21/2023 at 3:47 PM, revealed she identified Resident #7 during the root cause analysis as the resident had a variable BIMS score ranging from five (5) to nine (9) out of 15 and a history of being a special operations agent in the armed forces, and presented himself/herself as a cognizant person. Observation of Resident #7, on 08/22/2023 at 10:16 AM, revealed the resident was sitting up on his/her bed painting suncatchers, and on 1:1 supervision with facility staff at that time. Observation of Resident #7, on 08/23/2023 at 2:00 PM, revealed Resident #7 was up in his/her wheelchair with State Registered Nursing Assistant (SRNA) at his/her side for 1:1 supervision while in line waiting to enter the facility's dining hall to participate in an afternoon activity. In an interview with Licensed Practical Nurse (LPN) #8, on 08/24/2023 at 3:30 PM, she stated she had last seen Resident #7, on 07/15/2023 between 5:00 PM and 5:30 PM, on the 300 Hall hallway. LPN #8 stated she was giving shift report when the girls from the 100 Hall came to the 300 unit to bring Resident #7 back and told her the resident had been found outside. She further stated that shocked her because the resident had never tried to exit seek before. In an interview with SRNA #14, on 08/24/2023 at 3:13 PM, she stated she had last seen Resident #7 around 6:15 PM to 6:20 PM on 07/15/2023. She stated Resident #7 had been in his/her room when she last saw the resident as she was picking up his/her dinner tray. In an interview with SRNA #22, on 08/30/2023 at 8:25 AM, he stated he had last seen Resident #7 self-propelling in his/her wheelchair on the 300 Hall around the nurses' station at 6:30 PM as he was going to get ice. In an interview on 08/24/2023 at 10:52 AM, SRNA #17 stated she was the staff member who found Resident #7 sitting outside the facility after she clocked out of work from her shift. She stated she had not heard a door alarm going off, but heard what might have been Resident #7's Undergird alarm sounding. SRNA #17 stated when she left the facility she happened to see Resident #7 sitting beside the fence near the front entrance as she walked by. She stated she then asked another SRNA, whose name she could not recall, to check and see if Resident #7 was allowed to be outside or if he/she was their own power of attorney (POA). The SRNA stated Resident #7 did not say anything to her or tell her why he/she was outside. She further stated she stayed with Resident #7 while the other SRNA went inside to check and got LPN #13 and they all three (3) escorted Resident #7 back inside the facility and returned him/her to his/her unit. Review of SRNA #17's timecard revealed she clocked out of work on 07/15/2023 at 6:40 PM. In an interview with LPN #5 on 08/24/2023 at 9:05 AM, she stated she had last seen Resident #7 self-propelling past the 300-unit nurses' station during shift change. The LPN stated none of the staff on the 300 unit where Resident #7 resided had been aware the resident was missing until he/she was brought back to the unit after his/her elopement. He further stated that had been around 6:30 PM, before Resident #7 was brought back to the 300 unit by the 100 Hall staff. During an interview with LPN #13, she stated she last saw Resident #7 in the front lobby of the facility sitting next to her at the beginning of her shift, right after she clocked in, on 07/15/2023, as she was punching in the door code to let a family member out of the facility. She stated she had clocked in for work at 6:38 PM. LPN #13 stated she should have been careful to not reveal the door code when entering it on the keypad; however, at the time she did not have any concerns about Resident #7 having exit-seeking behaviors. She further stated Resident #7 had not been exit-seeking in the past and was always going all over the facility and went back to his/her room without any issues. In addition, LPN #13 stated the facility's process before Resident #7's elopement had been to change the door codes when needed. Review of LPN #13's timecard revealed the LPN clocked in a 6:38 PM on 07/15/2023. In an interview with the Director of Nursing (DON), on 09/07/2023 at 8:43 AM, she stated she was notified by the night shift supervisor that Resident #7 had been found sitting outside the facility. She stated she did not have to respond though because the Corporate Nurse, who lived nearby the facility, responded to the event, and therefore, never went to the facility that day. The DON stated she assisted with the facility's investigation beginning on 07/16/2023. In an interview with the Executive Director (ED), on 09/07/2023 at 10:18 AM, she stated she had been notified of the elopement event involving Resident #7 immediately after it happened by the Nightshift Nursing Supervisor at 6:30 PM. She stated she then notified the Regional Nurse Consultant because she only lived five (5) minutes from the facility. The ED stated the Regional Nurse Consultant went to the facility to make sure Resident #7 was okay and everything that needed to be done was put in motion, and she arrived at the facility shortly after that. She further stated Resident #7 was placed on 1:1 supervision at that time. The facility alleged it had taken the following actions: 1. Corrective Action for Resident #7 who had been affected by the deficient practice for F 689: Resident #7 was wearing tan jogging pants, a T-shirt, and shoes at the time he/she was found outside of the facility. Continued review revealed the weather was 82.4 degrees, wind was at three (3) miles per hour (mph), with 79% humidity, according to the website local conditions.com at 7:00 PM for the facility's location. 2. Corrective action included a head-to-toe skin assessment of Resident #7 that was completed with no injury noted. Further review revealed the action also included a check of Resident #7's Wander Guard alert bracelet to ensure it was in place to his/her right ankle on 07/15/2023. 3. Corrective action for Resident #7 included Resident #7 being placed on one to one (1:1) supervision on 07/15/2023, and his/her care plan updated to reflect the increased supervision by the Registered Nurse (RN). No further care plan revisions were completed as the resident remained 1:1 with facility staff at all times and was to do so for the remainder of time he/she resided in the facility or was no longer able to be independently mobile. 4. Corrective action also included notification of Resident #7's Physician (MD) and responsible party (RP) on 07/15/2023. 5. Further corrective action (for Resident #7) included a new BIMS assessment and St. Louis University Mental Status (SLUMS) assessment which was a test for Dementia that measured aspects of cognition on a scale from 0-30, given to Resident #7 by the Speech Therapist on 07/16/2023. A score of 0-30 indicated Dementia. 6. Corrective action included a new elopement assessment completed on Resident #7 on 07/15/2023, which identified him/her as at risk for elopement. 7. Further corrective action included a head count of facility residents performed by each unit nurse on 7/15/2023. All residents residing in the facility were accounted for and present. 8. Corrective action also included the residents residing in the facility that have been identified as risk for elopement had wander guards in place. Wander Guards were checked for functioning and placement by the charge nurses on 07/15/2023. 9. Corrective action included door codes changed by the Plant Operations (Ops) Director on 07/15/2023. Key pad covers were ordered and placed by the Plant Ops Director on the two (2) main exit doors on 07/21/2023. 10. Further corrective action included checking all doors and windows in the facility by Plant Ops Director on 7/15/2023 to ensure all doors/windows were locked, secured, and that delayed egress was functioning properly. 11. Corrective action also included all current residents being reassessed for elopement potential by the DON, Unit Manager, Infection Control/Risk Manager, Wound Nurse, MDS Coordinators and charge nurse starting on 07/15/2023 and completed on 07/16/2023. 12. Corrective action included all residents currently residing in the facility that had been identified at risk for elopement had care plans reviewed or implemented to reflect current needs of the residents on 07/16/2023 by the MDS Nurse and/or Regional Nurse. 13. Further corrective action included a review of the elopement binders for accuracy by the Social Services Director (SSD) on 07/16/2023. 14. Corrective action included a thirty (30) day look back in the electronic medical record operating system, point click care (PCC), on all events that had occurred in the facility and 24-hour report for exit seeking behavior; this was started on 07/15/2023 and competed on 07/16/2023. 15. Corrective action included the DON, Unit Manager, Assistant Director of Nursing (ADON), MDS Coordinators and Regional Nurse Consultant completing a thirty (30) day look back of nurses' notes for exit seeking behaviors and/or elopements with wandering behavior identified on residents in the facility currently identified as at risk for elopement. This was started on 07/15/2023 and completed on 07/16/2023. 16. Corrective action included providing education to Administrative staff on 07/16/2023 by the Nurse Consultant on the policies for implementing and following care plans. Care Plan Policy and Procedure education was to include the following: Elopement/wandering care plan interventions, creating, reviewing, implementing, and following the care plan and updating care plan with changes in condition. All staff receiving education could not return to work until the education was provided, post-test administered related to elopement policy and procedures and 100% score obtained. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. That process continued until all managers obtained a 100% score on post-test. All post-tests were reviewed for compliance by the Nurse Consultant. 17. Corrective action also included re-educating facility staff to include as necessary (PRN) and Agency as well as licensed nurses and nurse aides, dietary, therapy, housekeeping and administrative staff on following policies and procedures to include elopement, missing resident, safety and supervision, accident and incident, behavior management and care planning, resident rights, Dementia, abuse and neglect, facility administration, Quality Assurance and Process Improvement (QAPI), and the Change of Condition policy and procedure per the IDT team, and communicating these specific interventions to all relevant staff which was started on 07/15/2023 and was completed for all current staff which included taking a post-test and scoring 100%, on the current working schedule by 07/21/2023. Staff not on the current schedule will receive education and be required to take a post-test and score 100%, before being permitted to work starting on 7/21/2023. 18. Corrective action included covering the exit door keypads to the main entrance and exit doors for the facility that would prevent residents or visitors from visualizing the key pad when code was being entered. 19. Further corrective action included starting on 07/15/2023, all doors were to be continued to be checked for proper function daily to ensure the delayed egress was functioning properly and the alarms were audible to alert staff, by members of the IDT team. 20. Corrective action included an elopement drill that was completed on 07/16/2023 by the Plant Operations manager. Elopement drills were to be conducted twice a day on day and night/ shifts, for one (1) week and weekly for four (4) weeks by Administrator, DON, or Department Head Managers. Then were to be conducted quarterly, thereafter. 21. Corrective action included the DON, RM, Wound Nurse, MDS or Regional Nurse were to monitor all residents, as well as new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decrease to Monday through Friday for three (3) months to determine if there were any new exit seeking behaviors and to ensure appropriate interventions have been implemented to ensure the safety of the residents. 22. Corrective action also included beginning on 07/16/2023, the following was to be reviewed daily by a member or members of the IDT team: Events in Risk Management, Clinical Summary 24-hour report, review new and readmissions for elopement assessments and updated care plans and elopement book as needed, Nurses notes, new or worsening exit seeking and/or wandering behavior tracking, care plan interventions for any identified new or worsening exit seeking and/or wandering behavior and Medication Administration Record (MAR) monitoring. 23. Corrective action included beginning on 07/16/2023, an elopement test that included questions regarding our policies on elopement, Dementia, QAPI, abuse reporting, change of condition, care plans, accidents and incidents, and safety and supervision. The testing was to be completed by employees and the employee must make a 100%, if not they must be re-educated and re-tested until 100% obtained. Staff not working on 07/17/2023 were to be educated upon return to work and a post test administered. 24. Corrective action included a nurse from the regional team or corporate office and/or the [NAME] President (VP) of Operations being available on site or by phone starting 07/15/2023. A member of the regional team was providing regional oversight from 7/15/2023 until immediacy was lifted either in person or by phone to ensure continued compliance with audits established by QAPI Committee. 25. Corrective action included a QAPI meeting conducted on 07/16/2023 to discuss the pending deficiencies with F656 in regards to care planning. QAPI was to continue to be ongoing weekly for four (4) weeks and the DON was to report the findings of all audits to QA. An immediate action plan was implemented and discussed to ensure compliance and any changes needed to the facilities plan were completed. The State Survey Agency validated the facility had taken the alleged actions: 1. In interview on 08/24/2023 at 10:52 AM, SRNA #17 stated on 07/15/2023 around 6:30 PM or so, she found Resident #7 sitting outside of the facility at the end of the sidewalk beside the fence after she clocked out of work for her shift. She stated she along with the nightshift nursing supervisor and another SRNA, brought Resident #7 back inside the facility and returned him/her to his/her unit. In an interview on 08/24/2023 at 1:55 PM, SRNA #16 stated she worked the evening shift on the night of Resident #7's elopement incident 07/15/2023. She stated she provided 1:1 supervision for Resident #7 after the elopement incident until the end of her shift on 07/16/2023 at 6:30 AM. 2. Record review of Resident #7's progress note dated 07/15/2023, revealed Resident #7 had a head to toe skin assessment performed by LPN #5 and his/her Wander Guard bracelet was removed and replaced with a new one. In an interview on 08/24/2023 at 9:05 AM, LPN #5 stated once Resident #7 was brought back to the 300 unit, she performed a head to toe skin assessment of him/her. She further stated she also checked Resident #7's Wander Guard bracelet and replaced it with a new one. 3. Review of Resident #7's care plan revealed the resident had been care planned for 1:1 supervision on 07/15/2023. In interview on 08/24/2023 at 1:55 PM, SRNA #16 stated she provided 1:1 supervision for Resident #7 on 07/15/2023, after the elopement incident until the end of her shift on 07/16/2023 at 6:30 AM. Observation of Resident #7 from 08/22/2023 through 09/07/2023, revealed Resident #7 currently remained on 1:1 supervision. 4. Review of Resident #7's progress noted dated 07/15/2023, revealed Resident #7's MD and RP were notified of the elopement event on 07/15/2023 at 6:45 PM. In an interview on 08/24/2023 at 9:05 AM, LPN #5 stated she contacted Resident #7's MD and RP to notify them of the elopement event on 07/15/2023. 5. Record review revealed a SLUMS Assessment had been completed for Resident #7 on 07/16/2023, by the Director of Rehab/Speech Therapy. Continued review revealed Resident #7 was assessed to have SLUMS Assessment score of twenty (20) out of thirty (30) on the SLUMS scale, which indicated he/she had Dementia (a SLUMS score of one [1] to twenty [20] indicated Dementia). In interview on 09/07/2023 at 12:12 PM, the Director of Rehab/Speech Therapy revealed she completed the SLUMS Assessment of Resident #7 on 07/16/2023. 6. Review of Resident #7 progress note dated 07/15/2023 revealed an elopement risk assessment was completed of the resident by LPN #5. In interview on 08/24/2023 at 9:05 AM, LPN #5 stated she performed a new elopement risk assessment on Resident #7 immediately after the elopement event on 07/15/2023. 7. In a telephone interview with the Weekend Nightshift Nursing Supervisor on 09/07/2023 at 3:28 PM, she stated, she along with each unit charge nurse, performed a head count of all residents in the facility, and each resident was accounted for. Review of the facility's Elopement Binder revealed all residents that resided in the faciltiy were accounted for by nursing staff on 07/15/2023. 8. In a telephone interview on 09/07/2023 at 3:28 PM, the Weekend Nightshift Nursing Supervisor stated she also performed the placement and function checks on the Wander Guard bracelets for all residents at risk for elopement on 07/15/2023. Observation on 08/25/2023 at 11:25 AM, revealed Unit Manager #1 demonstrated the testing and function of Resident #7's Wanderguard Bracelet, which was observed to be functioning properly. 9. In an interview on 08/22/2023 at 9:25 AM, the facility's Maintenance Director stated he changed the door keypad codes and placed covers over the keypads by 07/21/2023. Observation of the facility's exit doors on 09/01/2023 at 4:00 PM, revealed covers over all the egress doors keypads as alleged. 10. In continued interview on 08/22/2023 at 9:25 AM, the facility Maintenance Director stated he checked all the facility's doors and windows on 7/15/2023 to ensure all doors/windows were locked, secured, and the delayed egress was functioning properly. 11. In interview on 08/24/2023 at 9:05 AM, LPN #5 stated she assisted in performing the new elopement assessment risks on all residents along with the other unit charge nurses, MDS Nurse, and the Regional Nurse Consultant onsite after the elopement incident on 07/15/2023 through 07/16/2023. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated the completion of the new elopement assessment risks of all residents had been conducted and the results of the assessments were located in the Elopement Binders. Review of facility's F656 Care Plan Binder on 09/07/2023 at 1:30 PM revealed residents had been reassessed for elopement. 12. In an interview with the facility MDS Nurse on 08/29/2023 at 2:00 PM, she stated she reviewed and updated the care plans for all residents deemed at risk for elopement on 07/16/2023. 13. In an interview on 09/07/2023 at 9:49 AM, the Social Services (SS) Assistant stated she, along with the Social Services Director, updated the elopement binders and care plans on 07/16/2023. She stated they updated the list of residents at risk for elopement and placed the new updated copies in all areas. The SS Assistant further stated they reviewed the elopement binders monthly to ensure that they were up to date. On 08/30/2023 at 10:30 AM, the SSA Surveyor went to each unit in the facility and located the Orange Elopement Binder at each nurses' station behind the desk. 14. In a telephone interview with Regional Corporate Nurse Consultant #1 on 09/01/2023 at 9:03 AM, she stated she performed audits of all nurses notes, 24 hour reports and documentation, and checked for other potential residents that were at risk for exit seeking behavior from 07/15/2023 to 07/16/2023. 15. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she completed a thirty (30) day audit from 07/15/2023 to 07/16/2023, of the nurses notes for residents at risk for elopement to see if there were any exit seeking behaviors documented. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation present of the thirty (30) day audit no other exit seeking behaviors were documented. 16. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she provided education regarding care plans to the administrative staff on 07/15/2023 and administered post tests to them. She stated that all staff made 100% scores and if they had not the staff member was reducated and had to retake the posttest until 100% was achieved. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation of all staff education and their post tests. 17. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she provided elopement education to facility staff along with Regional Corporate Nurse Consultant#1 beginning on 07/15/2023 and administered post tests to them. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation noting all staffs' education and posttests. In interview on 08/31/2023 at 4:10 PM and 4:15 PM with RN #3; and at 4:30 PM with LPN #16 revealed they stated they received education on elopement. In interview on 09/06/2023 at 10:20 AM, Staff Developement Coordinator/Infection Preventionist stated he received the education and took the post tests. In interview on 09/01/2023 at 2:20 PM, Dietary Aide #1 stated she received the education and had taken a post test on elopement. 18. Observation of the facility front door and staff exit door on 08/22/2023 revealed the keypads were covered with a plastic privacy cover to obstruct viewing of the code being entered. In an interview on 08/22/2023 at 9:25 AM, the Maintenance Director stated he installed the covers to the door keypads shortly after the elopement event on 07/15/2023. 19. In an interview with the Maintenance Director on 08/22/2023 at 9:25 AM, he stated the exit doors were checked daily for proper functioning and returned demonstration of how the doors function at that time. He stated he and the ED, DON and some nurses performed the checks. In interview on 09/01/2023 at 9:03 AM, Regional Nurse Consultant #1 and at Executive Director both stated they assisted with checking the exit doors starting on 07/15/2023, and the door checks were continuing to be performed. 20. In an interview on 08/22/2023 at 9:25 AM, the Maintenance Director stated he conducted the elopement drills for facility staff on 08/16/2023. The Maintenance Director stated the elopement drills were conducted twice a day, and occurred at least once on each shift for four (4) weeks after the event, then the drills were conducted weekly and PRN. In interview on 09/07/2023 at 8:43 AM, the DON stated she the elopement drills were being conducted as required. In an interview on 09/07/2023 at 10:18 AM, the ED stated the elopement drills had been conducted as required. Review of Elopement Binder on 09/06/2023 revealed elopement drills were being conducted on each shift starting 07/16/2023 for next four (4) weeks. Interview on 08/24/2023 at 10:52 AM, with SRNA #17; on 08/25/2023 at 8:55 AM with SRNA #15; and on 08/25/2023 at 8:50 AM with LPN #6 they all stated they part[TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a person-centered Comprehensive Care Plan (CCP) which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for six (6) of forty-seven (47) sampled residents (Residents #1, #16, #17, #18, #19 and #88). 1. Review of Resident #1's CCP revealed the facility assessed Resident #1 as a fall risk, on 05/29/2018, with a history of impaired cognition and restless/anxious behaviors, balance problems of which resident required extensive assistance with bed mobility, transfers, and toileting. On 01/01/2020, the resident was ordered a low air loss (LAL) mattress (alternating pressure system) developed for the comfort of the resident and related to risk for pressure ulcers; however, the resident was not care planned for the air mattress. Resident #1's care plan provided no evidence of ordered guidelines to ensure appropriate settings that correlated with the resident's weights or documented evidence of a monitoring system in place to ensure proper functioning of the air mattress and safety of the resident. On 02/16/2022, Resident #1 had an unwitnessed fall with an injury, whose root cause was determined to be the air mattress, which caused the resident to roll out of the bed and onto the floor. Continued review of Resident #1's CCP revealed care plan interventions for staff to observe for any moods/behaviors that might contribute to falls when the resident was restless in the wheel chair, and to offer position changes, to include increased supervision of visual checks when the resident was up in his/her wheel chair; however, no specific guidelines were provided. On 02/29/2020, the facility initiated the intervention for staff to ensure resident to be up only one (1) to two (2) hours as tolerated in the reclining wheelchair, and to include increase visual checks when resident was up in chair. However, Resident #1 sustained a second fall with injury on 07/08/2022 from his/her wheelchair, while in the lounge area without supervision. It was reported Resident #1 was trying to get up and screaming that he/she just wanted to go back to bed. Resident #1's record review and staff interviews revealed the resident had been in the wheelchair for approximately four (4) hours with multiple requests and attempts to return to bed during that time; therefore, staff failed to implement the resident's care planned interventions while up in the wheelchair. 2. Review of Resident #16's medical record revealed the facility assessed the resident to be a risk for falls related to gait/balance problems since admission. Resident #16's Physical Therapy (PT) discharge recommendations, dated 04/27/2023, revealed the resident was to ambulate with no assistive device, stand by assist (SBA)/contact guard assist (CGA) while observing oxygen saturation. However, the resident's care plan dated 04/26/2023, revealed the resident was independent in the room with a walker, and interventions included the resident to wear proper non-skid footwear when up and practice oxygen tube safety. Resident #16 stated he/she was in the bathroom on 05/04/2023, without wearing nonskid footwear, stepped over oxygen tubing, lost his/her balance, and fell hitting his/her left shoulder. However, staff failed to implement proper nonskid footwear or address the PT's discharge recommendations to ensure the resident's safety. 3. Review of Resident #17's medical record revealed the facility assessed the resident to be a risk for falls due to weakness, impaired cognition, and decreased mobility. Review of Resident #17's care plan dated 03/29/2023, revealed the resident required a contour mattress to prevent falling out of bed. On 04/01/2023 interventions added included extensive assistance of two (2) staff members for bed mobility, transfers, and bathing, and the resident was non-ambulatory. Resident #17 experienced a fall on 04/17/2023 by rolling out of bed and did not have a contour mattress on the bed. This care plan intervention had not been implemented. 4. Review of Resident #18's medical record revealed the facility assessed the resident to be a high risk for falls due to gait and balance issues related to a Cardiovascular Accident (CVA) with right side hemiplegia. Review of Resident #18's fall investigations revealed the resident had a fall on 04/08/2023 and another fall on 04/17/2023, and both involved the resident falling out of bed. Interventions in the care plan for the first fall, such as ensure the urinal was at the bedside was not developed, and staff did not assist the resident to the bathroom as per the care plan. For the second fall, interventions were developed of fall mat to the side of the bed, and move the resident closer to the nurses' station. However, per observation and interviews, staff failed to implement fall safety interventions as Resident #18 was not moved closer to the nurses' station and did not have a mat placed to the side of his/her bed. 5. Review of Resident #19's care plan revealed the resident was dependent on a two (2) person physical assistance for bathing, bed mobility, toileting, and transfers. The resident was placed on a Low Air Loss (LAL) mattress since date of admission; however, no resident specific guidelines were provided to ensure safety of the mattress. Resident #19 rolled from the bed to the floor while Certified Nursing Assistant (CNA) #7 was performing personal care. CNA #7 stated she did not look at the Kardex (nurse aide care plan) to see the resident required a two (2) person assistance with personal care. 6. Review of Resident #88's care plan revealed CNA #4 failed to implement the care plan for residents at risk for behaviors, and the resident exhibited abusive behaviors to include verbal and physical aggression toward staff during personal care. Consequently, CNA #4 failed to implement behavioral interventions and cursed at the resident. The facility's failure to ensure residents' care plans were resident specific related to their physical needs, behaviors and required supervision as well as guidelines to address the settings and required staff for assisting residents on LAL mattresses with interventions implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 07/08/2022 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K; 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K; 42 CFR §483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR 483.75 Quality Assurance and Performance Improvement (F867), at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. The facility was notified of the Immediate Jeopardy on 05/26/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, with the facility alleging removal of the Immediate Jeopardy on 06/01/2023. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on 06/01/2023, prior to exit on 06/10/2023, which lowered the scope and severity (S/S) to an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled Comprehensive Care Plan, dated 01/13/2018, revealed staff members were to ensure the resident or his/her representative was included in all aspects of the person-centered care plan. Per the policy, the planning was to include the provision of services to enable the resident to live with dignity and support the resident's goals, choices, and preferences which included, but were not limited to, goals related to the resident's daily routines. The policy stated care plans must be prepared with input from the Interdisciplinary Team (IDT), which included, but was not limited to the Physician, a Registered Nurse (RN), and a Nurse Aide with responsibility for the resident. The policy also stated staff should include input from the resident and his/her representative to the extent practicable. Per the policy, the care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. 1. Review of Resident #1's closed medical record revealed the facility admitted the resident, on 05/11/2018, with diagnoses that included Unspecified Dementia without Behavioral Disturbance, Need for Assistance with Personal Care, Age-Related Osteoporosis without Current Pathological Fracture, and Specified Disorders of Bone Density. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 01/11/2022, revealed the resident had no history of falls since admission and was not interviewable, with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), which indicated severe cognitive impairment. The assessment also indicated Resident #1 was at risk for pressure ulcer/injury, but had no unhealed pressure ulcers; however, the resident was currently treated with a pressure reducing device for chair and bed. The assessment also indicated the resident required extensive assistance of two (2) staff members for bed mobility, transfers, and toileting. Review of Resident #1's CCP, initiated 05/29/2018, revealed staff identified that the resident was at risk for falls related to the fall risk score, balance problems, weakness, restless/anxious behaviors at times, required assistance with transfers and bed mobility, and possible side effects of medication. Interventions implemented since admission included staff to ensure one-half (1/2) side rails while in bed for turning and repositioning, bed in lowest position, mechanical lift for transfers, call light in reach, and promote use of appropriate footwear when up. Additional interventions were added on 06/13/2018, to include increased supervision of visual checks when resident was up in his/her chair; however, no resident guidelines were provided. Additionally, interventions added on 02/29/2020, indicated staff was to ensure resident to be only up one (1) to two (2) hours as tolerated in the reclining wheelchair, and to increase visual checks when resident was up in the chair; however, no resident guidelines were provided to explain the type of supervision, such as one-to-one (1:1) and the time frame of visual checks. Review of Resident #1's Physician's orders for January 2020, revealed an order for an air mattress (alternating pressure system developed for the comfort of the resident) every day and night shift. However, the resident was not care planned for the air mattress, as no ordered setting guidelines were provided based on the resident's weight or documented evidence of a monitoring system in place to ensure the safety and functioning of the air mattress and to ensure proper settings to correlate with the resident's weight. Review of Resident #1's Incident Audit Report, dated 02/16/2022 at 9:35 PM, revealed the resident was found on the floor next to his/her bed, and the resident stated he/she did not know what happened or how he/she ended up on the floor. Resident #1 was sent to the Emergency Department (ED), and the Computed Tomography (CT) scan showed an acute fracture of the anterior/posterior C2 (cervical) vertebrae. The Interdisciplinary Team (IDT) concluded the root cause of the fall was from the air mattress (the resident rolled out of the bed). Therefore, a new intervention was to discontinue the air mattress and apply a contour mattress (edges on the mattress were built higher than the center to keep the resident from rolling out/off the bed). Review of Resident #1's Incident Audit Report, dated 07/08/2022 at 2:30 PM, revealed the resident was found lying in the floor next to his/her wheelchair in the lounge on the 200 Unit. The resident was trying to get up and screaming that he/she just wanted to go back to bed. The IDT concluded the root cause of the fall was the resident desired a position change. The resident was sent to the hospital. Resident #1's hospital record, dated 07/08/2022 revealed x-ray imaging showed Resident #1 had an acute nondisplaced fracture of the proximal tibial metaphysis; bilateral tibial fracture, and right distal fibula avulsion fractures, with no surgical intervention recommended. Review of Resident #1's care plan updated 07/13/2022, after Resident #1's second fall on 07/08/2022, revealed interventions to include when resident was restless in the bed or chair, offer position change, and every fifteen (15) minute supervision checks. However, the interventions that were in place before the fall to ensure resident to be only up one (1) to two (2) hours as tolerated in the reclining wheelchair, and to increase visual checks when resident was up in the chair were not implemented. During an interview on 05/18/2023 at 2:25 PM with Licensed Practical Nurse (LPN) #9, she stated air mattresses would increase residents' risk for falls, and she would expect staff to increase supervision with residents on air mattresses, ensure the bed was in the lowest position, and bed rails were in place, if ordered. She stated interventions should be implemented to prevent falls and care planned appropriately. She stated, if this was not done, residents could fall again with an adverse outcome, as Resident #1 did, with his/her second fall. LPN #9 stated there should have been one-to-one (1:1) supervision, and the resident should only have been up in the chair for two (2) hours, as care planned. During an interview on 05/19/2023 at 12:15 PM with CNA #34, he stated he did not receive any type of training or education from the facility. However, he stated he knew if a resident was up and requested to go back to bed, it was the resident's right to be placed back to bed. He said this was especially true if the resident was attempting to get up on his/her own and was care planned with guidelines when up in a wheelchair. Further, he stated most of the time when residents were in the dayroom/lounge, there was no supervision, no one-to-one (1:1) monitoring, or staff to sit with the residents. He added related to air mattresses, he believed they put the residents at risk for falls, due to their body alignment, and it could push the resident out of the bed. Therefore, he stated training and education should be done to ensure resident safety. During an interview on 05/22/2023 at 4:45 PM with LPN #4, she stated she had worked at the facility since June 2021, and since that time, no staff members had stayed in the dayroom/lounge/dining room on the 200 Unit to supervise residents. She added, if a resident was eating, the resident might have a staff to monitor; however, there was no schedule for monitoring. She stated, staff will take turns and work together to ensure resident safety. Further, LPN #4 stated there was no documentation log and/or charting system to ensure residents' siderails were in place, the bed in the lowest position, and air mattress settings were accurate. She stated it was the nurse's responsibility to ensure resident safety and ensure care plans were being implemented accurately, and if not, it could put residents at risk of having a negative outcome, such as falls with or without injuries. During an interview on 05/24/2023 at 4:45 PM with RN #7, she stated she was aware Resident #1 had fallen prior to the current fall, and the resident had requested to go back to bed approximately thirty (30) minutes prior to this fall. She stated, however, she was not familiar with Resident #1's care plan, interventions, or that the resident was a fall risk. Therefore, RN #7 stated this put the resident at danger for an injury. In addition, RN #7 stated the facility did not provide the education needed for residents at risk, the investigation process, or updating the care plan. She added, the facility did not do a thorough investigation, which was the resident's right. She stated if staff was not familiar with the resident, not getting educated on the care plan put the resident at risk. During an interview on 05/18/2023 at 3:53 PM with the Assistant Director of Nursing (ADON), she stated air mattresses increased a resident's risk for falls, and she expected staff to increase supervision with residents that had an air mattress. The ADON stated she did not recall Resident #1's second fall; however, she would expect staff to implement the care plan interventions, because she said, They are a safeguard for the residents, and I would have expected my staff to assist the resident back to bed, it is the residents right. In addition, the ADON stated she did not recall any education that was provided to staff or any discussion related to the resident's second fall, as she stated, I might not have been there, not involved. During an interview on 05/24/2023 at 9:30 AM with the Director of Nursing (DON), she stated she had not been monitoring the air mattresses, and she did not check the care plans to ensure the air mattresses were care planned with the setting accuracy. Therefore, the DON stated, if the setting was not correct and monitored, the mattress would be of no benefit to the resident, putting him/her at risk. In addition, the DON stated supervision meant direct visualization of the resident, into the room to see the resident to ensure resident safety. She added, in the 200 Unit dayroom/lounge, it was right outside of the nurses' station; however, staff could not see the resident unless inside the room. Further, the DON stated she expected staff to supervise and listen to the residents and their requests, to always ensure resident safety, and to have a staff member in the dining room/lounge, not just at mealtimes. She stated at other times, residents should expect staff to monitor them due to potential choking, falls, and/or other incidents. During an interview on 05/24/2023 at 10:22 AM with Advanced Practice Registered Nurse (APRN) #1, related to Resident #1's second fall, the APRN stated she would expect the resident to be monitored in the dining room related to his/her history in order to prevent another injury. She stated, per the resident request's and the intervention to be up in the wheelchair as tolerated, obviously, the resident was not tolerating being up and should have been put back to bed. She stated this resulted in a negative outcome that could have been prevented. 2. Review of Resident #16's medical record revealed the facility admitted the resident, on 06/29/2022, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia/Hypercapnia, and Dependent on Oxygen (O2). Review of Resident #16's Quarterly MDS Assessment, dated 03/14/2023, revealed the resident had no history of falls since admission was assessed to have a BIMS score of fifteen (15) of fifteen (15), which indicated the resident had intact cognitive response. The assessment also indicated Resident #16 was assessed for oxygen therapy; was independent with bed mobility, personal hygiene, transfers, and toileting; was independent with set up assistance with dressing and eating; and was independent with walker in room for ambulation. Review of Resident #16's CCP, initiated on 06/30/2022, revealed staff identified that the resident had an activities of daily living (ADL) self-care performance deficit related to weakness, impaired mobility, impaired gait/balance, pain, and shortness of air (SOA). Interventions indicated the resident was independent with a walker in the room for ambulation, to give assistance upon request for locomotion, and was independent with bed mobility, personal hygiene, transfers, and toileting. Additional interventions were added on 07/01/2022 for staff to assist with ADLs per resident's request and when there was increased SOA. Additionally, on 07/01/2022, the resident was care planned as at risk for falls related to gait/balance problems and medication regimen. Interventions indicated staff was to be sure the resident's call light was within reach, encourage the resident to always wear nonskid footwear, and Physical Therapy (PT) to evaluate and treat as ordered or as needed (PRN). Review of Resident #16's Incident Audit Report, dated 05/04/2023 at 8:07 PM, revealed the resident was found sitting in the bathroom floor with his/her back against wall, and the resident was not wearing nonskid socks. The resident stated he/she tripped over the oxygen tubing and hit his/her head on the wall. Per Resident #16's hospital medical record diagnostic imaging of the left shoulder, dated 05/05/2023, the resident had a chronic left clavicle fracture with displacement. Review of Resident #16's care plan, updated on 05/04/2023, after the resident's fall on 05/04/2023, revealed interventions for staff to ensure the resident was educated on wearing proper nonskid footwear and oxygen tubing safety. An additional intervention, on 05/30/2023, revealed the resident was ordered retractable oxygen (O2) tubing. Review of Resident #16's Physical Therapy discharge summary recommendations, dated 04/27/2023, revealed the resident's maximum potential had been achieved as he/she was able to tolerate prolonged ambulatory distance with no assistive device (AD). The discharge summary stated the resident continued to require stand by assist (SBA)/contact guard assist (CGA) while observing oxygen saturation. However, the resident's care plan, dated 04/26/2023, revealed the resident was independent in the room with the walker. During an interview on 05/24/2023 at 8:30 AM, Restorative Aide (RA) #1 stated there was an issue with the PT discharge plan not matching the resident's Kardex and care plan. 3. Review of Resident #17's medical record revealed the facility admitted the resident, on 03/13/2023, with diagnoses that included Alzheimer's Disease with Dementia, Atrial Fibrillation (on Plavix, an anticoagulant), and COPD. Resident #17 was assessed to be a risk for falls due to weakness, impaired cognition, and decreased mobility. Review of Resident #17's admission MDS Assessment, dated 03/17/2023, revealed the resident had no history of falls since admission. Further, the resident was assessed to have a BIMS score of ninety-nine (99), which indicated the resident could not complete the BIMS assessment tool. The assessment also indicated Resident #17 triggered for mood and behavioral symptoms. The assessment also indicated the resident required extensive assistance of two (2) staff members for bed mobility, bathing, transfers, and toileting, and the resident was non-ambulatory. Review of Resident #17's CCP, dated 03/13/2023, revealed the resident required extensive assistance with Activities of Daily Living (ADL); required assistance of two (2) staff for bed mobility, transfers, and bathing; and the resident was non-ambulatory. In addition, staff identified that the resident was at risk for falls related to new environment, balance problems related to weakness, use of psychotropic medication, poor safety awareness, and behaviors. Interventions indicated staff was to ensure call light within reach when in room, hands on assist with transfers, and observe for any fall related side effects from psychotropic medications, such as increased drowsiness or dizziness and staggering gait. Continued review revealed Resident #17 was care planned for altered psychosocial needs related to dementia with interventions for staff to monitor behavior every shift and document if noted; provide non-pharmacological interventions such as one-to-one (1:1) supervision (specify); however, no one-to-one (1:1) resident guidelines were provided to ensure the resident's safety. According to Resident #17's plan of care, dated 03/29/2023, an intervention was added for a contour pressure reducing mattress; however, the resident had not been care planned for another type of mattress prior to this intervention. Review of Resident #17's Incident Audit Report, dated 04/17/2023 at 12:49 AM, revealed the resident was lying in the floor, on his/her back beside the bed. The report stated the resident had rolled out of bed, hitting his/her face on the floor, with lacerations and hematoma to the forehead and bridge of the nose. Review of Resident #17's hospital medical record revealed a CT scan showed the resident had an acute minimally displaced nasal/septum fracture. Review of Resident #17's plan of care updated on 04/17/2023, after resident fall on 04/17/2023, revealed interventions for an additional contour pressure reducing mattress to define parameters of mattress; although, the resident had been care planned for a contour mattress dated on 03/29/2023. Additional interventions initiated on 04/17/2023 to include fall mat to the left side of the bed, and per family request, the right side of the bed was to be against the wall. The Executive Director (ED) stated, in an interview on 05/23/2023 at 11:10 AM, she did not know how the fall could have been prevented unless staff would have put the contour mattress on sooner (which was care planned on 03/29/2023 but not done). She stated the reason for the mattress change was to have a barrier to help prevent the resident from falling from the bed. She further stated, Resident #17 did fine when up in a wheelchair because he/she was not as fidgety. 4. Review of Resident #18's medical record revealed the facility admitted the resident, on 02/15/2023, with diagnoses that included Alzheimer's Disease with Dementia, Cardiovascular Accident (CVA) with Right Side Hemiplegia and Depression. Review of Resident #18's Quarterly MDS Assessment, dated 04/03/2023, revealed the resident was assessed with a BIMS score of twelve (12) of fifteen (15), which indicated moderate cognitive impairment. The assessment also indicated Resident #18 had a history of falls since admission with injury. According to the MDS assessment, Resident #18 required the extensive assistance of two (2) persons, and physical assistance for transfers, bed mobility, bathing, and toileting. However, the assessment for how the resident walked between locations in his/her room indicated activity did not occur. Additionally, the assessment indicated the resident was incontinent of bowel and bladder, with no toileting program currently being used to manage the resident's bowel/bladder incontinence. Review of Resident #18's CCP, initiated on 03/07/2023, revealed staff identified that the resident was at risk for falls related to gait/balance problems, use of antidepressant medication, and the resident would raise and lower height of bed on his/her own. According to the plan of care related to the resident's risk for falls, interventions indicated staff was to ensure the resident's reacher was close to him/her to grasp items; the resident wore appropriate footwear; and staff was to observe for fall related side effects from antidepressants, such as increased drowsiness, dizziness, or a staggering gait. Continued review of Resident #18's plan of care revealed the resident had functional bladder incontinence related to dementia and impaired mobility with interventions as indicated for staff to encourage and assist the resident with transferring to the bathroom commode during rounds and would need to stay with the resident and check every two (2) to three (3) hours and as required for incontinence. Further review revealed an additional intervention added on 03/22/2023, for standard mattress changed to forty-two (42) inch wide mattress. Review of Resident #18's Incident Audit Report, dated 04/08/2023, revealed between 4:00 PM to 5:00 PM the resident was found on floor at the foot of both beds in his/her room; the fall was unwitnessed; and no injury resulted from the fall. Per the report, the resident was attempting to transfer self to the bathroom when the fall occurred. The report stated Resident #18 was noted to have incontinence when assessed post-fall. Review of Resident #18's plan of care revealed an update on 04/10/2023, which indicated for staff to keep urinal within reach when the resident was in bed. However, in the resident's care plan, prior to the fall, staff had failed to develop this intervention to address the resident's functional bladder incontinence and had failed to assist the resident to the bathroom. Review of Resident #18's Incident Audit Report, dated 04/17/2023, revealed at 7:50 PM, Resident #18 sustained another fall within nine (9) days from the initial fall on 04/08/2023; however, this unwitnessed fall resulted in the resident having a nasal/septum fracture and fracture of the anterior maxillary process. Resident #18 was found on his/her stomach lying in the floor beside the bed. Resident #18 stated, I fell out of bed. Further review of the report revealed on 04/18/2023, the IDT reviewed and concluded the root cause was that the resident lies on his/her side in bed when resting. Since the resident was currently on a wider mattress, new interventions were to consider moving the resident to a room closer to the nurses' station and place a fall mat to the left side of the bed. Review of Resident #18's plan of care updated on 04/17/2023, after the resident's second fall with a major injury, revealed interventions to include to consider moving the resident to a room closer to the nurses' station, bilateral pivot assist bars to assist with bed mobility and transfers, and a fall mat to the left side of the bed when the resident was in the bed. However, observations revealed Resident #18 had not been moved to a room closer to the nurses' station and did not have a mat placed to the left side of the bed on 05/19/2023 or 05/22/2023. During an interview on 05/23/2023, with the Social Services Director (SSD), she stated Resident #18 did not have a mat on the morning of 05/23/2023, and she requested a fall mat be brought to the room. During an interview on 05/23/2023, with the Maintenance Supervisor, he stated Resident #18, for over a month, did have a fall mat in the room. However, he stated it was folded up and against the wall. 5. Review of Resident #19's record revealed the facility admitted the resident, on 09/10/2021, and the resident was assessed to be a high risk for falls due to muscle rigidity secondary to Parkinson's Disease with other diagnoses that included Unspecified Dementia and Aphasia. Review of Resident #19's Quarterly MDS Assessment, dated 03/14/2023, revealed the resident had no history of falls since admission and was not interviewable, with a BIMS score of ninety-nine (99), which indicated the resident was unable to complete the BIMS assessment instrument. The assessment also indicated Resident #19 required extensive assistance of two (2) staff members for bed mobility, transfers, dressing and toileting (incontinent of bowel and bladder), but was not on a toileting program. According to the assessment, Resident #19 was at risk for pressure ulcers (PU) and was assessed to need a pressure reducing bed/mattress. Review of Resident #19's CCP, initiated 09/22/2021, revealed staff identified that the resident was at risk for falls related to balance problems, due to weakness, impaired vision, incontinence, and impaired cognition. Interventions indicated staff was to ensure the resident was centered in the bed after providing care. Continued review revealed Resident #19 was care planned for altered psychosocial needs related to dementia with interventions for staff to monitor behavior every shift and document if noted, provide non-pharmacological interventions such as redirect with activity, offer fluid/food, offer reassurance/conversation, one-to-one (1:1) supervision (specify); however, no specific one-to-one (1:1) guidelines were provided for staff, and it was not specified. Ongoing revi[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 to prevent accidents or hazards. In addition, the facility failed to conduct a thorough fall investigation that led to a root cause determination; along with the development and implementation of an action plan after each fall for five (5) of forty-seven (47) sampled residents (Residents #1, #16, #17, #18 and #19). 1. On [DATE], Resident #1 was ordered an air mattress (alternating pressure system) for his/her comfort, without assessing the resident's needs and safety for the device. Review of the manufacture's recommendation for the air mattress revealed that to avoid the risk of death or injury from falling, staff were to read the user manual prior to its use. Continued review of the manufacture's recommendation revealed it was the requirement that the residents would be assessed and monitored for its use, for the resident's safety. Subsequently, on [DATE], the resident experienced a fall from his/her air mattress and sustained injuries which resulted in a Cervical (neck) Fracture. In addition, Resident #1 sustained a second fall on [DATE] from his/her wheelchair while in the lounge area. Resident #1, prior to his/her fall, told staff he/she wanted to go to bed. Interviews and record review revealed Resident #1 was in his/her wheelchair for approximately four (4) hours without staff acknowledging the resident's request. As a result, the resident attempted to stand from his/her wheelchair and fell on the floor. The resident sustained a Displaced Fracture of the Proximal Tibial Metaphysis Bilaterally. The resident returned to the facility on [DATE], with Hospice/Palliative care services and expired on [DATE]. 2. On [DATE], Resident #16 stated he/she was in the bathroom, stepped over his/her oxygen tubing, and lost his/her balance. The resident fell and hit his/her left shoulder on the wall of his/her bathroom. The resident sustained a Chronic left Clavicle Fracture with Displacement. The facility identified the root cause of the resident's fall was the lack of the non-skid footwear. However, the facility failed to implement changes to the resident's oxygen tubing, to reduce the resident's falls risk. 3. On [DATE], Resident #17 was found lying on the floor, on his/her back, beside his/her bed. Further review revealed Resident #17 hit his/her face on the floor. The resident sustained injuries to include a nasal bone and Septum Displaced Fracture. Review of the facility's falls incident report revealed the facility failed to complete a thorough investigation to support the determination of the root cause of restless. 4. On [DATE], Resident #18 sustained a fall out of his/her bed and the Hospital Record revealed, the facility had removed the resident's bed railings due to safety concerns. The facility's investigation revealed the resident fell out of bed. However, there was no other investigation completed to determine the root cause of the resident's fall to ensure appropriate interventions were in place to prevent the resident's falls. The resident sustained injuries which included a Nasal Septum Fracture and Fracture of the Anterior Maxillary process. 5. On [DATE], Certified Nursing Assistant (CNA) #7 performed incontinence care without another staff member. Resident #19 rolled from his/her bed to the floor during incontinence care. The root cause was determined to be the resident was on an air mattress; however, the facility failed to determine within the root cause analysis that the resident was assessed to have two (2) staff to assist with his/her bed mobility. The resident sustained injuries to include a nasal bone fracture with a 9 centimeter (cm) facial laceration . The facility's failure to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents has caused or is likely to cause serious harm or serious injury to the residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K; 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K; 42 CFR §483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR §483.75 Quality Assurance and Performance Improvement, at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. 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 Fall Management, dated [DATE], revealed a fall was an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface, which included onto a bed, chair, or bedside mat. The policy stated injury related to a fall was any documented injury that occurred as a result of or was recognized within a short period of time (hours or to a few days) after the fall and attributed to the fall. According to the policy, a major injury included bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. Continued review of the policy also revealed a fall risk observation was completed on admission, quarterly, and annually, with any significant change in condition, and with any fall, and was utilized to identify individuals who were at high risk for falls. Further review of the policy revealed fall prevention was achieved through an interdisciplinary approach to managing risk factors and implementing appropriate interventions to reduce the risk of falls. Continued review of the policy revealed staff were to develop a plan of care, which included general and specific interventions to reduce fall risk. The policy further revealed staff were to investigate falls and complete a root cause analysis and determine an intervention based on information gathered from the investigation of the falls. The policy also stated the investigation and root cause analysis of a fall may include medications that place a resident at risk for falls, intrinsic/extrinsic fall risk factors, time of day, and devices used at the time of the fall. Review of the Low Air Loss Mattress owner's manual titled Invacare Micro Air MA65 Series, dated [DATE], revealed to avoid the risk of death or injury from falling: Invacare suggested staff read and used the User Manual prior to using the product. Further, rails were to be in the raised position whenever a {resident} patient was in the bed, proper {resident}patient assessment and monitoring was required to prevent injury, variations in bed rail dimensions, and mattress thickness, size, or density would increase the risk of injury. Further review revealed staff were to work with a therapist, physician, and other medical staff to perform assessments to complete {resident} patient monitoring, to avoid death, injury. 1. Review of Resident #1's Closed Medical Record revealed the facility admitted the resident on [DATE] with diagnoses that included: Unspecified Dementia without Behavioral Disturbance, Age Related Osteoporosis without current Pathological Fracture, and Fatigue. Continued review revealed the resident was placed under hospice/palliative care on [DATE] and expired at the facility on [DATE]. Review of Resident #1's Physician Orders for [DATE] revealed an air mattress (alternating pressure system) was ordered for the comfort of the resident; every day/night shift. Review of Resident #1's admission Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had no history of falls since admission. Continued review revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. Further review revealed the resident was at risk for pressure ulcer/injury and was assessed to have had no unhealed pressure ulcers. Review of Resident #1's Comprehensive Care Plan initiated on [DATE] revealed the resident was care planned for at risk for falls related to: his/her fall risk score, balance problems, weakness, restless/anxious behaviors, required assistance with transfers, bed mobility, and possible side effects of his/her medication. Interventions implemented since admission included staff were to ensure one-half (1/2) side rails while in bed for turning and repositioning, bed in the lowest position, mechanical lift for transfers, call light in reach, and promote the use of appropriate footwear when up. Additional interventions were added on [DATE], to include increased supervision of visual checks when the resident was up in his/her chair. Additionally, interventions were added on [DATE], indicating staff were to ensure the resident was to only be up one (1) to two (2) hours as tolerated in a reclining wheelchair. The facility failed; however, to ensure the resident was assessed and monitored for his/her air mattress, to ensure the safety of the resident to prevent injury, as well as, failed to care plan for and manage for the risk factors and implementation of the intervention to reduce the risk of falls while utilizing the air mattress, as per the facility's policy. 1 a.) Review of the facility's Incident Audit Report dated [DATE] at 9:35 PM revealed the resident was found on the floor next to his/her bed, with his/her feet towards the head of the bed and his/her head next to the wall. The resident was noted to have had a knot on his/her left side of his/her scalp. The resident stated he/she did not know what happened or how he/she ended up on the floor. According to the incident report, there were no witnesses to the incident and the resident was assessed to have no injuries. Continued review of the incident report, revealed the resident's pain level was not assessed, and the predisposing environmental/situational factors were not documented. Further review of the facility's incident report revealed on [DATE], the facility's Interdisciplinary Team (IDT) met and concluded the root cause was that the resident was unable to provide a description of his/her fall related to impaired mental status due to his/her diagnosis of Dementia. Review of the Nurse's Progress Note, dated [DATE] at 10:00 PM, revealed the resident had a change in condition; a fall with a hematoma to the left side of his/her scalp. Review of the Nurse's Progress Note, dated [DATE] at 09:30 AM, revealed the resident complained of neck and left arm pain upon movement. Further review of the Note revealed an order was obtained to send Resident #1 to the emergency room (ER) for an evaluation. Review of Resident #1's Hospital Medical Record, dated [DATE], revealed the resident had an admitting diagnosis of an initial fall encounter, a Nondisplaced Fracture of the second Cervical Vertebrae (vertebrae of the neck, immediately below the skull) related to a fall. During a telephonic interview on [DATE] at 10:25 AM, with Certified Nursing Assistant (CNA) #33, she stated she no longer worked at the facility. CNA #33 stated she was familiar with Resident #1 and recalled working the day Resident #1 was found on his/her floor. According to the CNA, she was working the 6:00 PM -6:00 AM shift and as she was walking up the hallway, she observed Resident #1 on the floor of his/her room with other staff at the resident's side. CNA #33 could not recall the exact date and/or time; however, she recalled Resident #1 to be fidgety and squirming around a lot. Further, she stated the resident had body alignment issues and the resident received a new fall mattress after his/her fall. CNA #33 stated that it was the facility's practice to provide an air mattress to the residents that tried to move around a lot. She further stated that if the air mattress was not straight or properly inflated, it could easily, at any time, cause the resident to fall off the mattress. CNA #33 stated residents deserve to have proper interventions and implemented procedures to ensure their safety and to prevent falls. In an interview, on [DATE] at 2:25 PM, with Licensed Practical Nurse (LPN) #9, she stated on [DATE], she was completing her rounds at approximately 10:00 PM to 11:00 AM, when she found Resident #1 on the floor, next to the side of the bed between the wall and the bed. The LPN stated Resident #1 could not recall what happened. LPN #9 stated the physician was notified and she was instructed not to send the resident out, but to continue to monitor the resident. Further interview with the LPN revealed the resident began to complain of pain in the early morning and was sent to the emergency room (ER) for evaluation. LPN #9 stated there was no night shift supervisor at that time; however, the Executive Director (ED) started the investigation process when she came in the next morning. LPN #9 further stated, on [DATE] at 2:25 PM, Resident #1 favored his/her right side and was on an air mattress; however, LPN #9 could not recall the resident's fall risk precautions at the time of the fall, but stated that after the resident's fall, his/her air mattress was switched out to a contour mattress and the resident was on every fifteen (15) minute checks upon return from the hospital. LPN #9 revealed the air mattresses would increase the resident's risk for falls and she would have expected staff to increase supervision with residents on air mattresses. LPN #9 stated interventions should have been put in place and implemented to prevent falls. In an interview, on [DATE] at 1:05 PM, with the Maintenance Supervisor, he stated he was responsible for setting up the air loss mattresses and that he would apply the settings, as per the nurses' instructions. The Maintenance Supervisor stated he did not follow a written physician's order, nor did he utilize the manufacturer's recommendation related to the low Air Loss mattresses. Further, the Maintenance Supervisor revealed he was not part of the Interdisciplinary Team (IDT) meetings, until recently, to discuss the facility's equipment. He stated the air mattresses were a risk factor for residents, especially those residents with mental impairments. In an interview on [DATE] at 3:53 PM with the Assistant Director of Nursing (ADON), she stated during the time of Resident #1's fall on [DATE], she was the Director of Nursing (DON), and she was made aware of the incident on [DATE], at approximately 10:00 PM. The ADON stated she was informed the resident had fallen out of bed and hit his/her head. She stated Resident #1 denied pain but displayed some disorientation. She stated at that time there was no procedure in place; she did not have a working list of residents on air mattresses, or staff that were responsible to monitor the airflow of the mattresses, nor a night shift supervisor to assist with falls investigation. She stated the Interdisciplinary Team (IDT) met the next morning with the Executive Director (ED) and discussed any incidents and changes of condition overnight and IDT, as a team determined the root cause was the resident's air mattress chambers could get full of air and repositioning the resident, increasing the resident's risk for falling out of his/her bed, therefore, new interventions were updated to discontinue the resident's air mattress and apply the contour mattress. Additionally, the ADON stated the air mattresses increased the resident's risk for falls. 1 b.) Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the resident was assessed for a history of falls, with major injury. Further review of the MDS revealed the resident continued to require extensive assistance of two (2) staff members for bed mobility, transfers, and toileting. Review of Resident #1's Nurse's Progress Notes dated [DATE] at 1:10 PM revealed the resident was up in a chair after lunch per the resident's request. Further review of the Note revealed ten (10) to fifteen (15) minutes later, the resident was asking to go back to bed. The resident kept trying to scoot himself/herself out of the chair. Review of the facility's Incident Audit Report dated [DATE] at 2:30 PM revealed the resident was found lying on the floor next to his/her wheelchair. Continued review revealed the resident was trying to get up and screaming that he/she just wanted to go back to bed. The resident had been in the lounge on the 200 Unit, visiting with his/her sister after lunch. Further, the resident stated, I fell out of my chair, wanna go to bed. According to the incident report, there were no witnesses to the incident, the resident was assessed for injuries, his/her pain was addressed, and no documentation of the resident's environmental assessment was reported. A continued review of the report revealed the resident's physiological factors included confusion, impaired memory, and incontinence. Further review of the facility's incident report revealed on [DATE], the facility's Interdisciplinary Team (IDT) met and discussed the resident's fall with injury. The IDT concluded the root cause of the resident's fall was the resident's desire for a position change. A continued review of the Nurse's Progress Notes, dated [DATE] at 3:05 PM, revealed the nurse heard someone yelling for help from the dining room. The resident was found lying on his/her right side, with his/her wheelchair beside him/her. The resident was observed to have a skin tear with bleeding from his/her left lower extremity. Further review revealed the resident's legs were contracted or smaller than the other leg. Review of Resident #1's Hospital admission Record, dated [DATE], revealed the resident was admitted with his/her status post fall from a wheelchair. Continued review revealed the resident was highly demented and x-ray imaging revealed a nondisplaced fracture of proximal tibial metaphysis; bilateral tibial fracture, and right distal fibula avulsion fractures. Further review of the hospital records revealed no surgical intervention was recommended. An additional review revealed the resident was positive for a Urinary Tract Infection (UTI). Review of Resident #1's Physician Orders, dated [DATE], revealed the resident was ordered to receive Hospice Services beginning [DATE]. Certified Nursing Assistant (CNA) #35, in a telephonic interview, on [DATE] at 8:15 PM, stated she worked for the facility in 2022. She stated she did not provide direct care to Resident #1; however, she recalled the resident yelling in the dining room, and he/she was found on the floor with a skin tear to his/her head. She stated another resident stated Resident #1 had requested to go back to bed for several hours, scooting himself/herself down in his/her wheelchair. CNA #35 added, if a resident was attempting to get up on their own and requesting to go back to bed, there would be a greater risk of a fall when the care plan was not followed. Interview on [DATE] at 5:00 PM with CNA #11, stated she worked the 200-unit and was familiar with Resident #1. She stated she believed he/she was the type of resident that tried to get up on his/her own and attempted to get out of bed and his/her wheelchair. CNA #11 recalled staff had gotten the resident up in a wheelchair sometime before lunch, that was all she could recall. Further, she stated if a resident requested to go back to bed, staff, should be proactive and respect the resident's request. She stated it was the resident's right and the staff's responsibility to promote and ensure resident safety to prevent injuries. During an interview on [DATE] at 8:53 PM with Nurse Aide (NA) #1, she stated she worked at the facility from [DATE] thru [DATE]. NA #1 stated she was familiar with Resident #1 and recalled the resident liked to get up and eat breakfast in the dining room with his/her sister, who was also a resident at the facility. She added, on the day of the incident, Resident #1 was up in his/her wheelchair for both breakfast and lunch and the resident was fine for a while as he/she napped in his/her wheelchair, then around lunch between 12:00 PM to 12:30 PM, a CNA told the resident she was going to change the resident and put him/her back to bed. NA #1 recalled pulling Resident #1 up in his/her chair numerous times, due to the resident wiggling in his/her wheelchair and recalled the resident asking to go back to bed about twenty (20) minutes prior to lunch. NA #1 stated the resident fell in the dining room later that afternoon. NA #1 stated all the staff was trying to monitor the residents in the dining room, with no specific designated staff to monitor. Additionally, NA #1 stated staff heard the resident hit the floor, he/she yelled as the wheelchair hit the dining room table. NA #1 stated Resident #1 was put at risk for a fall from the beginning when he/she had requested to go back to bed and demonstrated restless/anxious behavior. In an interview, on [DATE] at 4:45 PM, with Registered Nurse (RN) #7, she stated she was employed at the facility from [DATE] thru [DATE]. She stated she had only worked on the 200-unit a couple of days when Resident #1 had a fall. RN #7 stated Resident #1 was up in his/her wheelchair between 11:00 AM to 3:30 PM. RN #7 stated she was monitoring/watching the resident, in the dining room; however, the resident had requested to go to bed, but RN #7 was in/out of the resident's rooms, passing medications and informed the resident, just a second, let me get a CNA to put you back to bed. RN #7 stated, she looked around and found a student to locate a CNA to assist with putting the resident back to bed. She stated, I was afraid the resident would get up and fall, and instructed the resident to not get up because she knew the resident had a fall prior. RN #7 stated she was the only nurse on the floor as the other nurse had gone on lunch break. She stated she continued to pass out medications to other residents. 2. Review of Resident #16's Admissions Medical Record revealed the facility admitted the resident on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia/Hypercapnia, Anxiety, and Depression. Review of Resident #16's Quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had no history of falls since admission and was assessed to have a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. The assessment also indicated Resident #16 was assessed for oxygen therapy. Continued review of the MDS assessment revealed the resident was independent with bed mobility, personal hygiene, transfers, and toileting. Continued review revealed the resident was assessed to require one (1) person assistance with bathing and one (1) person assistance with a walker out of his/her room for ambulation. Review of Resident #16's Comprehensive Care Plan initiated [DATE] revealed the resident was care planned for Activities of Daily Living (ADL), self-care performance deficit related to weakness, impaired mobility, impaired gait/balance pain, and shortness of air (SOA). Further review revealed interventions included: the resident was independent with his/her walker in his/her room for ambulation, assistance upon request for locomotion, independent with bed mobility, personal hygiene, transfers, and toileting. Additional interventions were added on [DATE] for staff to assist with ADLs per the resident's request and when increased SOA. A continued review of the resident's Comprehensive Care Plan revealed the resident was care planned to be at risk for falls related to gait/balance problems, and medication regimen. Further review revealed interventions included: staff was to ensure the resident's call light was within reach, encourage resident to always wear nonskid footwear and Physical Therapy (PT) was to evaluate and treat as ordered or as needed (PRN). Review of the facility's Incident Audit Report, dated [DATE] at 8:07 PM, revealed Resident #16's roommate yelled for help. Review of the report revealed the Kentucky Medication Aide (KMA) was walking down the hallway and went into the resident's room. Resident #16 was noted sitting on his/her buttock on the bathroom floor with his/her back against the wall. A continued review of the report revealed Registered Nurse (RN) #1 noted the resident had his/her socks on that was not his/her nonskid socks. The resident stated he/she tripped over his/her oxygen cord. Further review of the report revealed the resident hit his/her head on the wall. He/she further stated his/her oxygen cord pulled causing the resident to trip over it. Review of the immediate action taken revealed an order was received to send the resident to the emergency room (ER). Additional review of the incident report, dated [DATE] at 8:07 PM, revealed the resident refused to go to the ER. Further review of the Report revealed a new order to send the resident to the ER if the resident changed his/her mind and the resident was educated on the proper footwear, and safety with oxygen tubing. Continued review of Resident #16's incident report revealed improper footwear was noted as predisposing situational factors. On [DATE] IDT reviewed the resident incident form and concluded the root cause of the resident's fall was the Lack of non-skid footwear. Further, interventions revealed staff were educated on the nonskid footwear for the resident. The facility; however, failed to address the resident's concern with tripping over his/her oxygen tubing. Review of Resident #16's Hospital emergency room Record, dated [DATE] at 4:01 PM, revealed an emergency room (ER) Primary Impression/Diagnosis was a Displaced Fracture of shaft of the left clavicle related to an unspecified fall, initial encounter. Review of Resident #16's Diagnostic Imaging plain film of his/her left shoulder impression, dated [DATE], revealed a chronic left Clavicle Fracture with displacement. Review of Resident #16's Comprehensive Care Plan was updated on [DATE], after the resident's fall, to include interventions for staff to ensure the resident was educated on the resident wearing proper nonskid footwear. The facility identified the root cause of the resident's fall on [DATE] and ordered the resident a retractable oxygen (O2) tubing. 3. Review of Resident #17's admission Medical Record revealed the facility admitted the facility on [DATE] with diagnoses that included Alzheimer's with Dementia, Asthma, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #17's Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident had no history of falls since admission. Further, the resident was assessed to have a Brief Interview of Mental Status (BIMS) score of 99, which indicated the resident's interview was unsuccessful. Continued review of the MDS revealed the resident was assessed to require an extensive assistance of two (2) staff members for bed mobility, bathing, transfers, and toileting. Review of Resident #17's Comprehensive Care Plan, dated [DATE], revealed the resident required extensive assistance with Activities of Daily Living (ADL's); required assistance of two (2) staff for bed mobility, transfers, and bathing. The resident was Care Plan for being non-ambulatory. Review of the resident's care plan related to falls revealed the resident was care planned to be a falls risk related to his/her new environment, balance problems related to weakness, use of psychotropic medication, poor safety awareness and behaviors. Interventions included staff were to ensure the resident's call light was within reach when in his/her room, hands-on assistance with transfers, and observe for falls related to his/her side effects from psychotropic medications such as increased drowsiness or dizziness, and staggering gait. Continued review revealed Resident #17 was care planned for altered psychosocial needs related to dementia with interventions for staff to monitor the resident's behavior every shift and document if noted, provide non-pharmacological interventions such as 1:1 supervision. Review of Resident #17's facility Incident Audit Report dated [DATE] at 12:49 AM revealed the resident was lying on the floor, on his/her back beside the bed. Further review, revealed the resident rolled out of the bed, hitting his/her face on the floor, with lacerations and a hematoma to his/her forehead. The resident complained of increased pain. Further review revealed the resident reported rolling out of bed face first, hitting his/her nose and forehead. The incident report revealed the resident remained oriented to person and situation. Continued review revealed confusion and impaired memory were noted as predisposing physiological factors with no evidence of other predisposing environmental, nor situational factors, and/or documented interviews to demonstrate a thorough investigation. A continued review of the incident report revealed the immediate action taken was to assist the resident to bed, apply pressure to the resident's wound, and the resident was sent to the emergency room (ER) for an evaluation. Review of Resident #17's Hospital Medical Record, dated on [DATE] at 12:37 AM, revealed the resident was triaged with a complaint of a fall with facial lacerations. A review of the resident's ED Disposition after Triage dictated by the emergency room (ER) Physician at 12:37 AM on [DATE] revealed the resident fell at approximately 12:10 AM and it was an unwitnessed fall with lacerations noted to his/her forehead and the bridge of the resident's nose was bleeding but was stopped prior to his/her arrival to the hospital. Review of the physician's documentation also revealed the resident had a vertical directed forehead laceration which measured 2.5 centimeters (cm) in length. The physician further documented that the forehead skin laceration was repaired with skin glue. Continued review of Resident #17's hospital record revealed a Preliminary Radiology Report for a CT scan revealed an acute minimally displaced nasal fracture and nasal septum. 4. Review of Resident #18's admission Medical Record revealed the facility admitted the resident on [DATE] with diagnoses that included Atrial Fibrillation, Alzheimer's/Dementia, Cardiovascular Accident (CVA) with right side hemiplegia, Depression, Diabetes Mellitus Type II, and Chronic Renal Failure (CRF) without dialysis. Review of Resident #18's Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the resident was assessed with a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was moderately impaired. The assessment also indicated Resident #18, had a history of falls since admission with injury. Further review of the MDS assessment revealed the resident required extensive assistance of two (2) persons physical assistance for transfers, bed mobility, bathing, and toileting. Review of Resident #18's Comprehensive Care Plan, initiated [DATE], revealed staff identified that the resident was at risk for falls related to gait/balance problems, and use [TRUNCATED]

Based on interview, record review, review of the facility's policy, and review of the facility's Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled its effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility was cited at the S/S of Immediate Jeopardy during the 06/10/2023 survey. Review of the 02/10/2020 Recertification Survey's Plan of Correction (POC), and the Abbreviated Survey's POC revealed the facility was previously cited at actual harm and Immediate Jeopardy (IJ). The 06/10/2023 survey had repeat deficiencies that had been cited on the 02/10/2020 survey. Review of the fall tracker revealed the facility had a total of one-hundred and eight (108) falls within a four (4) month time period. Of the 108 falls, thirty-three (33) falls resulted in injuries. The facility's Administrator failed to have an effective system in place to investigate the root cause of the residents' falls; failed to develop and implement an action plan after each fall or when there was a change in the resident's condition; and failed to accurately assess the resident and/or residents' environment to determine whether adequate supervision and/or assistive devices necessary to prevent accidents. In addition, the facility was cited six (6) Immediate Jeopardy deficiencies and Substandard Quality of Care (SQC) during this survey. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 07/08/2022 at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices; 42 CFR 483.21 Comprehensive Person-Centered Care Plans ( F656), 42 CFR 483.70 Administration (F835), 42 CFR 483.70 Governing Body (F837), 42 CFR 483.75 Quality Assurance and Performance Improvement QAPI/QAA program (F867) and at 42 CFR 483.70 Medical Director (F841). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices. The facility was notified of the Immediate Jeopardy on 05/26/2023. An acceptable removal plan was received on 06/07/2023. The State Survey Agency determined the immediacy had been removed, 06/01/2023, as alleged, prior to exit on 06/10/2023. Non-compliance remained in the areas of 42 CFR 483.25 Quality of Care (F689) at a S/S of an E; 42 CFR Comprehensive Person-Centered Care Plans (F656) at a S/S of an E; 42 CFR 483.70 Administration (F835) at a S/S of an E; 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI) Program (F867) at a S/S of an E; 42 CFR 483.70 Governing Body (F837) at a S/S of an E; and 42 CFR 483.70 Medical Director (F841) at a S/S of an E. Additional deficient practice was also identified at F583 at a S/S of an E; F600 at S/S of a D; and F602 at S/S of a D; and F761 at a S/S of an E. Refer to F656; F689; F837; F841; and F867. The findings include: Review of the facility's policy titled, Administrator, revised April 2007, revealed the licensed Administrator was responsible for the day-to-day functions of the facility. Continued review revealed the facility's governing body had appointed the Administrator who was dually licensed in accordance with current federal and state requirements. The Administrator was responsible for: Management of day-to-day functions in the facility; residents' rights to fair and equitable treatment, self-determination, individuality, etc.; implementation of established resident care policies and other operational policies and procedures necessary to maintain compliance with current laws, regulations and guidelines governing long-term care facilities; liaison to the governing board, medical staff; and other professional and supervisory staff; evaluation and implementation of recommendations from the facility's committees (Quality Assessment and Assurance); ensure adequate number of personnel employed to meet residents' needs; and, ensuring the facility admitted residents whom it could provide adequate care. Review of the facility's, Job Description for the Administrator, undated, revealed the Administrator directed and performed quality assessment and assurance functions, oversight of the facility's Quality assurance process, including but not limited to regulatory compliance rounds to monitor performance and to continuously improve quality. Implementation of programs to gather and analyze data for trends and to institute actions to resolve problems promptly. Further review revealed the Administrator reported and made recommendations to appropriate committees to include the Governing Body and Medical Director. Continued review revealed the Administrator ensured adherence to proper safety procedures, including but not limited to, prompt investigation and reporting of injury. Ensured proper documentation was maintained, including but not limited to, documentation of investigations, incidents, meetings, staff training and education, to include QAPI improvement plans. The job description further revealed the Administrator developed and updated policies and procedures to reflect the philosophy of the facility, professional standards, and legal requirements. Review of the 02/20/2020, Recertification Survey's POC revealed previously cited deficiencies, included F689, Quality of Care: Free from Accidents/Hazards/Supervision/Devices. The facility failed to have an effective system in place to investigate the root cause of the residents' falls, failed to develop and implement an action plan after each fall or when there was a change in the resident's condition, and failed to accurately assess the resident and/or residents' environment to determine whether adequate supervision and/or assistive devices necessary to prevent accidents associated with falls. Based on observations, interview and record review throughout the survey, revealed the Administrator failed to develop and/or implement an effective system to ensure person-centered Comprehensive Care Plans (CCP) which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment related to falls and supervision; failed to develop and implement care plans related to resident specific guidelines of equipment; (LAL) mattresses and oxygen tubing. Further, the facility failed to provide effective Administrative and Governing body oversight of day-to-day operations of the facility and failed to ensure an effective Quality Assurance Program to provide quality care and services to meet the needs of the residents. During interview on 05/24/2023 at 9:30 AM, with the Director of Nursing (DON), she stated she had been in the DON role since March 2023, and since the last month or so (no specific date provided), she directly reported to the Executive Director (ED). She stated she was involved with care conferences (morning clinical meeting) related to residents' falls and incidents; observe the environment and update the care plan with resident involvement. The DON stated falls were QA'd (Quality Assurance) and discussed, all the data would continue to be QA'd, once a month on Thursday with the physician's involvement. She stated that however, the normal previous routine/procedure, the QA process was to conduct a through chart review and room check; no resident specific discussion. The DON stated her job was to provide oversight to the nursing department and report any concerns to the Administrator. Additionally, she stated she was responsible for the care needs of the facility's residents and supervision of its nursing staff. The DON stated she ensured residents received the necessary care and services and provided the supervision of nursing staff. Further interview revealed the [NAME] President of Clinical Operations and the [NAME] President of Operations (VPO) had been present in the building daily and provided support, education and resources. The Medical Director (MD), stated during interview on 05/05/2022 at 2:30 PM, that in his role as the Medical Director he would coordinate care and if issues were discovered, he would communicate with the Executive Director (ED). The MD further stated that he would expect the staff to follow the residents' plans of care and implement the interventions as ordered. He stated they knew what the problems were, as well as the residents' patterns; unfortunately, they did not follow through. In addition, the MD stated the facility had a high turnover rate and it was difficult to build a system with inconsistent staffing, that was not trained nor educated on the proper care needs of the residents. He further stated this contributed to the increase in falls. However, the MD stated he was engaged in the Quality Assurance Performance Improvement (QAPI) metrics related to falls trending upwards. During interview on 06/10/2023 at 9:44 AM, with the Executive Director (ED), she stated she had been in the role since July 2022 and was responsible for the day-to-day functioning of the facility and was responsible to ensure the facility operated within the state and federal guidelines and maintained regulatory compliance regarding previously cited deficiencies. She also stated she was the Quality Assurance Coordinator and was responsible for the program. In addition, she stated she was required to ensure the ongoing audits related to previously cited deficiencies were reviewed, and if any concerns were identified, they were corrected immediately. The ED stated the facility had put audits in place; however, the facility was focused on the tracking and trending of previous falls specific to the facility's percentages and numbers, not resident specific as to the change with the current Plan of Correction (POC). The ED stated, We were not establishing the actual root cause, neglecting the overall 'resident specific' picture/part, nor the collaborative involvement that was needed, in order to get down to the actual root cause of the fall; therefore, missing the most important parts and potentially putting the residents at higher risk. Currently, a more specific procedure was in place to ensure an immediate and thorough investigation starting with staff education. This included agency staff and a more in-depth education process prior to working, more thorough interviews, resident environmental aspect, resident behaviors, fall risk/history starting from admission and most importantly, to ensure the correct interventions for the right resident. Consequently, if these factors were not addressed as previous, it put the resident at risk with a negative outcome, that could have been prevented. Interview on 06/10/2023 at 10:28 PM, with the [NAME] President of Operations (VPO) revealed he started with the corporation on 05/30/2023. He stated he provided in person oversight to include the Executive Director (ED) and [NAME] President of Clinical Operations (VPCO) starting 05/31/2023. He stated he was involved with the revisions of the POC on 06/05/2023. The VPO stated his role was to provide general operational oversight; policy review and revision, preventive measures to ensure understanding with standards of care, policies and implementation. The VPO stated, the difference in the facility corrections from 2020 falls plan of correction (POC) compared to the current POC, was education with the importance and focus of the root cause analysis; looking into the injuries, appropriate risk factors, starting from the admission process and ensuring proper resident specific preventive measures were in place and sustained. He added, these preventive measures should have already been implemented and a part of the process. However, the procedure moving forward was now to promote resident reviews with the audit and reeducate the staff to include Agency, prior to onboarding, thorough evaluations of risk and appropriateness of interventions, and of importance to look at the resident and address the injuries. In addition, he added the facility's number one goal was to educate at the best of their ability, try to reduce Agency staffing; make accountable for their actions and dismiss the wrong, control the environment, reeducate staff daily and prioritize importance of resident safety and quality of care. Interview on 06/09/2023 at 1:40 PM, with [NAME] President of Clinical Operations (VPCO) revealed she was a member of the facility's Governing Body (GB), which included the ED and VPO, per policy. The VPCO stated her role was to provide facility oversight and ED guidance and education of policies and procedures. She stated she was onsite beginning 05/17/2023, to provide support to staff while the State Survey Agency was in the building with concerns. Additionally, since 05/17/2023 she had been in the facility, periodically attended QAPI, provided a lot of on the spot training; researched QAPI tools to provide education and procedure with root cause analysis, facility trending to increase resident supervision, initiate proper procedure for staff to notify the ED, DON and self, to ensure the investigation was proper. The VPCO stated the facility's failure related to falls, was because there was no system in place. She stated she felt the facility was looking at contributing factors instead of the root cause of the fall, neglecting the resident's needs and not investigating the why did the fall happen, in order to promote a thorough investigation. The VPCO stated the staff were attempting to identify the root cause; however, they needed to provide a more appropriate root cause. She stated there was the need for education on the importance of a system wide approach and how to improve the interviews; the nurse would include their part, but now we need to include the pre-fall with other staff and ensure an immediate investigation/action was performed related to the root cause, with appropriate immediate interventions, and more supervision. Additionally, a new Performance Improvement Plan (PIP) committee was initiated. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, alleging removal of the Immediate Jeopardy on 06/01/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Beginning 05/19/2023, the [NAME] President of Clinical Services (VPCS) re-educated the Executive Director (ED), the Director of Nursing (DON) and the staff Development Coordinator (SDC) on the facility's fall policy. This education included: ensure completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition; ensure that care plans interventions were implemented based on findings of the fall risk assessment; implement an immediate intervention following each fall including a root cause analysis; and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions to include the need for increased supervision or assistive devices as deemed necessary. 2. a.) On 05/19/2023, the Executive Director (ED) and Director of Nursing (DON) ensured that the Staff Development Coordinator (SDC) started re-educating all current Licensed Nurses and Certified Nursing Assistants (CNAs) on the facility's fall policy. The education included, but was not limited to initiating an investigation as to the cause of the fall, implementing an immediate intervention with consideration of the need for increased supervision or the addition of assistive devices, and reviewing/updating the care plan with each fall. b.) Education also included that low air loss mattress settings would be compatible with resident's weight, comfort and appropriate functioning of the mattress. c.) Documentation was added to the electronic medical record (EMR) for verification of low air loss mattress settings every shift to ensure that it remained at the appropriate level for each resident. d.) Staff was educated that residents who required the use of an air loss mattress would require two (2) staff members to assist with turning and repositioning in bed to decrease the risk of falls, and to notify the Nurse Manager if changes were needed regarding the support surface. e.) Newly hired staff, agency staff and staff who had not been educated by 05/31/2023 would receive this education prior to working their next shift. 3. Beginning 05/22/2023, a post education test was administered by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Unit Managers (UM) for all current Licensed Nurses and Certified Nursing Assistants (CNAs) following education to ensure care plan interventions were in place. a.) If a score of 100 percent (100%) was not obtained, re-education would be completed until proficiency was obtained, until score of 100%. b.) Staff members not working on 05/22/2023 would have the education provided and a post-test completed prior to working in the facility. c.) Agency staff and staff on leave of absence would have the education provided and be required to complete the post-test prior to working in the facility. d.) Findings of the tests would be reviewed by the Executive Director (ED) and/or Director of Nursing (DON) to ensure compliance. 4. a.) On 05/22/2023, the Executive Director (ED) and Director of Nursing (DON) ensured the DON/ADON/UM/Nursing Supervisor/Licensed Nurse would complete visual observation rounds on six (6) residents daily across all shifts and all units including weekends and holidays, to ensure care plan interventions were in place to decrease the risk of falls/injuries times two (2) weeks, then six (6) observations three (3) times a week for two (2) weeks, then six (6) observations weekly times four (4) weeks, then six (6) residents monthly until further recommendations by the QAPI committee. The QAPI Committee include: the Executive Director (ED), the Director of Nursing (DON), Infection Preventionist (IP), Maintenance Director, Human Resource Business Partner (HRBP) and the Medical Director (MD). b.) Findings would be reported by a member of the IDT as listed above and would report daily in the QAPI meeting to the Director of Nursing and/or Executive Director to ensure compliance and that corrective actions had been initiated. c.) Residents would be selected by the [NAME] President of Clinical Services (VPCS) and/or DON to ensure residents identified at high risk for falls would be reviewed at least once in the two (2) week cycle. d.) Corrective action would be completed immediately and staff would be reeducated to ensure care plan interventions were in place to decrease the risk of falls/injuries. 5. On 05/23/2023, the Executive Director (ED) ensured that a review was conducted by the [NAME] President of Clinical Services (VPCS), Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Manager (UM) for all current residents' who have experienced a fall within the last 90 days to ensure appropriate notification of physician, responsible party, completion of a root cause analysis, care plan interventions were updated to reflect current needs identified during the root cause analysis, and completion of neurological checks as indicated. Corrective actions were completed as indicated. 6. On 05/23/2023, Managers and Department Leaders, consisting of the ED, DON, ADON, SDC, Activities Director (AD), Business Office Manager (BOM), Social Services Director (SSD), Social Services Coordinator/Assistant (SSA), Unit Manager (UM), Medical Records Coordinator (MRC), and the [NAME] President of Clinical Services (VPCS) completed visual rounds to compare and ensure the residents' care plans/Kardex falls interventions were in place for residents with falls in the last 90 days and ensure interventions were identified and placed on the Certified Nursing Assistants (CNAs) Kardex and were implemented to decrease the risk of falls. 7. a.) Beginning 05/23/2023, the DON, ADON, or Unit Manager (UM) would perform Quality Assurance review audits for residents who experienced a fall to ensure a root cause analysis had been completed with appropriate interventions implemented, the care plan was reviewed/updated, ensure interventions in place and listed on the CNAs Kardex or Point of Care (POC) documentation in electronic medical record (EMR), and follow up documentation was completed by the end of the 72 hours post fall period daily in the QAPI meeting. b.) Areas of concern would be addressed immediately or education or increase in audits. c.) Findings would be reported to the Executive Director (ED) and the Quality Assurance Performance Improvement Committee daily times two (2) weeks, then weekly times four (4) weeks, then monthly thereafter or as determined by the QAPI committee. 8. On 05/29/2023, the Executive Director (ED) and Director of Nursing (DON) received education provided by the Chief Operating Officer (COO) regarding their responsibility to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident. 9. On 05/29/2023, the Executive Director (ED) and Director of Nursing (DON) received education by the [NAME] President of Clinical Services (VPCS) on the past three (3) year's survey history; the policies for falls; accident investigation to include root cause analysis utilizing CMS five (5) Whys, care plan development, care plan revision; the roles and expectations of the administration of the facility; the roles and responsibility of the Governing Body (GB); the roles and responsibilities of the Medical Director (MD), and roles and responsibilities of the Quality Assurance and Improvement (QAPI) committee. 10. a.) On 05/29/2023, the Executive Director (ED) ensured that the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), and the [NAME] President of Clinical Services (VPCS) conducted a review of the falls for Residents #16, #17, #18, and #19 within the last 90 days with a root cause analysis completed or updated as indicated. b.) Review of each resident included an assessment of the resident and the resident's environment to determine the need for increased supervision and/or assistive devices were needed to avoid further accidents. c.) Updated interventions were added to the care plans for Residents #16, #17, #18, and #19 related to the findings of the root cause analysis as indicated on 05/30/2023. 11. a.) Beginning 05/29/2023, an Ad hoc (prime contractor for CMS Website Development Support (CMS WDS) program, which covered many public-facing portions of HealthCare.gov.) A QAPI meeting by the ED, DON, VPCS, Infection Preventionist (IP), Social Service Director (SSD), and Licensed Nurse, was held with the Medical Director (MD) on 05/29/2023 to discuss the above stated plan to ensure care plan interventions were implemented and continued to be in place for residents to decrease the risk of falls/injuries. b.) Findings of audits and corrective actions were discussed, no further recommendations were made by the MD at that time. 12. On 05/29/2023, a Stand-down QAPI meeting was held daily by the Executive Director to review the above stated, to discuss findings of audits of plans for F656, F657, F689, F835, F837, F841, and F867, and determine concerns that may require immediate action. Corrective actions would be initiated immediately. 13. Starting 05/29/2023, a QAPI meeting was held daily times two (2) weeks, then weekly for four (4) weeks, then monthly to ensure continued compliance with the above stated plan with follow-up and recommendations by the governing body, appropriate interventions by the Medical Director (MD), and an effective QAPI to decrease the risk of falls/injuries, for recommendations and further follow-up as indicated. 14. a.) On 05/29/2023, the Executive Director (ED) and Director of Nursing (DON) initiated the plan that beginning 05/25/2023, the Clinical Interdisciplinary Team would review residents who experienced a fall during the morning clinical meeting to ensure a Root Cause Analysis (RCA) was determined, all appropriate interventions to include: consideration of the need for increased supervision and/or assistive devices as deemed appropriate were implemented to assist in preventing further falls, review and update the care plan as appropriate, and ensure intervention was on the Care Plan/CNA Kardex. b.) The DON/ADON/SDC/UM would make an IDT Nurse's Note with the root cause of the fall and intervention that was in place, and add any further interventions recommended by IDT. If further recommendations were suggested, the Licensed Nurse would add to the care plan. c.) A Nurse Manager would validate that the intervention was in place daily in the QAPI meeting. The IDT would evaluate the effectiveness of the intervention(s) and for latent injuries related to the fall daily in the QAPI meeting. d.) The Director of Nursing (DON) would be responsible for ensuring the above meeting was completed as per the plan. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 06/01/2023: 1. Interview on 06/09/2023 at 1:40 PM, with the VPCS indicated on 05/19/2023, the [NAME] President of Clinical Services (VPCS) re-educated the Executive Director (ED), the Director of Nursing (DON) and the staff Development Coordinator (SDC) on the facility's fall policy to include ensuring completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition, ensuring that care plan interventions were implemented based on the findings of the fall risk assessment, implementing an immediate intervention following each fall including a root cause analysis, and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions to include the need for increased supervision or assistive devices as deemed necessary. 2. a.) Review of staff education sheets and staff interviews revealed on 05/19/2023, the Executive Director (ED) and Director of Nursing (DON) ensured that the Staff Development Coordinator (SDC) started re-educating all current Licensed Nurses and Certified Nursing Assistants (CNAs) on the facility's fall policy, including but not limited to initiating an investigation as to the cause of the fall, implementing an immediate intervention with consideration of the need for increased supervision or the addition of assistive devices, and reviewing/updating the care plan with each fall. b.) Education also included that low air loss mattress settings were compatible with resident's weight, comfort and appropriate functioning of the mattress. c.) Observation and record review revealed documentation was added to the electronic medical record (EMR) for verification of low air loss mattress settings every shift to ensure that it remained at the appropriate level for each resident. d.) Staff was educated that residents who required the use of an air loss mattress would require two (2) staff members to assist with turning and repositioning in bed to decrease the risk of falls, and to notify the Nurse Manager if changes were needed regarding the support surface. e.) Newly hired staff, agency staff and staff who had not been educated by 05/31/2023 received this education prior to working their next shift. 3. Review of staff education sheets and interview on 06/09/2023 at 3:05 PM, with the SDC revealed that beginning 05/22/2023, a post education test was administered by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Unit Managers (UM) for all current Licensed Nurses and Certified Nursing Assistants (CNAs) following education to ensure care plan interventions were in place. a.) If a score of 100 percent (100%) was not obtained, re-education was completed until proficiency was obtained, until score of 100%. b.) Staff members not working on 05/22/2023, had the education via in-person or phone communication provided and a post-test was completed and verified prior to working in the facility. c.) Agency staff and staff on leave of absence had the education provided via in-person or phone communication and required completed post-test prior to working in the facility was verified and validated on 06/09/2023. d.) Findings of the tests were reviewed by the Executive Director (ED) and/or Director of Nursing (DON) to ensure compliance. Interview on 06/09/2023 at 3:05 PM, with the SDC stated she had been re-educated on the Care Plan policy per the VPCS and explained the importance of care plan interventions to decrease the risk of resident falls. 3. Review of staff education sheets revealed on 05/19/2023, the SDC started re-educating all the current Licensed Nurses and Certified Nurse Assistants (CNAs) on the facility's care plan policy, to include ensuring that interventions were implemented and in place to decrease the risk of falls. Staff interviews on 06/09/2023 and 06/10/2023 revealed the staff were educated prior to working in the facility. Interview with LPN #15 on 06/09/2023 at 3:45 PM, revealed she had received education on fall risk, accidents/incidents, abuse, low air loss mattress, correct orders with settings and Kardex training in-services to ensure safety for fall risk residents. Interview with Registered Nurse (RN) #6, on 06/09/2023 at 5:00 PM, revealed she had recent education on 06/04/2023 on fall risk residents related to care plan interventions in place and correct documentation. This included resident rights and low air loss mattress orders and settings to ensure resident safety. Interview with Certified Nurse Aide #4 on 06/09/2023 at 4:07 PM, revealed recent training on falls risk; low air loss mattress; abuse; and residents' rights on 06/04/2023. The training also included to ensure the Kardex was to be looked at every for resident's needs and to verify fall risk residents. 4. a.) Review of the facility's documentation to include meeting minutes revealed on 05/22/2023, the Executive Director (ED) and the Director of Nursing (DON) ensured the DON/ADON/UM/Nursing Supervisor/Licensed Nurses completed visual observational rounds on six (6) residents daily across all shifts and all units including weekends and holidays, to ensure care plan interventions were in place to decrease the risk of falls/injuries times two (2) weeks, then six (6) observations three (3) times a week for two (2) weeks, then six (6) observations weekly times four (4) weeks, then six (6) residents monthly until further recommendations by the QAPI committee consisting of the Executive Director (ED), the Director of Nursing (DON), Infection Preventionist (IP), Maintenance Director, Human Resource Business Partner (HRBP) and with the Medical Director (MD). b.) Findings were reported by a member of the IDT as listed above and were reported daily in the QAPI meeting to the Director of Nursing and/or Executive Director to ensure compliance and that corrective actions had been initiated. c.) Residents were selected by the [NAME] President of Clinical Services (VPCS) and/or the DON to ensure residents identified at high risk for falls were reviewed at least once in the two (2) week cycle. d.) Corrective actions were completed immediately, and staff were reeducated to ensure care plan interventions were in place to decrease the risk of falls/injuries. Interview on 06/09/2023 at 4:00 PM, with the SSD stated there were daily QAPI meetings with the ED and VPCS to go over falls, governing body, and care plans. She stated she received education on falls/incidents/air mattress/PIP, and QAPI. The SSD stated she felt it had been beneficial. She stated the QAPI and PIP were not well known to staff, n[TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its Governing Body was actively engaged in ensuring its policies were effectively implemented regarding the management and operation of the facility. The facility's Governing Body failed to ensure the facility sustained substantial compliance in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices, F689; 42 CFR 483.70 Administration, (F835); 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI), F865; 42 CFR 483.70 Governing Body, F837; and 42 CFR 483.70 Medical Director, F841. In addition,, review of the facility's fall tracker documentation revealed the facility noted a total of one-hundred and eight (108) falls occurred within a four (4) month time period. Of the one-hundred and eight (108) falls, thirty-three (33) of the falls resulted in injuries to the resident. (Refer to F656, F689, F835, and F867) The facility's failure to have an effective system to ensure its Governing Body was actively engaged in ensuring its policies were effectively implemented regarding the management and operation of the facility has caused or is likely to cause serious harm or serious injury to the residents. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 07/08/2022 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Develop/Implement Person-Centered Comprehensive Care Plans, (F656) at a S/S of a K; 42 CFR 483.25 Quality of Care, Accidents and Supervision (F689) at a S/S of a K; 42 CFR 483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR 483.75 Quality Assurance and Performance Improvement, (F867) at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, Accidents and Supervision (F689). The facility was notified of the Immediate Jeopardy on 05/26/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, with the facility alleging removal of the Immediate Jeopardy on 06/01/2023. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on 06/01/2023, prior to exit on 06/10/2023. The findings include: Review of the facility's policy titled, Governing Body, undated, revealed the Governing Body in accordance with 42 CFR Section 483.70(d), appointed the designated Administrator. Per review, the Administrator, who was licensed by the State, was responsible for the management of the facility and was to report to and be accountable to the Governing Body. Continued review revealed the policy stated the Governing Body was responsible for and accountable for the facility's QAPI Program. The policy further noted the Governing Body was to fulfill its referenced duties through a combination of onsite visits; Zoom or telephonic conferences; and performance of audits, performed on a scheduled and/or an as-needed basis In addition, the policy revealed the facility's Governing Body was responsible for and accountable for its QAPI Program. During the Recertification Survey, dated 03/05/2020 the facility was cited at 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656 and 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices, F689, at a Scope and Severity (S/S) of a K. During the current survey Immediate Jeopardy was again identified in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656 and 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices, F689, at a S/S of a K. In an interview on 05/05/2022 at 2:30 PM, the Medical Director stated his role as Medical Director was to coordinate care and if issues were discovered, he communicated with the facility's Executive Director (ED). The Medical Director stated he expected facility staff to follow residents' plans of care and implement their interventions as ordered. He stated staff knew what residents' problems were, as well as the resident's patterns; unfortunately; however, the facility had not followed through with necessary interventions. Per the Medical Director, the facility had a high staff turnover rate and it was difficult to build an effective system with inconsistent staffing, who were not trained nor educated on the proper care needs of the residents. He further stated the high turnover rate and inconsistent staffing who were not trained and educated on residents' care needs contributed to the increase in falls. The Medical Director stated however, he was engaged in the facility's QAPI metrics regarding residents' falls trending upwards. In an interview on 06/10/2023 at 9:44 AM, the ED stated she was responsible for the facility's day to day functioning and was responsible for ensuring it operated within state and federal guidelines and maintained regulatory compliance regarding previously cited deficiencies. She stated she was the facility's Quality Assurance (QA) Coordinator and was responsible for the QA program. The ED stated she was required to ensure ongoing audits related to previously cited deficiencies were reviewed, and if any concerns were identified, they were corrected immediately. According to the ED, the facility had implemented audits and revealed the facility had been focused on tracking and trending previous falls specific to the facility's percentages and numbers, and not on resident specific falls. Per the ED, currently, a more specific procedure has been initiated to ensure an immediate and thorough investigation starting with staff education, to include agency staff and a more in-depth education process prior to working, more thorough interviews, reviewing resident environmental factors, resident behaviors, fall risk/history starting from admission and most importantly, to ensure the correct interventions for the right resident. The ED further stated consequently, due to those factors not being addressed as previously, it put the resident at risk for a negative outcome, which could have been prevented. In an interview on 06/10/2023 at 10:28 PM, the [NAME] President of Operations (VPO) stated he started with the corporation on 05/30/2023. He stated he provided in person oversight to the facility's Governing Body, to include the ED and [NAME] President of Clinical Operations (VPCO) starting 05/31/2023, and had been involved with the revisions of the POC on 06/05/2023. The VPO stated his role was to provide general operational oversight; policy review and revision; and preventive measures to ensure understanding with standards of care, policies and implementation. He stated the difference in the facility's corrections from the 2020 falls POC was the education; focusing on the importance of ensuring a root cause analysis and looking into injuries; assessing appropriate risk factors starting from the admission process and ensuring proper resident specific preventive measures were in place and sustained. According to the VPO, those preventive measures should have already been implemented by the facility previously and been a part of its process. He stated however, the procedure moving forward was now to promote resident review with audits; and reeducation of staff to include all agency staff prior to beginning work, regarding thorough evaluations of residents' risk and appropriateness of their interventions, and of the importance of assessing the resident and addressing their injuries. In addition, he stated the facility's number one (1) goal was educating staff to the best of its ability on a daily basis; trying to reduce the use of agency staffing; having accountability for its actions and controlling the environment, and prioritizing the importance of resident safety and quality of care. In an interview on 06/09/2023 at 1:40 PM, the VPCO stated she was a member of the facility's Governing Body which also included the ED and VPO, as per policy. The VPCO stated her role was to provide oversight of the facility and guidance for the ED and education regarding policies and procedures. She stated she had been onsite beginning 05/17/2023, to provide support for staff while Surveyors were in the building. The VPCO stated on 05/19/2023, she identified there were no orders in place and had performed an audit of residents on air mattresses. She stated after the audit two (2) residents on Low Air Loss (LAL) mattresses had those mattresses discontinued. Per the VPCO, since 05/17/2023 she had been present in the facility providing a lot of on the spot training; periodically attending QAPI meetings; researching QAPI tools to use to provide education and procedure with root cause analysis. She stated she also assisted with facility trending to increase resident supervision; initiating a proper procedure for staff to notify the ED, DON and herself, to ensure the facility's investigation were proper. The VPCO stated the facility's failure related to falls, directly having no system in place, she felt had been from looking at contributing factors instead of the root cause of the falls; neglecting the resident needs; and not investigating the why the fall had happened, in order to promote a thorough investigation. She stated staff had attempted to identify the root cause; however, they needed to provide a more appropriate root cause. The VPCO stated there was a need for education on the importance of a system wide approach and improving interviews. Per the VPCO, nurses had their part; however, now the facility needed to include pre-fall education with other staff and ensure an immediate investigation/action was performed related to the root cause, with appropriate immediate interventions implemented, and more supervision provided. Additionally, she further stated a new Performance Improvement Plan (PIP Committee had been initiated. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, alleging removal of the Immediate Jeopardy on 06/01/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Beginning on 05/17/2023, a member of the Governing Body would do the following: onsite at a minimum of four (4) days a week and available by phone twenty-four (24) hours a day seven (7) days a week. (a). Audit incidents and accidents. (b). Complete a review of investigations of incidents and accidents. (c). Ensure QAPI processes and procedures that included results of all audits, analysis of audits, identification of Root Cause of system failures, implementation of corrective actions, and tracking and trending of the facility's processes. 2. On 05/19/2023, the ED and DON received education given by the [NAME] President of Clinical Services (VPCS) on the policies for falls, and accident investigation. The education included: root cause analysis; care plan development; and care plan revisions. 3. On 05/29/2023, the VPCS, a member of the Governing Body, reviewed the removal plans with the ED for F656, F689, F835, F837, F841, and F867 to ensure understanding of the requirements of each plan and to ensure adherence to the plan(s) to decrease the risk of potential injuries to residents related to falls. 4. (a). Beginning 05/29/2023, a review was to be completed with the ED by a member of the Governing Body that included the VPCO. The VPCS, each week beginning 05/29/2023, would follow up to include audits and plans initiated to correct identified concerns. (b). The process also included follow-up with staff members, department heads, external consultant, residents and/or families to assist in evaluating ongoing compliance or deficient practices with the removal plan and/or facility processes regarding the regulatory intent of F656, F657, F689, F835, F837, F841, and F867. (c). Any concerns identified regarding review with the ED were to be immediately addressed/corrected by the ED and discussed with another member of the Governing Body (VPCS or VPCO). (d). Immediate actions were to be taken to ensure the residents' well-being and compliance with the identified regulatory violations. The findings were to be reported to the Chief Operating Officer (COO) starting on 05/29/2023 by the VPO or VPCO weekly. 5. Beginning 05/29/2023, the COO completed education with the members of the Governing Body regarding their roles and responsibilities to provide oversight of the management and operation of the facility to ensure the facility was administered effectively, and to ensure the facility had an effective QAPI program. 6. (a). On 05/29/2023, the ED and DON received education by the VPCS on the roles and expectations of: the administration of the facility, the Governing Body, the Medical Director, and the QAPI Committee. (b). The VPCS re-educated the ED, DON, and Medical Director on the revised Accidents and Incidents/Falls, Investigating and Reporting policies to include notification of the ED and DON. (c). On 05/29/2023, a post test was administered to the ED and DON by the VPCS to validate understanding of the above education. 7. (a). Beginning 05/23/2023, an Ad hoc QAPI meeting was held with the Medical Director regarding the plan for consistent reviews by the Governing Body to ensure the removal plans were followed consistently and to discuss the weekly review with the ED as stated above. No further recommendations were made by the Medical Director regarding the plan. (b). A stand down QAPI meeting was to be held daily by the ED to review the above stated plan, to discuss findings of audits, and determine concerns which might require immediate action. 8. Starting 05/29/2023, a QAPI meeting was to be held daily for two (2) weeks, then weekly times four (4) weeks, then monthly thereafter to ensure continued compliance with the above stated plan to ensure continued compliance with follow-up and recommendations by the Governing Body. 9. (a). On 05/30/2023, the ED provided education to the Department managers which included: the DON, ADON, SDC, UM, MDS Coordinator, SSD, SSC, BOM, AD, DD, RSD, HKS, and MA regarding the roles and responsibilities of the Governing Body. (b). The education included the availability of the Governing Body with concerns, grievances, or need of resources to assist in ensuring the highest level of care and services to the residents in the facility. 10. (a). On 05/30/2023, the education was initiated with facility staff by the SDC, DON, ADON, Nursing Supervisor or VPCS regarding the roles and responsibilities of the Governing Body. (b). The education included the availability of the Governing Body with concerns, grievances, or need of resources to assist in ensuring the highest level of care and services to the residents in the facility. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 06/01/2023 as alleged: 1. Per observation and interview, beginning 05/17/2023, a member of the Governing Body was onsite daily at the facility, at a minimum of four (4) days a week and available by phone twenty-four hours a day seven (7) days a week as alleged. (a). Review of the facility's documentation revealed on 05/17/2023, an audit was conducted of residents' incidents and accidents. Continued review revealed the audit encompassed the investigations and review of the investigation process to ensure the QAPI processes and procedures which included results of all audits, analysis of audits, identification of Root Cause of system failure and implementation of corrective actions, and tracking and trending of the facility's processes were completed. (b). In an interview on 06/09/2023 at 1:40 PM, the VPCS stated when the State Survey Agency (SSA) Surveyors entered the building on 05/17/2023, with concerns, an audit of residents with falls/incidents/accidents was initiated and conducted. The VPCS stated concerns had been identified regarding no Physician's Orders related to the mattresses. The facility began a thorough audit review at that time to address the concerns. (c). In continued interview on 06/09/2023 at 1:40 PM, the VPCS stated she ensured QAPI processes and procedures that included results of all audits, analysis of audits, identification of Root Cause of system failures, implementation of corrective actions, and tracking and trending of facility processes were completed. 2. In interview on 06/09/2023 at 1:40 PM, the VPCS stated on 05/19/2023, she educated the ED and DON on the policies for falls, accident investigation to include root cause analysis, care plan development, and care plan revision. 3. On 05/29/2023, the VPCS, a member of the Governing Body, reviewed the removal plans with the ED for F656, F689, F835, F837, F841, and F867 to ensure understanding of the requirements of each plan and ensure adherence to the plan(s) to decrease the risk of potential injuries to residents related to falls. 4. (a). In interview on 06/09/2023 the VPCS and VPCO stated beginning 05/29/2023, a review was completed with the ED by a member of the Governing Body, which included the VPCO, and VPCS. They stated the review was to continue to be completed each week beginning 05/29/2023, for actions with follow up including audits and plans which had been initiated to correct identified concerns. (b). In continued interview on 06/09/2023 the VPCS and VPCO stated the process also included follow-up with staff members, department heads, the external consultant, residents and/or families to assist with evaluating ongoing compliance or deficient practices regarding the removal plan and/or the facility's processes related to the regulatory intent of F656, F657, F689, F835, F837, F841, and F867. The VPCS and VPCO stated any concerns identified regarding the review with the ED were to be immediately addressed/corrected by the ED and discussed with another member of the Governing Body (VPCS or VPCO). (d). In additional interview on 06/09/2023 the VPCS and VPCO stated immediate actions were taken to ensure residents' well-being and compliance with the identified regulatory violations. They stated the findings were to be reported to the COO starting on 05/29/2023 by the VPO or VPCO weekly. In an interview on 06/10/2023 the facility's COO, VPCO and SVPCS stated the ED and DON received education on the facility's past three (3) year's survey history, the facility's policies for falls, and accident investigation to include root cause analysis utilizing the Centers for Medicare and Medicare Services (CMS) five (5) Whys. They further stated the education included Care Plan development, Care Plan revision, the roles and expectations of: administration of the facility; the Governing Body; the Medical Director; and the QAPI Committee. 5. In an interview on 06/10/2023 the COO stated beginning 05/29/2023, his role included completing the education with the members of the Governing Body regarding their roles and responsibilities to provide oversight to the management and operation of the facility to ensure it was administered effectively, and to ensure the facility had an effective QAPI program. 6. (a). In interview on 06/10/2023 with the ED and DON they stated they both received education on 05/29/2023, provided by the VPCS on the roles and expectations of administration of the facility, the Governing Body, the Medical Director; and the QAPI Committee. (b). In interview on 06/09/2023 at 1:40 PM, the VPCS stated she had re-educated the ED, DON, and Medical Director on the revised Accidents and Incidents/Falls, Investigating and Reporting policies which included notification of the Administrator (ED) and DON. In continued interview on 06/09/2023 at 1:40 PM, the VPCS stated she re-educated the ED, DON, and SDC on 05/19/2023, on the facility's fall policy, and ensuring completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition. She stated the re-education also included ensuring care plan interventions were implemented based on findings of the fall risk assessment, implementing an immediate intervention following each fall including a root cause analysis, and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions that included the need for increased supervision or assistive devices as deemed necessary. In interview on 06/09/2023 at 1:40 PM, the VPCS stated the facility's QAPI met daily specifically for falls, to look at all falls, for prevention, root cause identification, behaviors and risk prone residents and interventions. She stated this was to be included on weekends and holidays, and the Medical Director was to be notified to keep him updated. The VPCS stated the communication had been enhanced, firsthand and had increased her awareness regarding the importance of frequent communication and having a continued onsite presence. (c). Review of the facility's documentation and staff educational personnel files revealed on 05/29/2023, a post test was administered to the ED and DON by the VPCS to validate their understanding of the above education. 7. (a). Review of the facility's documentation and meeting minutes revealed beginning 05/23/2023, an Ad hoc QAPI meeting was held with the Medical Director regarding the plan for consistent reviews by the Governing Body to ensure the removal plans were followed and to discuss the weekly review with the ED. Further review revealed no additional recommendations were made by the Medical Director regarding the plan. Review of the QAPI meeting minutes revealed the ED, DON, VPCS, Infection Preventionist (IP), SSD, Licensed Nurse, and Medical Director met on 05/29/2023 to discuss the facility's plan to ensure care plan interventions were implemented and continue to be in place for residents to decrease the risk of falls/injuries. Further review revealed findings of audits and corrective actions were discussed, with no further recommendations made by the Medical Director at that time. (b). Review of the facility's documentation and meeting minutes revealed a stand down QAPI meeting was held daily by the ED to review the plan, discuss findings of the audits, and determine concerns which might require immediate action. Review of the facility's documents and meeting minutes revealed the follow-up with staff members, department heads, external consultant, residents and/or families to assist in evaluating ongoing compliance or deficient practices with the removal plan and/or the facility's processes regarding the regulatory intent of F656, F657, F689, F835, F837, F841, and F867. Review of the facility's documentation revealed beginning 05/29/2023, a review was completed with the ED by a member of the Governing Body to include the VPCO, and VPCS each week beginning 05/29/2023, for actions with follow up to include audits and plans which had been initiated to correct identified concerns. 8. Review of the facility's documentation revealed starting 05/29/2023, a QAPI meeting was to be held daily for two (2) weeks, then weekly times four (4) weeks, then monthly thereafter to ensure continued compliance with the above stated plan to ensure continued compliance with follow-up and recommendations by the governing body. In interview on 06/09/2023 at 1:40 PM, the VPCS stated the QAPI had been meeting daily specifically regarding falls, looking at prevention, root cause identification, resident behaviors and risk prone residents and interventions. The VPCS stated the Medical Director was to be notified and be kept updated. She further stated communication had been enhanced, which had increased her awareness of the importance of frequent communication and having a remaining onsite presence. In interview on 06/10/2023, the COO, VPCO and Senior [NAME] President of Clinical Services (SVPCS) stated education had been provided to the ED and DON as alleged specific to their roles and responsibilities to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident. 9. (a). Review of the facility's documentation, and staff educational training sheets revealed on 05/30/2023, the ED provided education to the Department Managers which included the DON, ADON, SDC, UM, MDS Coordinator, SSD, SSC, BOM, AD, DD, RSD, HKS, and MA regarding the roles and responsibilities of the facility's Governing Body. In interview on 06/09/2023 at 4:00 PM, the SSD stated daily QAPI meetings occurred with the ED and VPCS to go over falls, Governing Body, and care plans. She stated she received multiple educations on falls/incidents/air mattress/PIP, and QAPI. The SSD stated she felt the education had been beneficial, and the QAPI and PIP were not well known to staff; however, now much more communication was occurring and more participation with the PIP. The SSD stated staff were educated on the residents' care plans and how to correct it if something was incorrect, and to perform visual rounds. She further stated all departments had been educated which included ensuring family notifications, care plan editing, medication reviews, psychiatric involvement and appointments. (b). Review of the staff educational training sheets revealed the education included the availability of the Governing Body for concerns, grievances, or the need of resources to assist in ensuring the highest level of care and services to the residents in the facility. In interview on 06/09/2023 at 3:05 PM, the SDC stated the team identified the facility's failure regarding the citations were related to the the importance of air mattress education needed to be provided, importance of one-on-one (1:1) supervision and other increased supervision of residents at high risk for falls, care plans needing to be updated and followed up on by the Interdisciplinary Team (IDT). The SDC stated the importance of proper care of residents, specific to the facility's systems failure was to ensure residents were toileted, repositioned, their pain addressed and personal items were in reach. She stated to ensure necessary follow through: more education of staff was needed to make them more observant; investigation of the root cause of incidents was needed; and ensuring appropriate fall interventions were in place and implementing them. The SDC stated the facility initiated increased QAPI education with staff, education with all departments and explained the QAPI process. According to the SDC, the IDT was now to evaluate to reduce residents' falls, other accidents/falls and provide a better quality of care, and staff were to be involved and have input with the PIP. She stated there had been a team meeting specific to falls and actual floor staff involvement/input to work more cohesively and improve resident safety. The SDC stated her involvement with the removal plan included education per the VPCS on all the implementations to improve resident quality of care and ensure their safety. She stated she performed all trainings of the QAPI, Fall/Accidents, low air loss mattress with required two (2) assistants, settings and checking a resident's coccyx, and ongoing education of abuse. The SDC stated she ensured all staff were educated one-on-one (1:1) in person, and/or via phone to perform competency testing. She further stated all current agency staff were educated, and new onboarding staff, had an introduction orientation packet that must be performed prior to working the floor with testing required. 10. (a). Review of the facility's documentation, review of the educational training sign-in sheets revealed on 05/30/2023, education had been initiated with staff by the SDC, DON, ADON, Nursing Supervisor or VPCS regarding the roles and responsibilities of the Governing Body. (b). Review of the facility's educational documentation revealed the education included the availability of the Governing Body for concerns, grievances, or need of resources to assist in ensuring the highest level of care and services to the residents in the facility. In interview on 06/10/2023 the COO, VPCO and SVPCS stated the ED and DON received education on the facility's past three (3) year's survey history, the facility's policies for falls, accident investigation to include root cause analysis utilizing the CMS five (5) Whys, Care Plan development, Care Plan revision, and the roles and expectations of: the administration of the facility; the Governing Body (RGB); the Medical Director (MD); and the QAPI Committee. In interview on 06/09/2023 at 4:00 PM, the SSD stated daily QAPI meetings with the ED and VPCS had been held to go over residents' falls, Governing Body, and care plans. She stated she received multiple educations on falls, incidents, air mattresses, PIP, and QAPI. According to the SSD, she felt it had been beneficial, as the QAPI and PIP had not been well known to staff, and now there was more communication and participation in the PIP. The SSD stated all departments were educated on the required items including ensuring family notification, care plans, editing care plans, medication reviews, psychiatric involvement, appointments, and fixing something if it was incorrect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to have an effective system in place to investigate the root cause of the resident's falls. The Medical Director was responsible for providing the staff direction related to the facility's policy and the current professional standard of practice and failed to ensure the coordination of medical care in the facility. As a result, five (5) of forty-seven (47) sampled residents experienced falls with major injuries. The facility's failure to have an effective system to ensure the Medical Director provided oversight of the residents medical care and failure to implement polices that was reflective of the current professional standards of practice has caused or is likely to cause serious harm or serious injury to the residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K; 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K; 42 CFR §483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR §483.75 Quality Assurance and Performance Improvement, at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. 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 scope and severity (S/S) of the IJ deficiencies was lowered to an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F656, F689, F835, F837, and F867) The findings include: Review of the Medical Director's responsibilities, dated [DATE], revealed the Medical Director was responsible for administrative decisions including recommending, developing, and approving facility policies related to residents' care, providing medical and clinical leadership in a multidisciplinary approach to resident care and care planning within the skilled long-term setting. Further review of the Medical Director's responsibilities revealed he was to assist the facility with the identification, evaluation, and resolution or medical and clinical concerns affecting resident care or quality of life. Review of the facility policy titled Fall Management, dated [DATE], revealed a fall was an unintentional change in position coming to rest on the ground, floor or onto the next lower surface, which included onto a bed, chair, or bedside mat. The policy stated injury related to a fall was any documented injury that occurred as a result of or was recognized within a short period of time (hours or to a few days) after the fall and attributed to the fall. According to the policy, a major injury included bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. Review of the policy also revealed a fall risk observation was completed on admission, quarterly, annually, with any significant change in condition, and with any fall, and was utilized to identify individuals who were at high risk for falls. Further review of the policy revealed fall prevention was achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce risk for falls. Review of the facility Low Air Loss Mattress owner's manual titled INVACARE Micro AIR MA65 Series dated [DATE], revealed to avoid risk of death or injury from falling: Invacare suggest read and use the User Manual prior to using the product, rails be in the raised position whenever a patient is on the bed, proper patient assessment and monitoring is required to prevent injury, variations in bed rail dimensions, and mattress thickness, size or density could increase the risk of injury, work with therapist, physician and other medical staff to perform assessment and patient monitoring, to avoid death, injury, or damage due to improper maintenance and inspection, always maintain and inspect equipment. Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, effective date [DATE], revealed the purpose of QAPI was to ensure the mission of the facility was actualized through the establishment of resident centered quality management processes, to ensure that proactive quality care and services were provided to each resident on a continuous basis, to ensure compliance with regulations and standards of practice and to provide timely solutions to spontaneous events. Further review of the policy revealed objectives of the QAPI program included a systemic process designed to ensure that care practices were consistently applied, and the facility met or exceeded an expected standard of quality. Review of the facility's Quality Assurance Performance Improvement (QAPI) Program review for [DATE], [DATE], [DATE] and [DATE] report revealed the QA committee failed to review the Plan of Correction (PoC) from the Recertification Survey with exit date of [DATE], in which the facility was cited at an Immediate Jeopardy (IJ), related to falls. Further review of the of the QAPI Program revealed there was no documentation to support the committee continued with Quality Measured comments or action plan for improvement. Continued review revealed there was no evidence the committee developed plans of action to correct identified quality deficiencies based on the root cause analysis and prioritization of topics of identified issues/concerns related to resident falls with major injury, and failed to maintain formal written documentation as evidence of ongoing quality management to promote and ensure the resident's safety. 1. Review of the facility's Incident Audit Report dated [DATE] at 9:35 PM, for Resident #1 revealed the resident was found on the floor next to his/her bed, with his/her feet towards the head of the bed and his/her head next to the wall. The facility identified the resident fell out of his/her low air lost (LAL) mattress. The resident was noted to have had a knot on his/her left side of his/her scalp. Further review revealed the resident did not know what happened or how he/she ended up on the floor. Continued review of the incident report, revealed the resident's pain level was not assessed, and the predisposing environmental/situational factors were not documented. Review of the Hospital Medical Record, dated [DATE], revealed the resident was admitted with diagnosis of a Nondisplaced Fracture of the second Cervical Vertebrae. Review of the QA minutes revealed no recommendation from the Medical Director, to include the review of the facility's policy or discussion of the standards of practice to assist with interventions to prevent the resident's fall, as per the facility's policy and the Medical Directors Job Responsibilities. Subsequently, on [DATE], Resident #1 experienced a second fall. Review of the facility's Incident Audit Report, revealed the resident was found lying on the floor next to his/her wheelchair. Continued review revealed the resident was trying to get up and screaming that he/she just wanted to go back to bed. The resident had been in the lounge on the 200 Unit, visiting with his/her sister after lunch. Further, the resident stated, I fell out of my chair, wanna go to bed. Review of the resident's Hospital Medical Record revealed the resident was diagnosed with a nondisplaced fracture of the proximal tibial methaphysis; bilateral tibial fracture, and right distal fibula avulsion fractures. Review of the QA minutes revealed no recommendation from the Medical Director, to include the review of the facility's policy or discussion of the standards of practice to assist with interventions to address the adequate supervision required to assist the resident to his/her bed. As a result, the resident was placed on Hospice Care. The resident expired on [DATE]. 2. Review of the facility's Incident Audit Report, dated [DATE] at 8:07 PM, revealed Resident #16's roommate yelled for help. Review of the report revealed the Kentucky Medication Aide (KMA) was walking down the hallway and went into the resident's room. Resident #16 was noted sitting on his/her buttock on the bathroom floor with his/her back against the wall. A continued review of the report revealed Registered Nurse (RN) #1 noted the resident had his/her socks on that was not his/her nonskid socks. The resident stated he/she tripped over his/her oxygen cord. Further review of the report revealed the resident hit his/her head on the wall. He/she further stated his/her oxygen cord pulled causing the resident to trip over it. Review of the immediate action taken revealed an order was received to send the resident to the emergency room (ER). Review of Resident #16's emergency room (ER) Record, dated [DATE], revealed the resident's primary impression/diagnosis was a displaced fracture of his/her shaft of the left clavicle related to an unspecified fall. Review of the QA committee minutes revealed no documentation to support the Medical Director offered recommendations to the facility staff to include a review of the facility's policy related to falls and/or care plan review. The facility failed to address the resident's concern related to the resident's oxygen tubing, which caused the resident's fall. 3. Review of the facility's Incident Audit Report dated [DATE] at 12:49 AM, revealed Resident #17 was found lying on the floor, on his/her back beside his/her bed. Further review, revealed the resident rolled out of the bed, hitting his/her face on the floor, with lacerations and a hematoma to his/her forehead. Continued review revealed confusion and impaired memory were noted as predisposing physiological factors with no evidence of other predisposing environmental, nor situational factors, and/or documented interviews to demonstrate a thorough investigation. A continued review of the incident report revealed the immediate action taken was to assist the resident to bed, apply pressure to the resident's wound, and the resident was sent to the emergency room (ER) for an evaluation. The Medical Director; however, failed to provide recommendation to the facility to include: reviewing the facility's policy related to falls, to assist with determining the root cause of the resident's fall, through an investigation, and failed to gather information from the investigation to develop an intervention that would be person-centered specific. Continued review of the incident report revealed the resident was sent to the hospital were it was documented the resident had facial laceration from his/her fall. 4. Review of the facility's Incident Audit Report dated [DATE], revealed Resident #18 was found on the floor at the foot of both beds in his/her room. Continued review of the incident report revealed that when staff asked the resident, What he/she was trying to do? The resident stated, pee. Further review of the incident report revealed that numerous episodes of urinary incontinence was noted in the resident's brief. The incident report revealed the resident only verbalized pee numerous times. Further review of the incident report revealed the resident attempted to transfer self to the bathroom. The incident report revealed there were no predisposing factor for the resident's environment, and the resident's psychological factors included confusion, weakness, and gait imbalance. Further review of the facility incident report revealed on [DATE], the facility's Interdisciplinary Team (IDT) reviewed the resident's fall and concluded the root cause analysis identified and documented as, resident with urgency to urinate, with the intervention provided to be incontinence care, and keep urinal in reach. The Medical Director; however, failed to provide recommendation to the facility to include: reviewing the facility's policies related to falls and care plans. Review of the resident's care plan revealed staff were to check on the resident every two (2) to three (3) hour to assist with transferring the resident to the bathroom and commode. Staff documented the resident had numerous episodes of urinary incontinence and the resident stated he/she had to pee; however, the Medical Director failed to offer a recommendation to the facility staff, to include increased supervision with transferring the resident to the bathroom, to prevent additional falls. Additionally, Resident #18 had a second (2nd) fall on [DATE]. Review of the facility's Incident Audit Report, dated [DATE], revealed Resident #18 was noted to be lying on his/her stomach on the floor beside his/her bed. The resident stated, 'I fell out of bed. Resident #18 was sent to the emergency room (ER) for evaluation and was found to have a nasal/septum fracture and fracture of the anterior maxillary process. Further review of the facility incident report revealed the Interdisciplinary Team (IDT) reviewed and concluded the root cause analysis was identified and documented as, the resident lies on his/her side in his/her bed when resting. However, there was no documentation to support the Medical Director provided a resolution, identification, or an evaluation to assist the facility staff developed appropriate interventions to prevent or reduce the resident's falls. Further review of the resident's Medical Record revealed the resident reported to the emergency room (ER) staff, on [DATE], that the facility removed the resident's bed railings from his/her bed, which caused the resident's fall. Additional review of the resident's record revealed the resident was not assessed or evaluated for bedrails, prior to his/her fall on [DATE]. Continued review of the resident's medical record revealed the Medical Director failed to address in the QA committee meeting the concern of the bedrails noted in the resident's hospital records. 5. Review of the facility's Incident Audit Form dated [DATE], revealed Resident #19 rolled from his/her bed on to the floor during incontinence care. Review of the witness statement revealed the Certified Nursing Assistant (CNA) #7 said she rolled the resident away from her and the resident rolled out of bed. Continued review of the incident form revealed incontinent was noted to be the only predisposing physiological factors listed on the form. IDT determined the root cause of the fall was determined to be the air mattress and the resident rolled on the opposite of staff. Review of the resident's care plan revealed the resident was assessed to have two (2) person assist with bed mobility; however the CNA who performed the resident's care worked independently. The IDT did not address this concern as part of the root cause nor was there documentation to support the Medical Director offered the facility staff a recommendation. On [DATE], IDT reviewed the incident report and determined the root cause analysis was determined and documented as the resident was on an air mattress and the resident rolled opposite staff. Further review revealed the intervention was to change the air mattress to contour mattress, and side rails were placed to use during care. However, the facility failed to determine within the root cause analysis that the resident was assessed to have two (2) staff to assist with his/her bed mobility. Review of Resident #19's Hospital Record, dated [DATE] at 9:52 AM, revealed the resident had a fall with laceration/hematoma. Continued review of the hospital record revealed the {resident} patient fell from bed without loss of consciousness. Further review revealed the {resident} patient had a 4 to 5-centimeter (cm) skin tear to his/her right jawline with no bleeding noted. The hospital record also revealed the resident had a moderate size blue hematoma with swelling to his/her right lateral elbow area and a smaller blue hematoma to his/her forearm. Further review of the hospital record revealed nasal bone fracture with a 9 cm facial laceration and contusion of the head and right forearm. In addition, review of the fall tracker revealed the facility had a total of one-hundred and eight (108) falls within a four (4) month time period, [DATE] thorough [DATE]. Of the 108 falls, thirty-three (33) falls resulted in injuries In an interview, on [DATE] at 4:45 PM, with the Minimum Data Set (MDSC) Coordinator, she stated she had been in the MDS role for one (1) year and was actively involved in the daily clinical meetings. Per the interview, she stated the IDT would discuss the recent falls and review the interventions in place and determine any new, needed interventions; however, she was not aware who was ultimately responsible to ensure the interventions were being implemented. Further, she stated she did not recall any interventions with Resident #1 being discussed or implemented. She added, previously she would just care plan the type of mattress, not include guidelines of weights and/or specifics. Continued interview with MDSC revealed if the resident's air mattress settings were not based on current weight and not accurate, it could cause a danger to the resident with a potentially dangerous outcome. She stated the bed rails would also now be care planned and the unit managers would be responsible for the bedrail assessments. The MDS Coordinator stated she often communicated with the Therapy Director (TD) to discuss changes to the resident's care plan, related to falls. Interview on [DATE] at 10:22 AM with the Advanced Registered Nurse Practitioner (ARNP), stated she was in house daily for more acute visits, and the Medical Director (MD) would see the more chronic residents two (2) times a month; however, stated the MD would begin seeing the resident's more often. The ARNP stated, typically, if a fall/incident occurred, she would assess the resident and implement orders immediately. She stated all staff should be familiar with the residents' plan of care and interventions for the safety and appropriateness of care for the resident. In an interview on [DATE] at 9:44 AM with the Executive Director (ED), she stated she had been in the role since [DATE] and was responsible for the day-to-day functioning of the facility and was responsible to ensure the facility operated within the state and federal guidelines and maintained regulatory compliance regarding previously cited deficiencies. She stated she was the Quality Assurance Coordinator and was responsible for the program. In addition, she stated she was required to ensure the ongoing audits related to previously cited deficiencies were reviewed, and if any concerns were identified, they were corrected immediately. The ED stated the facility had put audits in place; however, the facility was focused on the tracking and trending of previous falls specific to the facility percentages and numbers, and was not resident specific. In an additional interview, on [DATE] at 2:45 PM with the Executive Director on [DATE] at 2:45 PM, she stated the Medical Director communicates with staff when he made his rounds; however, there was no formal education/training specific to falls with staff. In an interview, on [DATE] at 2:30 PM, the Medical Director (MD), stated his role as the Medical Director was to coordinate care and if issues were discovered, he would communicate with the facility Executive Director (ED). Further interview revealed he would expect staff to follow the residents plan of care and implement the interventions as ordered. Per the interview, the MD stated the facility had a high turnover rate and it was difficult to build a system with inconsistent staffing. He further stated the inconsistent staffing contributed to the increase in the residents falls as the staff were unfamiliar with the resident and their behaviors. The MD further stated he was involved with the QA process; however, the facility focused more on percentage of falls the residents had and were not focus on the specific resident. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1.a.) Beginning on [DATE], the Executive Director (ED) reviewed the responsibilities of the Medical Director (MD) with him. The Medical Director's responsible included: administrative decisions, recommending, developing, and approving the facility's policies related to the residents' care; and providing medical and clinical leadership in a multidisciplinary approach to resident care planning within the skilled long-term care facility. b.) The falls policy was reviewed, revised and approved on [DATE]. 2. a.) On [DATE], the Executive Director reviewed the removal plans with the Medical Director for F656, F689, F835, F837, F841, and F867 to ensure understanding of the requirements of each plan and to request recommendations for further interventions to decrease the risk of potential injuries to residents related to falls/injuries in the facility. b.) The Medical Director stated he understood the plans and made no recommendations. 3. On [DATE], the Executive Director (ED) reviewed the education provided to the Director of Nursing (DON) and the Staff Development Coordinator (SDC) provided by the [NAME] President of Clinical Services (VPCS) on [DATE], regarding the facility's fall policy. a.) To include ensuring completion of fall risk assessments on admission, quarterly, and with a change in a resident's condition, ensuring that care plan interventions were implemented based on findings of the fall risk assessment, implementing an immediate intervention following each fall, completion of a thorough investigation following each fall, including a root cause analysis. b.) Discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions to include the need for increased supervision or assistive devices as deemed necessary. c.) The Medical Director made no further recommendations regarding this education. 4. a.) On [DATE], the Executive Director informed the Medical Director that on [DATE], the SDC started re-educating all current Licensed Nurses and Certified Nursing Assistants (CNAs) on the facility's fall policy, including but not limited to initiating an investigation as to the cause of the fall, implementing immediate interventions with consideration of the need for increased supervision or the addition of assistive devices, and reviewing/updating the care plan with each fall. b.) Education also included that low air loss mattresses settings would be compatible with resident's weight, comfort and appropriate functioning of the mattress. c.) Documentation was added to the Electronic Medical Record (EMR) for verification of low air mattress settings every shift to ensure that it remained at the appropriate level for each resident. d.) Staff were educated that residents who required an air loss mattress would require two (2) staff members to assist with turning and repositioning in bed to decrease the risk of falls, and to notify the nurse manager if changes were needed regarding the support surface. e.) The Nurse Manager would utilize the support surface algorithm from New Source Medical. f.) Newly hired staff, agency staff and staff who had not been educated would receive this prior to working their next shift. g.) The Medical Director made no further recommendations regarding the education of staff members. 5. a.) On [DATE], the Executive Director discussed with the Medical Director that beginning [DATE], the Licensed Nurse would initiate and investigate all falls, implement an immediate intervention and update the care plan. b.) The Clinical Interdisciplinary Team would review residents who had experienced a fall during the morning clinical meeting to ensure a Root Cause Analysis (RCA) was determined, all appropriate interventions to include consideration of the need for increased supervision and/or assistive devices as deemed appropriate were implemented to assist in preventing further falls, review and update the care plan as appropriate, and ensure the intervention was on the Care Plan/CNA Kardex. c.) The DON/ADON/SDC/UM would make an IDT Nurses' Note with the root cause of the fall and intervention that was in place, add any further interventions recommended by IDT. If further recommendations were suggested, the Licensed Nurse would add to the care plan. 6. On [DATE], the Executive Director (ED) informed the Medical Director (MD) that a stand down QAPI meeting would be held daily by the ED to review the above stated, to discuss findings of audits, and determine concerns that may require immediate action. Any adverse findings would be shared with the Medical Director by the Executive Director or Director of Nursing daily for recommendations. 7. a.) On [DATE], an Ad hoc Quality Assurance Process Improvement (QAPI) meeting was held by the Executive Director, the Director of Nursing, Infection Preventionist, Licensed Nurse, and with the Medical Director to discuss the plan initiated to decrease the risk of falls. b.) The method of ensuring that a root cause analysis was completed as part of the investigation following a fall, that consideration was given to the need for increased supervision to decrease the risk of further falls/injuries, that consideration was discussed regarding the need for a change in the resident's environment, the potential need for assistive devices, education provided to staff, and audits for monitoring compliance with fall interventions. c.) No further recommendations were made by the medical director related to this plan. 8. On [DATE], an Ad hoc QAPI meeting would be held daily times two (2) weeks, then weekly for four (4) weeks to discuss the plan, review findings of the above stated audits, and to request the need for further actions and/or modifications to the plan. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy by [DATE]: 1.a.) Facility documentation review and interview with the Executive Director (ED), she stated on [DATE] she went over the responsibilities of the Medical Director (MD) with the Medical Director to include the responsibility for administrative decisions. b.) Facility documentation revealed on [DATE], the falls policy was reviewed, revised and approved on [DATE], by the Medical Director. 2. a.) Facility documentation and during interview with the Executive Director (ED), on [DATE], she stated on [DATE], she reviewed the removal plans with the Medical Director for F656, F689, F835, F837, F841, and F867 to ensure understanding of the requirements of each plan and to request recommendations for further interventions to decrease the risk of potential injuries to residents related to falls/injuries in the facility. b.) Facility documentation revealed the Medical Director stated understanding of the plans and made no recommendations. 2. Facility documentation and during interviews on [DATE] and [DATE],the ED stated on [DATE], that she had reviewed the education provided to the Director of Nursing (DON) and the Staff Development Coordinator (SDC) provided by the [NAME] President of Clinical Services (VPCS) on [DATE], regarding the facility's fall policy. a.) The education included: ensuring completion of fall risk assessments on admission, quarterly, and with a change in a resident's condition, ensuring that care plan interventions were implemented based on findings of the fall risk assessment, implementing an immediate intervention following each fall, completion of a thorough investigation following each fall, including a root cause analysis. b.) Discussion by the Interdisciplinary Team (IDT) included to review/update the resident's care plan following each fall for further interventions that may require the need for increased supervision or assistive devices as deemed necessary. c.) The Medical Director made no further recommendations regarding this education. During interview on [DATE] at 3:05 PM, with the SDC, she stated she had been re-educated on the Care Plan policy per the VPCS. She stated she explained the importance of care plan interventions to decrease the risk of residents' falls. During interview on [DATE] at 1:40 PM, with the VPCS, she stated on [DATE], she re-educated the Executive Director (ED), the Director of Nursing (DON) and the staff Development Coordinator (SDC) on the facility's fall policy, to ensure completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition, ensuring that care plans interventions were implemented based on findings of the fall risk assessment, implementing an immediate intervention following each fall including a root cause analysis, and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions. 3. On [DATE], the VPCS, SDC and the DON stated re-education was provided per the VPCS on [DATE]. During interviews on [DATE] thru [DATE], related to the facility's fall policy, the VPCS, SDC and the DON stated education began [DATE] and consisted of the importance to ensure completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition were completed. They also stated that the reeducation included to ensure that care plan interventions were implemented based on the findings of the fall risk assessment, implementing an immediate intervention following each fall including a root cause analysis, and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions to include the need for increased supervision or assistive devices as deemed necessary. 4. a.) Facility documentation and review of staffs' personnel records specific to education and sign-in sheets revealed on [DATE], the Executive Director informed the Medical Director that on [DATE], the SDC started re-educating all current Licensed Nurses and Certified Nursing Assistants (CNAs) on the facility's fall policy, including but not limited to initiating an investigation as to the cause of the fall, implementing an immediate intervention with consideration of the need for increased supervision or the addition of assistive devices, and reviewing/updating the care plan with each fall. b.) Education also included that low air loss mattresses settings would be compatible with the resident's weight, comfort and appropriate functioning of the mattress. c.) Documentation was added to the Electronic Medical Record (EMR) for verification of low air mattress settings every shift to ensure that it remains at the appropriate level for each resident. d.) Staff were educated that residents who required an air loss mattress would require two (2) staff members to assist with turning and repositioning in bed to decrease the risk of falls, and to notify the nurse manager if changes were needed regarding the support surface. e.) The Nurse Manager would utilize the support surface algorithm from New Source Medic[TRUNCATED]

Based on interview, record review, review of the facility's policies, documents, Executive Director's Job Description, and Plan of Correction (PoC) submitted for the 03/05/2020 Recertification Survey, it was determined the facility failed to have an effective process in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track adverse resident events, analyze their causes, and implement effective preventive action. The facility failed to ensure there was an effective system in place to regularly review and analyze audit data, including data collected under the QAPI program, and act on available data to make improvements and maintain substantial compliance. In addition, review of the facility's documentation revealed fall tracker information noting the facility had a total of one-hundred and eight (108) falls within a four (4) month timeframe, 01/01/2023 through 04/30/2023, of which thirty-three (33) of those fall resulted in injuries. However, there was no documented evidence the facility discussed the one-hundred and eight (108) falls, nor reviewed the resident's previous falls, analyzed the time of day and staff patterns for each fall in order to determine the root cause of the falls and to implement person centered interventions to prevent further falls. Interview and record review revealed the facility had no system in place to thoroughly investigate the root cause of residents' falls. Additionally, there was no documented evidence to support the facility's QAPI analyzed the data collected to decrease the occurrence of residents' falls. The continued failure of the facility to utilized the data collected resulted in a lack of action to correct the systemic, high-risk issue of residents' falls. The facility's failure to have an effective system in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process has caused or is likely to cause serious harm or serious injury to the residents. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 07/08/2022 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Develop/Implement Person-Centered Comprehensive Care Plans, (F656) at a S/S of a K; 42 CFR 483.25 Quality of Care, Accidents and Supervision (F689) at a S/S of a K; 42 CFR 483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR 483.75 Quality Assurance and Performance Improvement, (F867) at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, Accidents and Supervision (F689). The facility was notified of the Immediate Jeopardy on 05/26/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, with the facility alleging removal of the Immediate Jeopardy on 06/01/2023. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on 06/01/2023, prior to exit on 06/10/2023. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, effective date of 03/19/2018, revealed the purpose of its QAPI was to ensure the mission of the facility was actualized through the establishment of resident centered quality management processes, and to ensure that proactive quality care and services were provided to each resident on a continuous basis. Continued review revealed the policy's purpose also included allowing access of direct care givers, manager, and customers to quality improvement mechanisms, ensuring compliance with regulations and standards of practice and providing timely solutions to spontaneous events. The policy noted the Executive Director (ED) was to be devoted to continuous quality assurance and improvement. Further review of the policy revealed the objectives of the facility's QAPI program included a systemic process designed to ensure care practices were consistently applied, and the facility met or exceeded an expected standard of quality. In addition, the facility's QAPI program developed and implemented appropriate plans of action to correct identified quality deficiencies based on root cause analysis and prioritization of topics identified and maintained formal written documentation as evidence of ongoing quality management. Review of the Executive Director's Job Description, undated, revealed the ED directed and performed quality assessment and assurance functions, including but not limited to: regulatory compliance rounds to monitor performance and to continuously improve quality. According to the job description, implementation of programs to gather and analyze data for trends and to institute actions to resolve problems promptly was a duty of the ED. In addition, per the job description, the ED was to ensure proper documentation was maintained, including but not limited to, meetings and QAPI improvement plans. Review of the facility's acceptable Plan of Correction (PoC) for the Recertification Survey, dated 03/05/2020, revealed for the substandard deficient practice which had been cited at F689, the facility had educated all licensed staff, the ED, Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Minimum Data Set (MDS) Coordinator, and the Staff Development Coordinator (SDC) on the Falls Management Policy which included completing the Morse Falls Risk Evaluation (a tool developed for assistance in identifying residents at risk for falling). Continued review of the PoC revealed education was completed for the ED, DON, ADON, and SDC regarding utilizing the Stop and Watch form, a communication form developed by the Centers for Medicare and Medicaid Services (CMS). Further review revealed the education also encompassed communicating a change in a resident's condition including, but not limited to, pain, concerns related to sleep changes, and/or needing increased help from staff. The education additionally included developing, implementing, and revising care plans to include appropriate interventions based on root cause analysis and review of previous falls to identify trends and assist in determining the most appropriate interventions. Additional review of the acceptable PoC, for the Recertification Survey dated 03/05/2020, revealed the Interdisciplinary Team (IDT) was to review in the facility's daily clinical meeting (Monday through Friday) each fall in the nursing shift report to ensure the falls risk evaluation had been completed for the resident involved. Continued review revealed the IDT was to review the involved resident's recent fall history, to include the five (5) Why's (a tool approved by CMS for identifying root cause analysis), completed by licensed nurses, to assist in determining the appropriate intervention at the time of the fall. Per review of the PoC, beginning on 01/20/2020, the Nursing Consultant, ED, DON, ADON, and Assistant Administrator were to be onsite at the facility to monitor the process related to adequate supervision to prevent accidents/incidents until the Immediate Jeopardy (IJ) was removed and substantial compliance had been achieved, and pending QAPI Committee review. PoC review revealed any concerns identified were to be addressed immediately and reported to the QAPI Committee weekly for review and for further recommendations. The PoC stated the QAPI Committee meeting was to be held at least bi-weekly to discuss issues with the Medical Director and also on an as needed basis. In addition, the PoC noted the IDT was to meet daily to discuss the findings and progress; review all falls daily with the Physician to ensure appropriate interventions were implemented. Review further revealed the PoC noted the ED, ADON Assistant Administrator, and DON were to ensure all newly hired staff and agency staff received education on New Hire Orientation or prior to working the floor. Review of the facility's fall tracker documentation revealed the facility noted a total of one-hundred and eight (108) falls occurred within a four (4) month time period, 01/01/2023 through 04/30/2023. Continued review revealed of the one-hundred and eight (108) falls, thirty-three (33) of the falls resulted in injuries to residents, which included twenty-three (23) residents who sustained repeated falls, and three (3) residents who had sustained fractures from falls. However, there was no documented evidence the facility's QAPI Committee discussed the one-hundred and eight (108) falls, nor reviewed the resident's previous falls, analyzed the time of day and staff patterns for each fall in order to determine the root cause of the falls and to implement person centered interventions to prevent further falls. Review of the facility's monthly QAPI Committee meeting minutes, from 02/28/2022 to 04/30/2023, revealed the Committee members noted as present were: the Social Services Director (SSD), the Medical Director (MD) via phone; Licensed Practical Nurse (LPN) #8; MDS Coordinator; Activities Director (AD); ED; Human Resources Director; Director of Nursing (DON); Advanced Practice Registered Nurse (APRN); Assistant Director of Nursing (ADON); and Unit Manager (UM). Continued review of the QAPI meeting minutes for the dates of 02/28/2022, 03/31/2022, 07/14/2022, and 04/20/2023 revealed no documented evidence the minutes included discussion of residents' falls (with or without injuries), reviewing residents' previous falls, performed a root cause analysis of the falls and/or implemented appropriate person-centered care plan interventions as per the PoC. Review revealed however, on 07/14/2022, the Quality Measures review which included falls indicated the facility's falls for June 2022, was noted as 49.1 %; for May 2022 as 66%; and for April as 70%, with the National average noted as 43.7%, and the State average as 47.3%. Per review, even though there was the Quality Measures review there were no comments, notes and/or an action plan documented, nor review of the PoC regarding the facility's noncompliance related to falls. Further review of the facility's last year of QAPI notes dated 02/28/2022 through current, 04/20/2023, revealed the facility's QAPI Committed failed to develop and implement appropriate plans of action to correct identified quality deficiencies based on root cause analysis and prioritization of topics of identified issues/concerns related to residents' falls with major injury. In addition, the facility's QAPI Committed failed to maintain formal written documentation as evidence of ongoing quality management to promote and ensure resident safety. During an interview on 05/23/2023 at 1:05 PM, the Maintenance Supervisor stated he had not been involved in the facility's morning IDT meetings and QAPI Committee meetings until this month. He stated his recent attendance was due to the recent need and question of equipment related to residents' accidents and falls. The Maintenance Supervisor stated that week he removed two (2) low air loss (LAL) mattresses from residents' beds due to recent auditing/monitoring of residents. He stated if a resident was mobile, then the resident did not need an air mattress. He further stated he could see the LAL mattresses being a risk factor for causing residents to fall, especially those residents with mental issues. During an interview on 05/24/2023 at 9:30 AM, the DON stated she had been in her role since March 2023. She stated in the last month or so (no specific date provided), she had been involved with care conferences related to resident falls and incidents, and had observed the environment and updated care plans with resident involvement. The DON stated information on falls was brought to the QAPI meetings and discussed. However, she stated she had not attended recent QAPI meetings. According to the DON, all the data related to residents' falls was to continue to be brought to the monthly QAPI Committee meetings, with the Medical Director's involvement: to discuss residents' history of falls since admission, behaviors and/or any contributing factors to include medications, residents environment and to discuss interventions with the QAPI team. She further stated however, the facility's normal previous routine, had been for the QA process to be done through chart reviews and room checks. In addition, she stated there had previously been no resident specific discussions related to falls. During an interview on 05/05/2022 at 2:30 PM, the Medical Director stated in his role he coordinated resident care, and if issues were discovered, he communicated with the ED. He stated he expected staff to follow resident's plans of care and implement the interventions as ordered. Per the Medical Director, staff knew what residents' problems were, as well as the resident's patterns; however, unfortunately, staff had not followed through. The Medical Director stated the facility had a high staff turnover rate which caused inconsistent staffing that made it difficult to build a system because the staff members were not trained or educated on the proper care needs of the residents. He stated all of that contributed to the increase in residents' falls. The Medical Director stated he was engaged in the facility's QAPI metrics related to falls, which had been trending upward in numbers. During an interview on 06/10/2023 at 9:44 AM, the ED stated she had been in her role since July 2022 and was responsible for ensuring the facility operated within state and federal guidelines and maintained regulatory compliance regarding previously cited deficiencies. The ED stated she was also responsible for the facility's day-to-day functioning, and was the Quality Assurance Coordinator and responsible for that program. She stated she was required to ensure the facility's ongoing audits related to previously cited deficiencies were reviewed, and any concerns identified were immediately corrected. The ED stated the facility had implemented audits; however, had focused on tracking and trending previous falls specific to the facility's percentages and numbers, and not onresident specific requirements as to the change with the current PoC. According to the ED, the facility's Interdisciplinary Team (IDT) had not been establishing the actual root cause of residents' falls and neglected the overall resident specific picture/part. She stated the collaborative involvement needed, in order to get down to the actual root cause of a resident's fall was missing. Therefore, she stated the falls review which occurred had been missing the most important parts and potentially had placed residents at higher risk of falls and/or injuries. She further stated if all risk factors were not addressed, it did put residents at risk of having a negative outcome which could have been prevented. During an interview on 06/10/2023 at 10:28 PM, the [NAME] President of Operations (VPO) stated he started working for the corporation on 05/30/2023. He stated he provided in person oversight to the facility's Governing Body which included the ED and [NAME] President of Clinical Operations (VPCO), starting on 05/31/2023, and had been involved with the revisions of the facility's PoC on 06/05/2023. The VPO stated his role was to provide general operational oversight of the facility; performing policy review and revision; and ensuring preventive measures for the understanding of standards of care, policies, and their implementation. He stated the difference in the facility's corrections from the 2020 falls PoC compared to the current PoC being developed was related to the education. He stated now the importance and focus was on root cause analysis, looking into the injuries, appropriate risk factors, starting from the admission process, and ensuring proper resident specific preventive measures were in place and sustained. The VPO stated those preventive measures should have already been implemented and a part of the facility's process. During an interview on 06/09/2023 at 1:40 PM, the [NAME] President of Clinical Operations (VPCO), stated she was a member of the facility's Governing Body (GB), which also included the ED and the VPO. The VPCO stated her role was to provide oversight of the ED and facility, guidance for the ED and education regarding policies and procedures. She stated beginning on 05/17/2023, she had been onsite to provide staff support while the State Survey Agency was in the building. The VPCO stated she identified on 05/19/2023, that no orders were in place for air mattresses, and she performed an audit of residents who had an air mattress. She stated the results of that audit resulted in her discontinuing two (2) residents' low air loss (LAL) mattresses. Per the VPCO, throughout that time she communicated with the Senior [NAME] President of Clinical Operations (SVPCO), and the SVPCO had been in agreement with her. She stated she periodically attended QAPI, performed a lot of on the spot training, and researched QAPI tools to provide education of root cause analysis and the facility's trending to increase resident supervision. The VPCO stated the facility's failure related to residents' falls had been that there was no system in place to determine the root cause of the falls, which resulted in neglecting the residents' needs. She stated that investigating the why of the fall happening, in order to promote a thorough investigation. She stated prior to the the deficiencies and auditing of residents' medical records, staff members attempted to identify the root cause of residents' falls. The VPCO stated however, staff had required additional education regarding root cause analysis, and explanation of the process of identifying the appropriate root cause. She stated audits revealed the need for staff education and the importance of a system-wide approach. According to the VPCO, it was determined there needed to be a procedure to improve the interview process, which included pre-fall resident information containing staff interviews/involvement. She stated there needed to be an immediate investigation/action implemented and followed through related to the actual root cause, of falls/incidents to promote an appropriate immediate intervention, such as increased supervision of the involved resident. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, alleging removal of the Immediate Jeopardy on 06/01/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following. 1. On 05/23/2023, the facility did not have documentation to support there was an effective QAPI Program to investigate the root cause of falls for Residents #1, #16, #17, #18, and #19. (a). Resident #1 no longer resided in the facility. (b). Falls for Residents #16, #17, #18, and #19 were reviewed by the QAPI Committee on 05/23/2023. A root cause analysis (RCA) was performed for each of the resident's falls, and care plan interventions were implemented related to findings of the RCA for each resident. 2. (a). On 05/23/2023, an audit of falls in the facility for the last ninety (90) days was conducted by the ED, DON, Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and [NAME] President of Clinical Services (VPCS). (b). Care plans were reviewed for residents who experienced a fall in the last three (3) months to ensure an appropriate intervention was in place to decrease the risk of falls. Corrective actions were completed as indicated. 3. (a). On 05/29/2023, the ED, DON, and Medical Director, through the QAPI Committee, initiated a performance improvement project (PIP) sub-committee comprised of the DON, ADON, SDC, Unit Manager (UM), Charge Nurse, Certified Nursing Assistant (CNA), Director of Rehabilitation Services, Activity Director (AD), and Housekeeping Supervisor. (b). The ED charged the PIP sub-committee team with analyzing the falls data, completing a trending of the data, completing a root cause analysis of falls in the facility, interviewing residents and staff regarding fall risk, utilizing feedback and information to develop a plan, and reporting the findings to the QAPI Committee by 05/30/2023. The facility's plan was to decrease the number of falls; and therefore, reduce the risk of injury from falls. 4. (a). On 05/29/2023, education was provided for the ED, DON, and Medical Director by the VPCS, regarding the requirement to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focused on indicators of the outcomes of care and quality of life. (b). Included in the education were the five (5) elements of QAPI and making the process an active part of identifying concerns and initiating PIPs to collect and analyze data, complete root cause analysis, develop a plan, and monitor the effectiveness of the plan. 5. On 05/29/2023, a Stand-down QAPI Committee meeting would be held daily by the ED to review the above, to discuss findings of audits of plans for F656, F689, F835, F837, F841, and F867 and determine concerns which might require immediate action. Corrective actions were to be initiated immediately. 6. On 05/29/2023, an Ad Hoc QAPI Committee meeting was held by the ED, DON, Infection Preventionist, Licensed Nurse, and Medical Director to discuss the plans initiated to decrease the risk of falls. (a). In the meeting they determined a method for ensuring a root cause analysis would be completed as part of the investigation following a fall; that consideration was given to the need for increased supervision to decrease the risk of further falls/injuries; that consideration was discussed regarding the need for a change in the resident's environment; the potential need for assistive devices; education provided to staff; and audits for monitoring compliance with fall interventions. (b). Discussion with the QAPI Committee included the development of a PIP to decrease the number of injuries related to falls and ensure an effective plan with monitoring was initiated. 7. Starting 05/29/2023, a QAPI Committee meeting was to be held daily times two (2) weeks, then weekly for four (4) weeks, then monthly to ensure continued compliance with the above stated plan to ensure continued compliance with follow-up and recommendations by the Governing Body. 8. Beginning 05/30/2023, education was conducted by the VPCS for the QAPI Committee, which included the DON, ADON, SDC, UM, Dietary Manager (DM), and Social Services Director (SSD) on the QAPI program. (a). Education included QAPI goals, elements of the QAPI program, facility implementation of the QAPI program, staff's role in the QAPI program, and how to communicate concerns, problems, or opportunities for improvement to the QAPI Committee. (b). Also discussed was the facility's current PIP, with a goal of reducing falls and injuries related to falls, and the role of staff in the PIP. Staff including agency staff and volunteers not in the facility on 05/31/2023, were to receive education prior to working in the facility. 9. (a). On 05/30/2023, education was initiated by the SDC for facility staff, agency staff, and volunteers on the QAPI program. (b). Education included QAPI goals, elements of the program, facility implementation of the QAPI program, staff's role in the QAPI program, and how to communicate concerns, problems, or opportunities for improvement to the QAPI Committee. (c). Also discussed was the facility's current Performance Improvement Project (PIP), with a goal of reducing falls and injuries related to falls, and the role of staff in the PIP. Staff including agency staff and volunteers not in the facility on 05/31/2023 would receive education prior to working in the facility. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 06/01/2023 prior to exit on 06/10/2023. 1. Review of the facility's documentation confirmed the facility's conclusion its QAPI had not been effective in investigating the root cause of Residents #1, #16, #17, #18, and #19's falls. (a). Review of Resident #1's closed record review confirmed the resident no longer resided in the facility. (b). Review of Residents #16's, #17's, #18's, and #19's records and review of the facility's QAPI Committee minutes dated 05/23/2023, confirmed the QAPI Committee performed a root cause analysis (RCA) of the residents' falls, and implemented care plan interventions related to the findings of the RCA for each resident. 2. (a). Review of the facility's falls audit documentation and tracking/trending report confirmed on 05/23/2023, the audit of falls was conducted for the past ninety (90) days by the ED, DON, ADON, SDC, and the VPCS. (b). The records of residents noted as having experienced a fall in the past ninety (90) days were reviewed, including their care plans and Kardex and corrective actions alleged were confirmed. In an interview on 06/09/2023 at 4:00 PM, the SSD stated she audited fall care plans last week. She stated she went through the care plans with an IDT note to audit the resident's fall risk and develop appropriate interventions as a team with the ED, Supervisors, Unit Managers, ADON, and DON. The SSD further stated the IDT identified and updated residents' fall risks and ensured appropriate interventions were developed for each fall risk resident's care plan. In an interview on 06/09/2023 at 3:05 PM, the SDC stated the IDT realized the facility's failures with the citations, which revealed the importance of air mattress education that needed to be provided for staff. The SDC stated the IDT also realized the importance of the need for increased supervision for residents at high risk for falls, including one-to-one (1:1) supervision, and the importance of updating care plans and the IDT following-up on care plans. She stated a system failure had been identified by the IDT specific to the importance of proper care for the residents. The SDC stated proper care for residents included ensuring residents were toileted timely, were repositioned as necessary, had their pain addressed, and had their personal items within reach. She stated staff members must ensure follow through with such actions, and have more education: on being observant, investigating the root cause of falls, updating the care plan with appropriate fall interventions, and implementing those interventions. Per the SDC, the facility's QAPI initiated actions were to increase QAPI education with staff and explain the QAPI process. She stated the IDT was now evaluating falls indepth to reduce the falls and providing a better quality of care to residents. The SDC stated staff were having input in the QAPI Performance Improvement Project (PIP) on falls initiated on 05/30/2023 and team meetings were being held, specific to falls, with floor staff involvement and input for staff to work more cohesively and improve resident safety. 3. (a). Review of the facility's QAPI Committee documentation revealed a meeting was held on 05/29/2023, in which the ED, DON, and MD, initiated a PIP sub-committee comprised of the DON, ADON, SDC, Unit Manager, Charge Nurse, CNA, Director of Rehabilitation Services, Activity Director, and Housekeeping Supervisor. (b). Continued review of the facility's QAPI Committee documentation revealed the ED charged the PIP sub-committee team with analyzing falls data, completing a trending of the data, and completing root cause analysis of falls. Review additionally revealed the ED also charged the PIP sub-committee with interviewing residents and staff regarding fall risk, utilizing the feedback and information to develop a plan, and reporting the plan to the QAPI Committee by 05/30/2023. Review further revealed the plan initiated on 05/30/2023, was to decrease the number of falls, and therefore the risk of residents' injury from falls. In interview on 06/09/2023 at 4:00 PM, the SSD stated the staff education on the QAPI process regarding the PIP was more beneficial now, as previously the QAPI and the PIP had not been very well known by staff. However, she stated now from the QAPI meetings and discussion of the PIP process to decrease the number of falls/injuries had promoted increased staff communication and participation with the PIP. 4. In an interview on 06/10/2023 at 9:33 AM, with the DON and at 9:40 AM, with the ED, they stated on 05/29/2023, they were provided education by the VPCS, and the Medical Director was also present for the education. They stated the education was regarding the requirement for developing, implementing, and maintaining an effective, comprehensive, and data driven QAPI program for the facility that focused on indicators of the outcomes of care and quality of life for residents. The ED stated the education also included identifying concerns, the five (5) elements of QAPI, initiating PIPs to collect and analyze data, completing root cause analysis, developing a plan, and monitoring the effectiveness of the plan. In an interview on 06/10/2023 at 1:40 PM with the facility's Corporate Operations Officer (COO), [NAME] President of Clinical Operations (VPCO) the COO stated education had been provided to the ED and DON specific to their roles and responsibilities to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident. 5. Review of the facility's QAPI Committee documentation revealed a Stand-down QAPI meeting was held daily beginning on 05/29/2023. Review of the minutes for the 05/29/2023 Stand-down QAPI meeting held at 3:00 PM, revealed the meeting was held to discuss the plans for the deficiencies identified at F656, F689, F835, F837, F841, and F867. Further review of the facility's QAPI Committee documentation revealed Stand-down QAPI meeting were held daily as alleged. In interview on 06/10/2023 at 9:44 AM, the ED stated on 05/29/2023, a Stand-down QAPI meeting was held and continued to be held daily in order to complete a comprehensive review of the plan of correction to include action taken for in-house cited resident(s); review of actions taken for residents not cited; and education plan and audit tools and schedule for completion. The ED stated a root cause analysis, Comprehensive Care Plan review for falls and IDT review of current and newly developed interventions occurred. He stated consultation with Therapy Services and/or Medical Director, and/or family/responsible party for cited residents as well as other residents at risk for falls was conducted as a portion of the review. Per the ED, facility staff were interviewed to elicit feedback on the care and services of the cited residents as well as encouraged to bring concerns to the QAPI Committee as it related to falls. 6. Review of the QAPI Committee minutes from the 05/29/2023 meeting revealed an Ad Hoc meeting was held to discuss the plans initiated to decrease the risk of falls. In attendance was the ED, DON, Infection Preventionist, Licensed Nurse, and the Medical Director. (a). Continued review of the 05/29/2023 Ad Hoc QAPI Committee minutes revealed the method determined to reduce falls was to ensure a root cause analysis (RCA) was completed as part of the investigation following a resident's fall, and for consideration to be given to the need for increased supervision of residents to decrease the risk of further falls/injuries. Review of the minutes further revealed it was additionally determined consideration was discussed regarding the need for a change in environm[TRUNCATED]

***The facility alleged the following was implemented to remove Immediate Jeopardy effective 01/29/2020: 1. Resident #259 no longer resides at the facility. 2. By 02/21/2020, the Pharmacist will complete a Medication Regimen Review for current residents, which will include psychoactive medications, to ensure there is a supporting diagnosis, and will review for necessity/indication for the medication. The Pharmacist will also review for psychoactive medications that may be contributing to falls. One hundred eleven (111) residents were reviewed. Recommendations to the Medical Director was made for sixty-three (63) residents, six (6) of which were recommendations for a gradual dose reduction of psychoactive medications. 3. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) assessed current residents for potential side effects from psychoactive medication on 02/21/2020, and ensured resident's Medication Administration Records (MAR) reflected the need to monitor for potential side effects of psychoactive medication. 4. The facility held a meeting on 02/24/2020 to evaluate residents receiving psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) was in attendance and the Medical Director attended by phone to review appropriate utilization of psychoactive medications, which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive is achieved. 5. The DON/ADON/Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on 02/25/2020. The Nurse Consultant/DON/ADON/ Wound Nurse will also review resident falls for the past 30 days to ensure a root cause analysis has been conducted and appropriate interventions are in place. This will include a review of the care plan to ensure updates have been entered. 6. The Social Service Director, Social Service Assistant, and the Clinical Liaison will interview residents with a BIMS of eight (8) and above to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. The interviews were completed by 02/27/2020 and any concerns identified will be reported to the Director of Nursing (DON) and/or Executive Director immediately and addressed by the appropriate department. 7. The Wound Nurse (LPN) and Clinical Liaison (LPN) will complete resident observations by 02/27/2020 for residents with a BIMS score of seven (7) and below to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. Concerns identified will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 8. The Human Resource Director, ADON, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab will interview current staff related to any knowledge of residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. The interviews will be completed by 02/27/2020 and any concerns will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. The DON/ADON and/or designee will review resident interviews, staff interviews, and resident observations by 02/27/2020 to ensure the physician is notified of any change in condition. The DON/ADON/ MDS nurse will review current resident and staff interviews to ensure that appropriate interventions were placed based on falls root cause analysis. 10. On 02/27/2020, the DON/ADON and/or designee will review fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. By 02/27/2020, the MDS Coordinator will review nursing notes for the past 30 days to ensure physician notification and care plan revision to reflect any change, including falls and behaviors. One resident was identified to not have a care plan related to a skin tear; however, the physician had been notified with orders for treatment. 12. By 02/27/2020, the DON and/or the ADON will review the Twenty-Four hour reports to ensure any change in a resident's condition has been addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. The Nurse Consultant/DON/ADON/SDC/RN Charge Nurse will review care plans on current residents to ensure appropriate documentation related to change in conditions, including but not limited to: pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. The reviews were completed by 02/27/2020. Five resident care plans were revised. 14. By 02/21/2020, the Nurse Consultant educated the ED/DON/ADON/SDC on utilizing Stop and Watch forms, a communication form developed by CMS to communicate changes related to change of condition. Education will include giving the completed Stop and Watch to the nurse and making a copy and leaving for the DON/ADON. The DON/ADON will review Stop and Watches and follow up on possible change of condition during the daily clinical meeting and was completed as appropriate. By 02/21/2020, the ED/DON/ADON/SDC will educate current staff regarding utilizing Stop and Watch forms for any change in condition, giving the completed form to the nurse, and making a copy for the DON. 15. The Nurse Consultant educated the ED/DON/ADON/SDC the DON/ADON on 02/24/2020 to review Stop and Watches forms to ensure they were acted upon appropriately to include physician notification for changes in condition, They were also educated to ensure appropriate interventions were implemented for falls based on root cause analysis of the fall, which includes the 5 Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention at time of fall. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. The SDC/DON/ADON/ED then educated licensed staff by 02/24/2020 regarding the utilization of the 5 Why's tool to determine the root cause of a fall to assist in determining the most appropriate intervention. In addition, current licensed nurses will be educated to notify the on-call Nurse Manager after a fall to review the root cause and the intervention for appropriateness. 16. By 02/27/2020, the ED/DON/ADON/SDC will educate current licensed staff on appropriate documentation including, but not limited to: changes in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or needing increased help from staff. 17. By 02/26/2020, the Nurse Consultant will educate the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and the Wound Care Nurse (LPN) on assuring that residents are assessed for potential medication side effects; to ensure a monitoring order is placed on the MAR to monitor for potential side effects of psychoactive medication; to review medication for necessity, including an appropriate diagnosis; and to ensure a medication review request is sent to the consultant pharmacist following a resident fall and upon admission/re-admission. Education included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate diagnosis for any psychotropic medication. The review will be conducted during the daily clinical meeting and will be followed-up by the Pharmacy Consultant. Any new medication orders will be reviewed by the DON/ADON/SDC for necessity to include appropriate diagnosis and or indication for the medication. 18. The Nurse Consultant will educate the DON/ADON/SDC on ensuring pharmacy reviews have occurred monthly and ensuring timely follow up of recommendations per facility policy, which states the recommendations will be received by the DON within 3 days of completion of review. The recommendations will be sent to the physician and the DON will verify the physician and Medical Director has received the review within 3 days. The DON should receive a response from the physician within 7 days. If a response is not received in 7 days, the DON/ADON will notify the physician for acceptance and/or a response to the recommendations that require action. If no response is received in 14 days, the DON/ADON will notify the Medical Director for further action. The DON/ADON will also notify the Executive Director and the Nurse Consultant. This education will occur on 02/26/2020. The DON, ADON, or Staff Development Coordinator will then will educate current licensed staff by 02/26/2020 on assuring that residents are assessed for potential side effects of medications, ensuring a monitoring order is placed on the MAR to monitor for potential side effects of psychoactive medication, reviewing medication for necessity to include appropriate diagnosis, and ensuring a medication review request will be sent to the consultant pharmacist following any resident fall. 19. The Pharmacy Director will re-educate the Registered Pharmacist by 02/27/2020 on accurately completing a Medication Regimen Review, which will include a supporting diagnosis for psychoactive medications, reviewing for necessity/indication for the medication, and reviewing for psychoactive medications that may be contributing to falls. The Pharmacist assigned to the facility at the time of the IJ has been removed as the Pharmacy Consultant. The current Pharmacy Consultant has been educated on the concerns related to regimen reviews, appropriate diagnoses related to psychoactive medications, and indication for necessity of medications by the ED on 2/26/2020. 20. For all education, a post education test will be administered by the Nurse Consultant/DON/ADON/SDC following education. If a score of 100% is not obtained, re-education will be completed until proficiency is obtained and their score is 100%. Five tests will be administered daily by ED/Assistant Administrator/ DON/ADON/SDC to ensure retention of education, until IJ is removed and approved through QAPI process. Current staff who have not received education by 02/27/2020 will be mailed a certified letter informing them to contact the Executive Director/DON/SDC prior to working the floor. Staffing Agencies currently being utilized will be mailed a certified letter on 02/27/2020 of the need to contact the ED/DON/SDC for education prior to working. The Executive Director/SDC or designee will ensure all newly hired staff and agency staff will receive education during New Hire Orientation or prior to working the floor. 21. The IDT will review in the daily clinical meeting (Monday through Friday) each fall and nursing shift reports to ensure the following is completed for any resident who sustained a fall: Falls Risk evaluation, to include the 5 Why's; physician notification; and care plan revision. In addition, the IDT will review Stop and Watch forms, progress notes, and physician orders to ensure care plans have been updated appropriately and physicians have been notified. 22. The Executive Director/Assistant Administrator/DON will conduct daily post clinical IDT meetings Monday-Friday for two weeks to review all identified Change of Condition and the effectiveness of medication to ensure notification of residents' physician as required. In addition, the Executive Director/Assistant Administrator/DON will review five (5) random resident records to ensure proper documentation has been completed related to any change in condition, physician notification, and the care plans are appropriate. Any issues identified will be corrected immediately and reported to the QAPI Committee for 3 months for further review and recommendations. 23. The facility will conduct weekly monitoring to evaluate psychoactive medication on residents, residents new prescribed psychoactive medications, and residents that have had medication dose adjustment. This psychoactive meeting will be conducted weekly by the facility IDT, (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and Pharmacist to review appropriate utilization of psychoactive medications which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 24. Beginning 01/20/2020, the Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at facility to monitor processes related to supervision to prevent accidents, care plan development/revision, and physician notification until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. An AD-HOC QAPI meeting is held at least bi-weekly and as needed to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 25. Beginning 02/29/2020, The Director of Nursing, Assistant Director of Nursing, or the Staff Development Nurse will review MAR's daily (Monday through Friday), during the Clinical Meeting, for two weeks, for documentation of side effect monitoring of psychotropic medication and appropriate diagnosis to support the necessity for newly ordered medication, new admissions, and readmissions. The Director of Nursing will also review falls to ensure the Medication Regimen Review has been sent to the consultant pharmacist daily (Monday through Friday) during the clinical meeting. The Director of Nursing will contact the Pharmacy Director, in 72 hours, if no communication from the review is received from the consultant pharmacist. Any concerns identified will be corrected immediately, and reported to QAPI committee for further review and recommendations. 26. The Executive Director will ensure the facility has conducted weekly monitoring, month over month, for 3 months to evaluate psychoactive medication on residents newly prescribed psychoactive medications, and residents that have had medication dose adjustments. This psychoactive meeting will be conducted weekly, by the facility IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and the Pharmacist to review appropriate utilization of psychoactive medications, which includes; antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 27. The Nurse Consultant or Director of Nursing will be in the center daily to monitor residents with new psychotropic medication orders to ensure side effect monitoring is completed. 28. Beginning 1/20/2020, Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at the facility to monitor process, related to psychotropic medications, until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. AD-HOC QAPI meeting is held at least bi-weekly, and as needed, to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 29. The Executive Director will review 5 random Admissions/Readmissions/Falls/New Medication Orders/ Monthly Pharmacy Reviews for timeliness, and to ensure proper documentation has occurred daily. Any issues identified will be corrected immediately, and reported to QAPI Committee for 3 months for further review and recommendations. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on 02/29/2020, as alleged: 1. Review of documentation revealed Resident #259 no longer resided at the facility. 2. Interview with the Administrator on 3/05/2020 at 5:15 PM and review of documentation revealed by 02/21/2020, the Pharmacist completed a Medication Regimen Review for current residents on psychoactive medications, to ensure there was supporting diagnosis, and necessity and indication for the use of the medication. The Pharmacist also reviewed psychoactive medications that could have contributed to falls. Further review of documentation and interview with the Administrator confirmed one-hundred and eleven (111) residents were reviewed by the Pharmacist. Review of facility documentation revealed the Pharmacist made recommendations to the Medical Director on 63 residents reviewed and six (6) of those recommendations were for gradual dose reductions of psychoactive medications. 3. Interview with the Director of Nursing (DON) on 3/05/2020 at 3:30 PM and review of documentation revealed she and Assistant Director of Nursing (ADON) #1 assessed current residents for potential side effects from psychoactive medication on 02/21/2020. The DON and ADON #1 reviewed the residents' Medication Administration Records (MAR)'s to ensure it reflected monitoring for potential side effects for residents that received psychoactive medications in the facility. 4. Interview with the DON on 3/05/2020 at 3:30 PM and review of facility documentation revealed a meeting occurred at the facility on 02/24/2020, which evaluated residents that received psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. Review of documentation also revealed The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) attended the meeting, as well as the Medical Director, which attended the meeting, by phone. Continued interview with the DON and further review of documentation revealed the meeting was conducted to review appropriate utilization of psychoactive medications, antipsychotic medications, hypnotic medications, antianxiety medications, and mood-altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive medications was achieved. 5. Review of documentation and an Interview with ADON #1 on 3/05/2020 at 3:15 PM revealed she and the DON as well as the Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on 02/25/2020. Further interview and review of documentation also revealed The Nurse Consultant, the DON, ADON, and the Wound Nurse reviewed resident falls for the past 30 days, to ensure a root cause analysis was conducted and appropriate interventions were in place. Review of documentation and further interview with ADON #1 also revealed resident care plans were also reviewed to ensure care plan updates had been completed as required. 6. Interview with the Social Service Director on 3/05/2020 at 5:00 PM and review of documentation revealed she and the Social Service Assistant, and the Clinical Liaison interviewed residents with a Brief Interview for Mental Status score (BIMS) of eight (8) or greater to identify residents with concerns related to change of condition, which included but not limited to; pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. Continued interview and review of documentation revealed the interviews were completed by 2/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 7. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed the Wound Nurse, Licensed Practical Nurse (LPN) and the Clinical Liaison (LPN) completed resident observations for residents with a BIMS of seven (7) and below to identify residents with concerns related to change of condition, which included but wasn't limited to; pain, changes in sleep patterns, needing increased help from staff, or concerns related to increased fall risks. The resident observations were completed by 2/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and were addressed by the appropriate department. 8. Interview with ADON #1 on 3/5/2020 at 3:15 PM and review of documentation revealed she and the Human Resource Director, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab interviewed current staff related to any knowledge of residents with concerns related to change of condition, which included but wasn't limited to: pain, concerns related to sleep changes, needed increased help from staff, or concerns related to increased fall risks. Further interview and documentation review revealed the interviews were completed by 02/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. Interview with the DON on 3/05/2020 at 3:30 PM and review of documentation revealed her and the ADON reviewed all resident and staff interviews and resident observations by 02/27/2020 to ensure the physicians were notified of any change in condition. Further review and interview with the DON revealed she and ADON #1 reviewed current resident and staff interviews to ensure that appropriate interventions were placed based on the root cause analysis of falls. 10. Review of documentation and Interview with the Administrator on 3/05/2020 at 5:15 PM and interview with the DON on 3/05/2020 at 3:30 PM revealed on 02/27/2020 the DON/ADON and/or designee reviewed fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed the Minimum Data Set (MDS) Coordinator reviewed nursing notes for the past 30 days to ensure physician notification and care plan revision were completed to reflect any change in condition, which included falls and behaviors. Continued interview and review of documentation revealed the reviews were completed by 2/27/2020. Review of documentation also revealed one (1) resident was identified to have no care plan related to a skin tear; however, the physician had been notified and orders for treatment was implemented. 12. Interview with the Administrator on 3/5/2020 at 5:15 PM and documentation review revealed by 02/27/2020, the DON and/or the ADON reviewed the twenty-four (24) hour reports and ensured any change in a resident's condition was addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. Interview with the Administrator on 3/5/2020 at 5:15 and documentation reviewed revealed the Nurse Consultant, DON, ADON #1 and others as assigned reviewed care plans for current residents to ensure appropriate documentation related to change in conditions, which included but was not limited to pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. Review of documentation revealed these reviews were completed by 02/27/2020, and care plan revisions were indicated for five (5) residents. 14. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and documentation review revealed the Nurse Consultant educated the Administrator, DON, ADON #1 and the Staff Development Coordinator /SDC on utilizing Stop and Watch forms, which is a communication form developed by CMS to communicate changes related to change in a residents condition. Further reviews also indicated the education included staffs requirement to provide a copy of the completed Stop and Watch form to the nurse and the DON or ADON. Further interview and record review revealed the DON and/or the ADON reviewed completed Stop and Watch forms and follow up were completed to ensure any possible changes of condition were completed as appropriate. Review of documentation revealed the education and reviews were completed by 2/21/2020. Review of documentation and Interviews with LPN #8 on 3/05/2020 at 11:05 AM, State Registered Nurse Aide (SRNA) #19 on 3/04/2020 and SRNA #20 on 3/05/2020 at 4:35 PM revealed current staff members were educated by the Administrator, DON, ADON and Staff Development Coordinator (SDC) related to utilizing Stop and Watch forms for any change in condition, and ensuring a copy of the completed form was provided to the nurse, and the DON. Documentation review also revealed the education was completed by 2/21/2020. 15. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed she educated the Administrator, DON, ADON and SDC on 02/24/2020 on the requirement to review Stop and Watch forms to ensure they were addressed appropriately to include physician notification for changes in condition. Education also included the requirement to ensure appropriate interventions were implemented for falls based on the root cause analysis of the fall, which included the five (5) Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention, when the falls occur. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. Interviews with LPN #8 on 3/05/2020 at 11:05 AM and LPN #9 on 3/05/2020 at 11:15 AM and review of documentation confirmed by 2/24/2020, the SDC, DON, ADON #1 and the Administrator educated licensed staff related to the utilization of the 5 Why's tool to assist in determining the root cause of a fall, and also to assist in determining the most appropriate intervention. In addition, current licensed nurses was educated to notify the on-call Nurse Manager after a fall occurred, to review the root cause and to ensure the intervention was appropriate. 16. Interview with LPN #9 on 3/05/2020 at 11:15 AM and interview with the Nurse Consultant on 3/05/2020 at 4:50 PM, as well as review of documentation revealed by 02/27/2020, current licensed staff was educated on appropriate documentation which included but wasn't limited to change in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or residents that needed increased help from staff. 17. Review of documentation and interviews on 03/05/20202 with the Nurse Consultant at 4:50 PM, with LPN #8 at 11:05 AM and LPN #9 at 11:15 AM revealed by 2/26/2020, the DON, ADON, SDC, and the Wound Care Nurse (LPN) were educated on ensuring residents were assessed for potential side effects of medications and to ensure a monitoring order was placed on the MAR to monitor for potential side effects of psychoactive medication; to review medication for necessity, that included an appropriate diagnosis; and to ensure a medication review request was sent to the consultant pharmacist after a resident had fallen and when residents were admitted or readmitted to the facility. The education also included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate diagnosis for any psychotropic medication. The review was conducted during the daily clinical meeting and was followed-up by the Pharmacy Consultant. All new medication orders were reviewed by the DON, ADON, and SDC for necessity to include appropriate diagnosis and or indication for the medication. 18. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed she educated the DON/ADON/SDC on ensuring pharmacy reviews occurred monthly and ensuring timely follow up of recommendations as indicated in the facility policy, which stated the recommendations would be received by the DON within three (3) days after the review was completed. The education provided, directed staff to ensure the recommendations were sent to the physician and the DON would verify that the physician and the Medical Director had received the review within three (3) days. The DON was directed to ensure she received a response from the physician within 7 days; and if a response was not received in 7 days, then she or the ADON would notify the physician for acceptance and/or a response to the recommendations. The DON was also informed if no response was received in 14 days, then she or the ADON would notify the Medical Director for further action. The DON and ADON were also directed to notify the Executive Director and the Nurse Consultant when concerns were identified. Review of documentation revealed the education occurred on 02/26/2020. Interviews on 3/05/2020 with the DON at 3:30 PM, with LPN #8 at 11:05 AM and LPN #9 at 11:15 AM and review of documentation revealed current licensed staff was educated by 02/26/2020 on ensuring residents were assessed for potential side effects of medications, and ensuring a monitoring order was placed on the MAR to monitor for potential side effects of psychoactive medication, reviewing medication for necessity to include appropriate diagnosis, and ensuring a medication review request was sent to the consultant pharmacist, after any resident experienced a fall. 19. Review of documentation and Interview with the Administrator on 3/05/2020 at 5:15 PM confirmed the Pharmacy Director re-educated the Registered Pharmacist by 02/27/2020, on accurate completion of a Medication Regimen Review, which included ensuring a supporting diagnosis was present for psychoactive medications, reviews included necessity/indication for use of the medication, and reviews occurred for psychoactive medications that may contribute to falls. Interview with the Administrator and review of documentation revealed the Pharmacist assigned to the facility at the time of the IJ was removed as the Pharmacy Consultant. The current Pharmacy Consultant was educated on the concerns related to regimen reviews, appropriate diagnoses related to psychoactive medications, and indication for necessity of medications by the Administrator on 02/26/2020. 20. Review of facility documentation revealed a post education test was administered by the Nurse Consultant/DON/ADON/SDC after the education was provided to staff. Documentation also revealed if a sco[TRUNCATED]

***The facility alleged the following was implemented to remove Immediate Jeopardy effective 01/29/2020: 1. Resident #259 no longer resides at the facility. 2. By 02/21/2020, the Pharmacist will complete a Medication Regimen Review for current residents, which will include psychoactive medications, to ensure there is a supporting diagnosis, and will review for necessity/indication for the medication. The Pharmacist will also review for psychoactive medications that may be contributing to falls. One hundred eleven (111) residents were reviewed. Recommendations to the Medical Director was made for sixty-three (63) residents, six (6) of which were recommendations for a gradual dose reduction of psychoactive medications. 3. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) assessed current residents for potential side effects from psychoactive medication on 02/21/2020, and ensured resident's Medication Administration Records (MAR) reflected the need to monitor for potential side effects of psychoactive medication. 4. The facility held a meeting on 02/24/2020 to evaluate residents receiving psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) was in attendance and the Medical Director attended by phone to review appropriate utilization of psychoactive medications, which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive is achieved. 5. The DON/ADON/Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on 02/25/2020. The Nurse Consultant/DON/ADON/ Wound Nurse will also review resident falls for the past 30 days to ensure a root cause analysis has been conducted and appropriate interventions are in place. This will include a review of the care plan to ensure updates have been entered. 6. The Social Service Director, Social Service Assistant, and the Clinical Liaison will interview residents with a BIMS of eight (8) and above to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. The interviews were completed by 02/27/2020 and any concerns identified will be reported to the Director of Nursing (DON) and/or Executive Director immediately and addressed by the appropriate department. 7. The Wound Nurse (LPN) and Clinical Liaison (LPN) will complete resident observations by 02/27/2020 for residents with a BIMS score of seven (7) and below to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. Concerns identified will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 8. The Human Resource Director, ADON, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab will interview current staff related to any knowledge of residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. The interviews will be completed by 02/27/2020 and any concerns will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. The DON/ADON and/or designee will review resident interviews, staff interviews, and resident observations by 02/27/2020 to ensure the physician is notified of any change in condition. The DON/ADON/ MDS nurse will review current resident and staff interviews to ensure that appropriate interventions were placed based on falls root cause analysis. 10. On 02/27/2020, the DON/ADON and/or designee will review fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. By 02/27/2020, the MDS Coordinator will review nursing notes for the past 30 days to ensure physician notification and care plan revision to reflect any change, including falls and behaviors. One resident was identified to not have a care plan related to a skin tear; however, the physician had been notified with orders for treatment. 12. By 02/27/2020, the DON and/or the ADON will review the Twenty-Four hour reports to ensure any change in a resident's condition has been addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. The Nurse Consultant/DON/ADON/SDC/RN Charge Nurse will review care plans on current residents to ensure appropriate documentation related to change in conditions, including but not limited to: pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. The reviews were completed by 02/27/2020. Five resident care plans were revised. 14. By 02/21/2020, the Nurse Consultant educated the ED/DON/ADON/SDC on utilizing Stop and Watch forms, a communication form developed by CMS to communicate changes related to change of condition. Education will include giving the completed Stop and Watch to the nurse and making a copy and leaving for the DON/ADON. The DON/ADON will review Stop and Watches and follow up on possible change of condition during the daily clinical meeting and was completed as appropriate. By 02/21/2020, the ED/DON/ADON/SDC will educate current staff regarding utilizing Stop and Watch forms for any change in condition, giving the completed form to the nurse, and making a copy for the DON. 15. The Nurse Consultant educated the ED/DON/ADON/SDC the DON/ADON on 02/24/2020 to review Stop and Watches forms to ensure they were acted upon appropriately to include physician notification for changes in condition, They were also educated to ensure appropriate interventions were implemented for falls based on root cause analysis of the fall, which includes the 5 Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention at time of fall. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. The SDC/DON/ADON/ED then educated licensed staff by 02/24/2020 regarding the utilization of the 5 Why's tool to determine the root cause of a fall to assist in determining the most appropriate intervention. In addition, current licensed nurses will be educated to notify the on-call Nurse Manager after a fall to review the root cause and the intervention for appropriateness. 16. By 02/27/2020, the ED/DON/ADON/SDC will educate current licensed staff on appropriate documentation including, but not limited to: changes in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or needing increased help from staff. 17. By 02/26/2020, the Nurse Consultant will educate the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and the Wound Care Nurse (LPN) on assuring that residents are assessed for potential medication side effects; to ensure a monitoring order is placed on the MAR to monitor for potential side effects of psychoactive medication; to review medication for necessity, including an appropriate diagnosis; and to ensure a medication review request is sent to the consultant pharmacist following a resident fall and upon admission/re-admission. Education included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate diagnosis for any psychotropic medication. The review will be conducted during the daily clinical meeting and will be followed-up by the Pharmacy Consultant. Any new medication orders will be reviewed by the DON/ADON/SDC for necessity to include appropriate diagnosis and or indication for the medication. 18. The Nurse Consultant will educate the DON/ADON/SDC on ensuring pharmacy reviews have occurred monthly and ensuring timely follow up of recommendations per facility policy, which states the recommendations will be received by the DON within 3 days of completion of review. The recommendations will be sent to the physician and the DON will verify the physician and Medical Director has received the review within 3 days. The DON should receive a response from the physician within 7 days. If a response is not received in 7 days, the DON/ADON will notify the physician for acceptance and/or a response to the recommendations that require action. If no response is received in 14 days, the DON/ADON will notify the Medical Director for further action. The DON/ADON will also notify the Executive Director and the Nurse Consultant. This education will occur on 02/26/2020. The DON, ADON, or Staff Development Coordinator will then will educate current licensed staff by 02/26/2020 on assuring that residents are assessed for potential side effects of medications, ensuring a monitoring order is placed on the MAR to monitor for potential side effects of psychoactive medication, reviewing medication for necessity to include appropriate diagnosis, and ensuring a medication review request will be sent to the consultant pharmacist following any resident fall. 19. The Pharmacy Director will re-educate the Registered Pharmacist by 02/27/2020 on accurately completing a Medication Regimen Review, which will include a supporting diagnosis for psychoactive medications, reviewing for necessity/indication for the medication, and reviewing for psychoactive medications that may be contributing to falls. The Pharmacist assigned to the facility at the time of the IJ has been removed as the Pharmacy Consultant. The current Pharmacy Consultant has been educated on the concerns related to regimen reviews, appropriate diagnoses related to psychoactive medications, and indication for necessity of medications by the ED on 2/26/2020. 20. For all education, a post education test will be administered by the Nurse Consultant/DON/ADON/SDC following education. If a score of 100% is not obtained, re-education will be completed until proficiency is obtained and their score is 100%. Five tests will be administered daily by ED/Assistant Administrator/ DON/ADON/SDC to ensure retention of education, until IJ is removed and approved through QAPI process. Current staff who have not received education by 02/27/2020 will be mailed a certified letter informing them to contact the Executive Director/DON/SDC prior to working the floor. Staffing Agencies currently being utilized will be mailed a certified letter on 02/27/2020 of the need to contact the ED/DON/SDC for education prior to working. The Executive Director/SDC or designee will ensure all newly hired staff and agency staff will receive education during New Hire Orientation or prior to working the floor. 21. The IDT will review in the daily clinical meeting (Monday through Friday) each fall and nursing shift reports to ensure the following is completed for any resident who sustained a fall: Falls Risk evaluation, to include the 5 Why's; physician notification; and care plan revision. In addition, the IDT will review Stop and Watch forms, progress notes, and physician orders to ensure care plans have been updated appropriately and physicians have been notified. 22. The Executive Director/Assistant Administrator/DON will conduct daily post clinical IDT meetings Monday-Friday for two weeks to review all identified Change of Condition and the effectiveness of medication to ensure notification of residents' physician as required. In addition, the Executive Director/Assistant Administrator/DON will review five (5) random resident records to ensure proper documentation has been completed related to any change in condition, physician notification, and the care plans are appropriate. Any issues identified will be corrected immediately and reported to the QAPI Committee for 3 months for further review and recommendations. 23. The facility will conduct weekly monitoring to evaluate psychoactive medication on residents, residents new prescribed psychoactive medications, and residents that have had medication dose adjustment. This psychoactive meeting will be conducted weekly by the facility IDT, (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and Pharmacist to review appropriate utilization of psychoactive medications which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 24. Beginning 01/20/2020, the Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at facility to monitor processes related to supervision to prevent accidents, care plan development/revision, and physician notification until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. An AD-HOC QAPI meeting is held at least bi-weekly and as needed to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 25. Beginning 02/29/2020, The Director of Nursing, Assistant Director of Nursing, or the Staff Development Nurse will review MAR's daily (Monday through Friday), during the Clinical Meeting, for two weeks, for documentation of side effect monitoring of psychotropic medication and appropriate diagnosis to support the necessity for newly ordered medication, new admissions, and readmissions. The Director of Nursing will also review falls to ensure the Medication Regimen Review has been sent to the consultant pharmacist daily (Monday through Friday) during the clinical meeting. The Director of Nursing will contact the Pharmacy Director, in 72 hours, if no communication from the review is received from the consultant pharmacist. Any concerns identified will be corrected immediately, and reported to QAPI committee for further review and recommendations. 26. The Executive Director will ensure the facility has conducted weekly monitoring, month over month, for 3 months to evaluate psychoactive medication on residents newly prescribed psychoactive medications, and residents that have had medication dose adjustments. This psychoactive meeting will be conducted weekly, by the facility IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and the Pharmacist to review appropriate utilization of psychoactive medications, which includes; antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 27. The Nurse Consultant or Director of Nursing will be in the center daily to monitor residents with new psychotropic medication orders to ensure side effect monitoring is completed. 28. Beginning 1/20/2020, Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at the facility to monitor process, related to psychotropic medications, until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. AD-HOC QAPI meeting is held at least bi-weekly, and as needed, to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 29. The Executive Director will review 5 random Admissions/Readmissions/Falls/New Medication Orders/ Monthly Pharmacy Reviews for timeliness, and to ensure proper documentation has occurred daily. Any issues identified will be corrected immediately, and reported to QAPI Committee for 3 months for further review and recommendations. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on 02/29/2020, as alleged: 1. Review of documentation revealed Resident #259 no longer resided at the facility. 2. Interview with the Administrator on 3/05/2020 at 5:15 PM and review of documentation revealed by 02/21/2020, the Pharmacist completed a Medication Regimen Review for current residents on psychoactive medications, to ensure there was supporting diagnosis, and necessity and indication for the use of the medication. The Pharmacist also reviewed psychoactive medications that could have contributed to falls. Further review of documentation and interview with the Administrator confirmed one-hundred and eleven (111) residents were reviewed by the Pharmacist. Review of facility documentation revealed the Pharmacist made recommendations to the Medical Director on 63 residents reviewed and six (6) of those recommendations were for gradual dose reductions of psychoactive medications. 3. Interview with the Director of Nursing (DON) on 3/05/2020 at 3:30 PM and review of documentation revealed she and Assistant Director of Nursing (ADON) #1 assessed current residents for potential side effects from psychoactive medication on 02/21/2020. The DON and ADON #1 reviewed the residents' Medication Administration Records (MAR)'s to ensure it reflected monitoring for potential side effects for residents that received psychoactive medications in the facility. 4. Interview with the DON on 3/05/2020 at 3:30 PM and review of facility documentation revealed a meeting occurred at the facility on 02/24/2020, which evaluated residents that received psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. Review of documentation also revealed The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) attended the meeting, as well as the Medical Director, which attended the meeting, by phone. Continued interview with the DON and further review of documentation revealed the meeting was conducted to review appropriate utilization of psychoactive medications, antipsychotic medications, hypnotic medications, antianxiety medications, and mood-altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive medications was achieved. 5. Review of documentation and an Interview with ADON #1 on 3/05/2020 at 3:15 PM revealed she and the DON as well as the Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on 02/25/2020. Further interview and review of documentation also revealed The Nurse Consultant, the DON, ADON, and the Wound Nurse reviewed resident falls for the past 30 days, to ensure a root cause analysis was conducted and appropriate interventions were in place. Review of documentation and further interview with ADON #1 also revealed resident care plans were also reviewed to ensure care plan updates had been completed as required. 6. Interview with the Social Service Director on 3/05/2020 at 5:00 PM and review of documentation revealed she and the Social Service Assistant, and the Clinical Liaison interviewed residents with a Brief Interview for Mental Status score (BIMS) of eight (8) or greater to identify residents with concerns related to change of condition, which included but not limited to; pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. Continued interview and review of documentation revealed the interviews were completed by 2/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 7. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed the Wound Nurse, Licensed Practical Nurse (LPN) and the Clinical Liaison (LPN) completed resident observations for residents with a BIMS of seven (7) and below to identify residents with concerns related to change of condition, which included but wasn't limited to; pain, changes in sleep patterns, needing increased help from staff, or concerns related to increased fall risks. The resident observations were completed by 2/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and were addressed by the appropriate department. 8. Interview with ADON #1 on 3/5/2020 at 3:15 PM and review of documentation revealed she and the Human Resource Director, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab interviewed current staff related to any knowledge of residents with concerns related to change of condition, which included but wasn't limited to: pain, concerns related to sleep changes, needed increased help from staff, or concerns related to increased fall risks. Further interview and documentation review revealed the interviews were completed by 02/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. Interview with the DON on 3/05/2020 at 3:30 PM and review of documentation revealed her and the ADON reviewed all resident and staff interviews and resident observations by 02/27/2020 to ensure the physicians were notified of any change in condition. Further review and interview with the DON revealed she and ADON #1 reviewed current resident and staff interviews to ensure that appropriate interventions were placed based on the root cause analysis of falls. 10. Review of documentation and Interview with the Administrator on 3/05/2020 at 5:15 PM and interview with the DON on 3/05/2020 at 3:30 PM revealed on 02/27/2020 the DON/ADON and/or designee reviewed fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed the Minimum Data Set (MDS) Coordinator reviewed nursing notes for the past 30 days to ensure physician notification and care plan revision were completed to reflect any change in condition, which included falls and behaviors. Continued interview and review of documentation revealed the reviews were completed by 2/27/2020. Review of documentation also revealed one (1) resident was identified to have no care plan related to a skin tear; however, the physician had been notified and orders for treatment was implemented. 12. Interview with the Administrator on 3/5/2020 at 5:15 PM and documentation review revealed by 02/27/2020, the DON and/or the ADON reviewed the twenty-four (24) hour reports and ensured any change in a resident's condition was addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. Interview with the Administrator on 3/5/2020 at 5:15 and documentation reviewed revealed the Nurse Consultant, DON, ADON #1 and others as assigned reviewed care plans for current residents to ensure appropriate documentation related to change in conditions, which included but was not limited to pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. Review of documentation revealed these reviews were completed by 02/27/2020, and care plan revisions were indicated for five (5) residents. 14. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and documentation review revealed the Nurse Consultant educated the Administrator, DON, ADON #1 and the Staff Development Coordinator /SDC on utilizing Stop and Watch forms, which is a communication form developed by CMS to communicate changes related to change in a residents condition. Further reviews also indicated the education included staffs requirement to provide a copy of the completed Stop and Watch form to the nurse and the DON or ADON. Further interview and record review revealed the DON and/or the ADON reviewed completed Stop and Watch forms and follow up were completed to ensure any possible changes of condition were completed as appropriate. Review of documentation revealed the education and reviews were completed by 2/21/2020. Review of documentation and Interviews with LPN #8 on 3/05/2020 at 11:05 AM, State Registered Nurse Aide (SRNA) #19 on 3/04/2020 and SRNA #20 on 3/05/2020 at 4:35 PM revealed current staff members were educated by the Administrator, DON, ADON and Staff Development Coordinator (SDC) related to utilizing Stop and Watch forms for any change in condition, and ensuring a copy of the completed form was provided to the nurse, and the DON. Documentation review also revealed the education was completed by 2/21/2020. 15. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed she educated the Administrator, DON, ADON and SDC on 02/24/2020 on the requirement to review Stop and Watch forms to ensure they were addressed appropriately to include physician notification for changes in condition. Education also included the requirement to ensure appropriate interventions were implemented for falls based on the root cause analysis of the fall, which included the five (5) Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention, when the falls occur. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. Interviews with LPN #8 on 3/05/2020 at 11:05 AM and LPN #9 on 3/05/2020 at 11:15 AM and review of documentation confirmed by 2/24/2020, the SDC, DON, ADON #1 and the Administrator educated licensed staff related to the utilization of the 5 Why's tool to assist in determining the root cause of a fall, and also to assist in determining the most appropriate intervention. In addition, current licensed nurses was educated to notify the on-call Nurse Manager after a fall occurred, to review the root cause and to ensure the intervention was appropriate. 16. Interview with LPN #9 on 3/05/2020 at 11:15 AM and interview with the Nurse Consultant on 3/05/2020 at 4:50 PM, as well as review of documentation revealed by 02/27/2020, current licensed staff was educated on appropriate documentation which included but wasn't limited to change in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or residents that needed increased help from staff. 17. Review of documentation and interviews on 03/05/20202 with the Nurse Consultant at 4:50 PM, with LPN #8 at 11:05 AM and LPN #9 at 11:15 AM revealed by 2/26/2020, the DON, ADON, SDC, and the Wound Care Nurse (LPN) were educated on ensuring residents were assessed for potential side effects of medications and to ensure a monitoring order was placed on the MAR to monitor for potential side effects of psychoactive medication; to review medication for necessity, that included an appropriate diagnosis; and to ensure a medication review request was sent to the consultant pharmacist after a resident had fallen and when residents were admitted or readmitted to the facility. The education also included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate diagnosis for any psychotropic medication. The review was conducted during the daily clinical meeting and was followed-up by the Pharmacy Consultant. All new medication orders were reviewed by the DON, ADON, and SDC for necessity to include appropriate diagnosis and or indication for the medication. 18. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed she educated the DON/ADON/SDC on ensuring pharmacy reviews occurred monthly and ensuring timely follow up of recommendations as indicated in the facility policy, which stated the recommendations would be received by the DON within three (3) days after the review was completed. The education provided, directed staff to ensure the recommendations were sent to the physician and the DON would verify that the physician and the Medical Director had received the review within three (3) days. The DON was directed to ensure she received a response from the physician within 7 days; and if a response was not received in 7 days, then she or the ADON would notify the physician for acceptance and/or a response to the recommendations. The DON was also informed if no response was received in 14 days, then she or the ADON would notify the Medical Director for further action. The DON and ADON were also directed to notify the Executive Director and the Nurse Consultant when concerns were identified. Review of documentation revealed the education occurred on 02/26/2020. Interviews on 3/05/2020 with the DON at 3:30 PM, with LPN #8 at 11:05 AM and LPN #9 at 11:15 AM and review of documentation revealed current licensed staff was educated by 02/26/2020 on ensuring residents were assessed for potential side effects of medications, and ensuring a monitoring order was placed on the MAR to monitor for potential side effects of psychoactive medication, reviewing medication for necessity to include appropriate diagnosis, and ensuring a medication review request was sent to the consultant pharmacist, after any resident experienced a fall. 19. Review of documentation and Interview with the Administrator on 3/05/2020 at 5:15 PM confirmed the Pharmacy Director re-educated the Registered Pharmacist by 02/27/2020, on accurate completion of a Medication Regimen Review, which included ensuring a supporting diagnosis was present for psychoactive medications, reviews included necessity/indication for use of the medication, and reviews occurred for psychoactive medications that may contribute to falls. Interview with the Administrator and review of documentation revealed the Pharmacist assigned to the facility at the time of the IJ was removed as the Pharmacy Consultant. The current Pharmacy Consultant was educated on the concerns related to regimen reviews, appropriate diagnoses related to psychoactive medications, and indication for necessity of medications by the Administrator on 02/26/2020. 20. Review of facility documentation revealed a post education test was administered by the Nurse Consultant/DON/ADON/SDC after the education was provided to staff. Documentation also revealed if a sco[TRUNCATED]

***The facility alleged the following was implemented to remove Immediate Jeopardy effective 01/29/2020: 1. Resident #259 no longer resides at the facility. 2. By 02/21/2020, the Pharmacist will complete a Medication Regimen Review for current residents, which will include psychoactive medications, to ensure there is a supporting diagnosis, and will review for necessity/indication for the medication. The Pharmacist will also review for psychoactive medications that may be contributing to falls. One hundred eleven (111) residents were reviewed. Recommendations to the Medical Director was made for sixty-three (63) residents, six (6) of which were recommendations for a gradual dose reduction of psychoactive medications. 3. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) assessed current residents for potential side effects from psychoactive medication on 02/21/2020, and ensured resident's Medication Administration Records (MAR) reflected the need to monitor for potential side effects of psychoactive medication. 4. The facility held a meeting on 02/24/2020 to evaluate residents receiving psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) was in attendance and the Medical Director attended by phone to review appropriate utilization of psychoactive medications, which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive is achieved. 5. The DON/ADON/Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on 02/25/2020. The Nurse Consultant/DON/ADON/ Wound Nurse will also review resident falls for the past 30 days to ensure a root cause analysis has been conducted and appropriate interventions are in place. This will include a review of the care plan to ensure updates have been entered. 6. The Social Service Director, Social Service Assistant, and the Clinical Liaison will interview residents with a BIMS of eight (8) and above to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. The interviews were completed by 02/27/2020 and any concerns identified will be reported to the Director of Nursing (DON) and/or Executive Director immediately and addressed by the appropriate department. 7. The Wound Nurse (LPN) and Clinical Liaison (LPN) will complete resident observations by 02/27/2020 for residents with a BIMS score of seven (7) and below to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. Concerns identified will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 8. The Human Resource Director, ADON, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab will interview current staff related to any knowledge of residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. The interviews will be completed by 02/27/2020 and any concerns will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. The DON/ADON and/or designee will review resident interviews, staff interviews, and resident observations by 02/27/2020 to ensure the physician is notified of any change in condition. The DON/ADON/ MDS nurse will review current resident and staff interviews to ensure that appropriate interventions were placed based on falls root cause analysis. 10. On 02/27/2020, the DON/ADON and/or designee will review fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. By 02/27/2020, the MDS Coordinator will review nursing notes for the past 30 days to ensure physician notification and care plan revision to reflect any change, including falls and behaviors. One resident was identified to not have a care plan related to a skin tear; however, the physician had been notified with orders for treatment. 12. By 02/27/2020, the DON and/or the ADON will review the Twenty-Four hour reports to ensure any change in a resident's condition has been addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. The Nurse Consultant/DON/ADON/SDC/RN Charge Nurse will review care plans on current residents to ensure appropriate documentation related to change in conditions, including but not limited to: pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. The reviews were completed by 02/27/2020. Five resident care plans were revised. 14. By 02/21/2020, the Nurse Consultant educated the ED/DON/ADON/SDC on utilizing Stop and Watch forms, a communication form developed by CMS to communicate changes related to change of condition. Education will include giving the completed Stop and Watch to the nurse and making a copy and leaving for the DON/ADON. The DON/ADON will review Stop and Watches and follow up on possible change of condition during the daily clinical meeting and was completed as appropriate. By 02/21/2020, the ED/DON/ADON/SDC will educate current staff regarding utilizing Stop and Watch forms for any change in condition, giving the completed form to the nurse, and making a copy for the DON. 15. The Nurse Consultant educated the ED/DON/ADON/SDC the DON/ADON on 02/24/2020 to review Stop and Watches forms to ensure they were acted upon appropriately to include physician notification for changes in condition, They were also educated to ensure appropriate interventions were implemented for falls based on root cause analysis of the fall, which includes the 5 Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention at time of fall. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. The SDC/DON/ADON/ED then educated licensed staff by 02/24/2020 regarding the utilization of the 5 Why's tool to determine the root cause of a fall to assist in determining the most appropriate intervention. In addition, current licensed nurses will be educated to notify the on-call Nurse Manager after a fall to review the root cause and the intervention for appropriateness. 16. By 02/27/2020, the ED/DON/ADON/SDC will educate current licensed staff on appropriate documentation including, but not limited to: changes in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or needing increased help from staff. 17. By 02/26/2020, the Nurse Consultant will educate the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and the Wound Care Nurse (LPN) on assuring that residents are assessed for potential medication side effects; to ensure a monitoring order is placed on the MAR to monitor for potential side effects of psychoactive medication; to review medication for necessity, including an appropriate diagnosis; and to ensure a medication review request is sent to the consultant pharmacist following a resident fall and upon admission/re-admission. Education included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate diagnosis for any psychotropic medication. The review will be conducted during the daily clinical meeting and will be followed-up by the Pharmacy Consultant. Any new medication orders will be reviewed by the DON/ADON/SDC for necessity to include appropriate diagnosis and or indication for the medication. 18. The Nurse Consultant will educate the DON/ADON/SDC on ensuring pharmacy reviews have occurred monthly and ensuring timely follow up of recommendations per facility policy, which states the recommendations will be received by the DON within 3 days of completion of review. The recommendations will be sent to the physician and the DON will verify the physician and Medical Director has received the review within 3 days. The DON should receive a response from the physician within 7 days. If a response is not received in 7 days, the DON/ADON will notify the physician for acceptance and/or a response to the recommendations that require action. If no response is received in 14 days, the DON/ADON will notify the Medical Director for further action. The DON/ADON will also notify the Executive Director and the Nurse Consultant. This education will occur on 02/26/2020. The DON, ADON, or Staff Development Coordinator will then will educate current licensed staff by 02/26/2020 on assuring that residents are assessed for potential side effects of medications, ensuring a monitoring order is placed on the MAR to monitor for potential side effects of psychoactive medication, reviewing medication for necessity to include appropriate diagnosis, and ensuring a medication review request will be sent to the consultant pharmacist following any resident fall. 19. The Pharmacy Director will re-educate the Registered Pharmacist by 02/27/2020 on accurately completing a Medication Regimen Review, which will include a supporting diagnosis for psychoactive medications, reviewing for necessity/indication for the medication, and reviewing for psychoactive medications that may be contributing to falls. The Pharmacist assigned to the facility at the time of the IJ has been removed as the Pharmacy Consultant. The current Pharmacy Consultant has been educated on the concerns related to regimen reviews, appropriate diagnoses related to psychoactive medications, and indication for necessity of medications by the ED on 2/26/2020. 20. For all education, a post education test will be administered by the Nurse Consultant/DON/ADON/SDC following education. If a score of 100% is not obtained, re-education will be completed until proficiency is obtained and their score is 100%. Five tests will be administered daily by ED/Assistant Administrator/ DON/ADON/SDC to ensure retention of education, until IJ is removed and approved through QAPI process. Current staff who have not received education by 02/27/2020 will be mailed a certified letter informing them to contact the Executive Director/DON/SDC prior to working the floor. Staffing Agencies currently being utilized will be mailed a certified letter on 02/27/2020 of the need to contact the ED/DON/SDC for education prior to working. The Executive Director/SDC or designee will ensure all newly hired staff and agency staff will receive education during New Hire Orientation or prior to working the floor. 21. The IDT will review in the daily clinical meeting (Monday through Friday) each fall and nursing shift reports to ensure the following is completed for any resident who sustained a fall: Falls Risk evaluation, to include the 5 Why's; physician notification; and care plan revision. In addition, the IDT will review Stop and Watch forms, progress notes, and physician orders to ensure care plans have been updated appropriately and physicians have been notified. 22. The Executive Director/Assistant Administrator/DON will conduct daily post clinical IDT meetings Monday-Friday for two weeks to review all identified Change of Condition and the effectiveness of medication to ensure notification of residents' physician as required. In addition, the Executive Director/Assistant Administrator/DON will review five (5) random resident records to ensure proper documentation has been completed related to any change in condition, physician notification, and the care plans are appropriate. Any issues identified will be corrected immediately and reported to the QAPI Committee for 3 months for further review and recommendations. 23. The facility will conduct weekly monitoring to evaluate psychoactive medication on residents, residents new prescribed psychoactive medications, and residents that have had medication dose adjustment. This psychoactive meeting will be conducted weekly by the facility IDT, (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and Pharmacist to review appropriate utilization of psychoactive medications which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 24. Beginning 01/20/2020, the Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at facility to monitor processes related to supervision to prevent accidents, care plan development/revision, and physician notification until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. An AD-HOC QAPI meeting is held at least bi-weekly and as needed to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 25. Beginning 02/29/2020, The Director of Nursing, Assistant Director of Nursing, or the Staff Development Nurse will review MAR's daily (Monday through Friday), during the Clinical Meeting, for two weeks, for documentation of side effect monitoring of psychotropic medication and appropriate diagnosis to support the necessity for newly ordered medication, new admissions, and readmissions. The Director of Nursing will also review falls to ensure the Medication Regimen Review has been sent to the consultant pharmacist daily (Monday through Friday) during the clinical meeting. The Director of Nursing will contact the Pharmacy Director, in 72 hours, if no communication from the review is received from the consultant pharmacist. Any concerns identified will be corrected immediately, and reported to QAPI committee for further review and recommendations. 26. The Executive Director will ensure the facility has conducted weekly monitoring, month over month, for 3 months to evaluate psychoactive medication on residents newly prescribed psychoactive medications, and residents that have had medication dose adjustments. This psychoactive meeting will be conducted weekly, by the facility IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and the Pharmacist to review appropriate utilization of psychoactive medications, which includes; antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 27. The Nurse Consultant or Director of Nursing will be in the center daily to monitor residents with new psychotropic medication orders to ensure side effect monitoring is completed. 28. Beginning 1/20/2020, Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at the facility to monitor process, related to psychotropic medications, until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. AD-HOC QAPI meeting is held at least bi-weekly, and as needed, to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 29. The Executive Director will review 5 random Admissions/Readmissions/Falls/New Medication Orders/ Monthly Pharmacy Reviews for timeliness, and to ensure proper documentation has occurred daily. Any issues identified will be corrected immediately, and reported to QAPI Committee for 3 months for further review and recommendations. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on 02/29/2020, as alleged: 1. Review of documentation revealed Resident #259 no longer resided at the facility. 2. Interview with the Administrator on 3/05/2020 at 5:15 PM and review of documentation revealed by 02/21/2020, the Pharmacist completed a Medication Regimen Review for current residents on psychoactive medications, to ensure there was supporting diagnosis, and necessity and indication for the use of the medication. The Pharmacist also reviewed psychoactive medications that could have contributed to falls. Further review of documentation and interview with the Administrator confirmed one-hundred and eleven (111) residents were reviewed by the Pharmacist. Review of facility documentation revealed the Pharmacist made recommendations to the Medical Director on 63 residents reviewed and six (6) of those recommendations were for gradual dose reductions of psychoactive medications. 3. Interview with the Director of Nursing (DON) on 3/05/2020 at 3:30 PM and review of documentation revealed she and Assistant Director of Nursing (ADON) #1 assessed current residents for potential side effects from psychoactive medication on 02/21/2020. The DON and ADON #1 reviewed the residents' Medication Administration Records (MAR)'s to ensure it reflected monitoring for potential side effects for residents that received psychoactive medications in the facility. 4. Interview with the DON on 3/05/2020 at 3:30 PM and review of facility documentation revealed a meeting occurred at the facility on 02/24/2020, which evaluated residents that received psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. Review of documentation also revealed The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) attended the meeting, as well as the Medical Director, which attended the meeting, by phone. Continued interview with the DON and further review of documentation revealed the meeting was conducted to review appropriate utilization of psychoactive medications, antipsychotic medications, hypnotic medications, antianxiety medications, and mood-altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive medications was achieved. 5. Review of documentation and an Interview with ADON #1 on 3/05/2020 at 3:15 PM revealed she and the DON as well as the Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on 02/25/2020. Further interview and review of documentation also revealed The Nurse Consultant, the DON, ADON, and the Wound Nurse reviewed resident falls for the past 30 days, to ensure a root cause analysis was conducted and appropriate interventions were in place. Review of documentation and further interview with ADON #1 also revealed resident care plans were also reviewed to ensure care plan updates had been completed as required. 6. Interview with the Social Service Director on 3/05/2020 at 5:00 PM and review of documentation revealed she and the Social Service Assistant, and the Clinical Liaison interviewed residents with a Brief Interview for Mental Status score (BIMS) of eight (8) or greater to identify residents with concerns related to change of condition, which included but not limited to; pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. Continued interview and review of documentation revealed the interviews were completed by 2/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 7. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed the Wound Nurse, Licensed Practical Nurse (LPN) and the Clinical Liaison (LPN) completed resident observations for residents with a BIMS of seven (7) and below to identify residents with concerns related to change of condition, which included but wasn't limited to; pain, changes in sleep patterns, needing increased help from staff, or concerns related to increased fall risks. The resident observations were completed by 2/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and were addressed by the appropriate department. 8. Interview with ADON #1 on 3/5/2020 at 3:15 PM and review of documentation revealed she and the Human Resource Director, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab interviewed current staff related to any knowledge of residents with concerns related to change of condition, which included but wasn't limited to: pain, concerns related to sleep changes, needed increased help from staff, or concerns related to increased fall risks. Further interview and documentation review revealed the interviews were completed by 02/27/2020 and any identified concerns were reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. Interview with the DON on 3/05/2020 at 3:30 PM and review of documentation revealed her and the ADON reviewed all resident and staff interviews and resident observations by 02/27/2020 to ensure the physicians were notified of any change in condition. Further review and interview with the DON revealed she and ADON #1 reviewed current resident and staff interviews to ensure that appropriate interventions were placed based on the root cause analysis of falls. 10. Review of documentation and Interview with the Administrator on 3/05/2020 at 5:15 PM and interview with the DON on 3/05/2020 at 3:30 PM revealed on 02/27/2020 the DON/ADON and/or designee reviewed fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed the Minimum Data Set (MDS) Coordinator reviewed nursing notes for the past 30 days to ensure physician notification and care plan revision were completed to reflect any change in condition, which included falls and behaviors. Continued interview and review of documentation revealed the reviews were completed by 2/27/2020. Review of documentation also revealed one (1) resident was identified to have no care plan related to a skin tear; however, the physician had been notified and orders for treatment was implemented. 12. Interview with the Administrator on 3/5/2020 at 5:15 PM and documentation review revealed by 02/27/2020, the DON and/or the ADON reviewed the twenty-four (24) hour reports and ensured any change in a resident's condition was addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. Interview with the Administrator on 3/5/2020 at 5:15 and documentation reviewed revealed the Nurse Consultant, DON, ADON #1 and others as assigned reviewed care plans for current residents to ensure appropriate documentation related to change in conditions, which included but was not limited to pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. Review of documentation revealed these reviews were completed by 02/27/2020, and care plan revisions were indicated for five (5) residents. 14. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and documentation review revealed the Nurse Consultant educated the Administrator, DON, ADON #1 and the Staff Development Coordinator /SDC on utilizing Stop and Watch forms, which is a communication form developed by CMS to communicate changes related to change in a residents condition. Further reviews also indicated the education included staffs requirement to provide a copy of the completed Stop and Watch form to the nurse and the DON or ADON. Further interview and record review revealed the DON and/or the ADON reviewed completed Stop and Watch forms and follow up were completed to ensure any possible changes of condition were completed as appropriate. Review of documentation revealed the education and reviews were completed by 2/21/2020. Review of documentation and Interviews with LPN #8 on 3/05/2020 at 11:05 AM, State Registered Nurse Aide (SRNA) #19 on 3/04/2020 and SRNA #20 on 3/05/2020 at 4:35 PM revealed current staff members were educated by the Administrator, DON, ADON and Staff Development Coordinator (SDC) related to utilizing Stop and Watch forms for any change in condition, and ensuring a copy of the completed form was provided to the nurse, and the DON. Documentation review also revealed the education was completed by 2/21/2020. 15. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed she educated the Administrator, DON, ADON and SDC on 02/24/2020 on the requirement to review Stop and Watch forms to ensure they were addressed appropriately to include physician notification for changes in condition. Education also included the requirement to ensure appropriate interventions were implemented for falls based on the root cause analysis of the fall, which included the five (5) Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention, when the falls occur. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. Interviews with LPN #8 on 3/05/2020 at 11:05 AM and LPN #9 on 3/05/2020 at 11:15 AM and review of documentation confirmed by 2/24/2020, the SDC, DON, ADON #1 and the Administrator educated licensed staff related to the utilization of the 5 Why's tool to assist in determining the root cause of a fall, and also to assist in determining the most appropriate intervention. In addition, current licensed nurses was educated to notify the on-call Nurse Manager after a fall occurred, to review the root cause and to ensure the intervention was appropriate. 16. Interview with LPN #9 on 3/05/2020 at 11:15 AM and interview with the Nurse Consultant on 3/05/2020 at 4:50 PM, as well as review of documentation revealed by 02/27/2020, current licensed staff was educated on appropriate documentation which included but wasn't limited to change in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or residents that needed increased help from staff. 17. Review of documentation and interviews on 03/05/20202 with the Nurse Consultant at 4:50 PM, with LPN #8 at 11:05 AM and LPN #9 at 11:15 AM revealed by 2/26/2020, the DON, ADON, SDC, and the Wound Care Nurse (LPN) were educated on ensuring residents were assessed for potential side effects of medications and to ensure a monitoring order was placed on the MAR to monitor for potential side effects of psychoactive medication; to review medication for necessity, that included an appropriate diagnosis; and to ensure a medication review request was sent to the consultant pharmacist after a resident had fallen and when residents were admitted or readmitted to the facility. The education also included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate diagnosis for any psychotropic medication. The review was conducted during the daily clinical meeting and was followed-up by the Pharmacy Consultant. All new medication orders were reviewed by the DON, ADON, and SDC for necessity to include appropriate diagnosis and or indication for the medication. 18. Interview with the Nurse Consultant on 3/05/2020 at 4:50 PM and review of documentation revealed she educated the DON/ADON/SDC on ensuring pharmacy reviews occurred monthly and ensuring timely follow up of recommendations as indicated in the facility policy, which stated the recommendations would be received by the DON within three (3) days after the review was completed. The education provided, directed staff to ensure the recommendations were sent to the physician and the DON would verify that the physician and the Medical Director had received the review within three (3) days. The DON was directed to ensure she received a response from the physician within 7 days; and if a response was not received in 7 days, then she or the ADON would notify the physician for acceptance and/or a response to the recommendations. The DON was also informed if no response was received in 14 days, then she or the ADON would notify the Medical Director for further action. The DON and ADON were also directed to notify the Executive Director and the Nurse Consultant when concerns were identified. Review of documentation revealed the education occurred on 02/26/2020. Interviews on 3/05/2020 with the DON at 3:30 PM, with LPN #8 at 11:05 AM and LPN #9 at 11:15 AM and review of documentation revealed current licensed staff was educated by 02/26/2020 on ensuring residents were assessed for potential side effects of medications, and ensuring a monitoring order was placed on the MAR to monitor for potential side effects of psychoactive medication, reviewing medication for necessity to include appropriate diagnosis, and ensuring a medication review request was sent to the consultant pharmacist, after any resident experienced a fall. 19. Review of documentation and Interview with the Administrator on 3/05/2020 at 5:15 PM confirmed the Pharmacy Director re-educated the Registered Pharmacist by 02/27/2020, on accurate completion of a Medication Regimen Review, which included ensuring a supporting diagnosis was present for psychoactive medications, reviews included necessity/indication for use of the medication, and reviews occurred for psychoactive medications that may contribute to falls. Interview with the Administrator and review of documentation revealed the Pharmacist assigned to the facility at the time of the IJ was removed as the Pharmacy Consultant. The current Pharmacy Consultant was educated on the concerns related to regimen reviews, appropriate diagnoses related to psychoactive medications, and indication for necessity of medications by the Administrator on 02/26/2020. 20. Review of facility documentation revealed a post education test was administered by the Nurse Consultant/DON/ADON/SDC after the education was provided to staff. Documentation also revealed if a sco[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and a review of the facility policy, it was determined the facility failed to ensure the Consulting Pharmacist conducted a review of two (2) of thirty-nine (39) sampled residents' medical records (Resident #259 and Resident #2) when conducting the Drug Regimen Review (DRR) to ensure medications were not causing unwanted, uncomfortable, or dangerous effects. Resident #259 was admitted to the facility on [DATE] with physician orders for psychotropic medications. Review of Resident #259's medical record revealed the resident sustained falls on [DATE], [DATE], and [DATE], after getting up unassisted. Interviews with staff revealed the resident also had insomnia. The licensed Pharmacist conducted a Medication Regimen Review (MRR) on [DATE], and indicated the resident's medical record listed potentially inappropriate supporting diagnoses for the use of the psychotropic drugs prescribed for the resident. However, the pharmacist failed to review the resident's medical record in an attempt to determine whether the psychotropic medications contributed to the resident's falls. Resident #259 sustained another fall on [DATE] at 9:26 PM after the pharmacy review was conducted. In addition, on [DATE] at 1:05 AM Resident #259 was found on the floor, lying on his/her left side in the hallway of the facility, and bleeding from his/her head. The resident was transferred to a local hospital on [DATE] and was diagnosed with an acute left frontotemporal subdural hemorrhage and acute left parietal, left posterior temporal, and right posterior temporal subarachnoid hemorrhage (bleeds in the brain). Resident #259 expired at 6:38 AM on [DATE], due to a Traumatic Brain Injury from the fall to the floor. In addition, the facility failed to address a pharmacy recommendation dated [DATE], per the facility's policy for Resident #2. The facility's failure to ensure residents' medical records were reviewed to ensure medications were not causing unwanted, uncomfortable, or dangerous effects has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE] prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: 1. Review of the facility's policy, Medication Regimen Review, Facility Process, dated [DATE], revealed the intent of the process was to prevent or minimize adverse consequences related to medication therapy to the extent possible by providing oversight by a licensed pharmacist, attending physician, medical director, and the Director of Nursing (DON). The policy defined adverse consequences as a broad term, which referred to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional/psychosocial status. The policy also indicated that the Medication Regimen Review would be a thorough evaluation of the resident's medication regimen with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The Medication Regimen Review would include a medical record review for the resident in order to prevent, identify, report, and resolve issues, which included medication-related problems, and collaborate with other members of the IDT, including the resident, their family, and/or the resident representative. Review of Resident #259's medical record revealed the facility admitted the resident on [DATE] with diagnoses including Dementia, Parkinson's disease, and Unspecified Symptoms and Signs Involving Cognitive Functions and Awareness. Review of Resident #259's Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident displayed no behaviors during the assessment period. The facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated cognitive impairment, and to require extensive assistance of two (2) staff members for toileting, bed mobility, and transfers. The MDS also revealed the resident had experienced one (1) fall since admission, with no injury. Review of Resident #259's physician orders dated [DATE] and [DATE] revealed the resident received the following medications: Divalproex Sodium (anticonvulsant) Delayed Release 250 milligrams (mg), and Lorazepam (anti-anxiety) 0.5 mg at bedtime for Parkinson's Disease. Resident #259 also received Mirtazapine (antidepressant) 15 mg at bedtime for treatment of Unspecified Symptoms and Signs Involving Cognitive Functions and Awareness. Review of Resident #259's record revealed the resident experienced falls on [DATE], [DATE], and [DATE], when attempting to get up unassisted. Review of Resident #259's Pharmacy Consultation Report dated [DATE] revealed the pharmacist identified concerns with the diagnoses listed as the indication for use for the psychotropic medications prescribed for the resident. The pharmacist's report indicated the resident's medical record listed potentially inappropriate supporting diagnoses for use of Lorazepam, Divalproex, and Mirtazapine. The pharmacist's report also cautioned, All psychotropics need appropriate indication. Interview with the facility Pharmacist on [DATE] at 9:45 AM revealed when reviewing Resident #259's medications on [DATE], she identified that the resident was receiving psychotropic medications without appropriate diagnoses or indications for their use. The Pharmacist stated she did not usually research the resident's medical record or inquire about falls the resident had sustained, even if a medication prescribed to the resident could potentially contribute to increased falls. The Pharmacist stated she was not aware that Resident #259 had experienced three (3) falls prior to the medication review and had not discussed Resident #259's medication use with the DON or any other member of the Interdisciplinary Team (IDT). In addition, the pharmacist stated she had not observed or spoken with Resident #259 or the resident's family member/representative. Interview with the DON on [DATE] at 2:05 PM revealed the Interdisciplinary Team (IDT) reviewed all newly admitted residents' medications to ensure that residents receiving psychotropic medications had the appropriate supporting diagnoses. However, the DON was unable to remember if Resident #259's medications had been reviewed on admission. The DON also acknowledged the facility had no process in place to monitor residents for potential adverse effects of psychotropic medications, including the potential for the medication(s) to be a contributing factor for sustained falls. According to the DON, the resident's physician had not reviewed or acted upon the pharmacist's recommendations prior to the resident's transfer from the facility. Interviews on [DATE] with Licensed Practical Nurse (LPN) #5 at 3:00 PM and LPN #2 at 9:10 PM, and on [DATE] at 11:35 AM with LPN #6 revealed the staff had not been instructed to monitor residents for potential adverse effects of psychotropic medication. Interview with Physical Therapy Assistant (PTA) #1 on [DATE] at 12:45 PM revealed he provided services to Resident #259 a couple of times; however, he was unable to get the resident to participate well in therapy because the resident was lethargic during each session. Continued review of Resident #259's medical record revealed the resident sustained another fall after attempting to get out of bed unassisted on [DATE] at 9:26 PM. In addition, review of a nurse's note revealed on [DATE] at 1:05 AM staff observed the resident lying on the floor on his/her left side, in the hallway in front of the nurses' station/dining room of the facility. The nurse's notes also revealed the resident had a large hematoma to the left temporal area and copious amount of bleeding also present from area. Resident #259 was transferred to the local hospital for further evaluation and treatment. Review of Resident #259's hospital record for Resident #259 dated [DATE] revealed the resident had a laceration to the left forehead, which extended to the skull, and an arterial bleed was present and bleeding in the brain. The resident expired on [DATE] at 6:38 AM from a Traumatic Brain Injury sustained from a fall. 2. Review of the policy, Medication Regimen Review (MRR) Facility Process, dated [DATE], revealed the attending physician is expected to sign the resident's individual MRR and document that he/she reviewed the pharmacist's identified irregularities; document the action taken or not taken, including the rationale for why the recommendation was rejected; and return the signed form to the Director of Nursing or designee within 7 days. If preferred by the physician, instead of signing the MRR form, the physician may document a progress note in the resident's medical record that states he has reviewed the Pharmacist's recommendations and either accepts the recommendations and provides new orders or documents rationale as to why the recommendation is rejected. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia with Behavioral Disturbance, Unspecified Psychosis, Alzheimer's Disease, and Anxiety Disorder. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident had moderate cognitive impairment. Review of the current physician orders, per electronic medical record (EMR), revealed as of [DATE], Resident #2 had orders for psychotropic medications that included BuSpar, Trazadone, Prozac, Seroquel, and Xanax. Review of the pharmacy recommendations revealed a consultation report dated [DATE], which recommended re-evaluation of the combination of Xanax, Prozac, and Seroquel and to consider dose reduction if appropriate for Resident #2. The physician checked that the recommendation was declined and did not wish to implement any changes due to reasons below. The recommendation was signed by the physician on [DATE]; however, there was no documentation as to the reason the recommendation was declined. Interview with the Director of Nursing (DON) on [DATE] at 11:19 AM, revealed the Assistant Directors of Nursing (ADONs) were responsible for ensuring pharmacy recommendations were acted upon timely. After reviewing Resident #2's pharmacy recommendation dated [DATE], she stated the ADONs and nurses knew they were required to ensure the physician's rationale was documented for declining a recommendation. Interview with ADON #1 on [DATE] at 9:55 AM, revealed she and ADON #2 audited pharmacy consultation reports/recommendations when returned from the physician to ensure they were complete and had a signature. The ADON stated she was not aware the physician had to document a rationale if a recommendation was declined. ***The facility alleged the following was implemented to remove Immediate Jeopardy effective [DATE]: 1. Resident #259 no longer resides at the facility. 2. By [DATE], the Pharmacist will complete a Medication Regimen Review for current residents, which will include psychoactive medications, to ensure there is a supporting diagnosis, and will review for necessity/indication for the medication. The Pharmacist will also review for psychoactive medications that may be contributing to falls. One hundred eleven (111) residents were reviewed. Recommendations to the Medical Director was made for sixty-three (63) residents, six (6) of which were recommendations for a gradual dose reduction of psychoactive medications. 3. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) assessed current residents for potential side effects from psychoactive medication on [DATE], and ensured resident's Medication Administration Records (MAR) reflected the need to monitor for potential side effects of psychoactive medication. 4. The facility held a meeting on [DATE] to evaluate residents receiving psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) was in attendance and the Medical Director attended by phone to review appropriate utilization of psychoactive medications, which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive is achieved. 5. The DON/ADON/Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on [DATE]. The Nurse Consultant/DON/ADON/ Wound Nurse will also review resident falls for the past 30 days to ensure a root cause analysis has been conducted and appropriate interventions are in place. This will include a review of the care plan to ensure updates have been entered. 6. The Social Service Director, Social Service Assistant, and the Clinical Liaison will interview residents with a BIMS of eight (8) and above to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. The interviews were completed by [DATE] and any concerns identified will be reported to the Director of Nursing (DON) and/or Executive Director immediately and addressed by the appropriate department. 7. The Wound Nurse (LPN) and Clinical Liaison (LPN) will complete resident observations by [DATE] for residents with a BIMS score of seven (7) and below to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. Concerns identified will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 8. The Human Resource Director, ADON, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab will interview current staff related to any knowledge of residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. The interviews will be completed by [DATE] and any concerns will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. The DON/ADON and/or designee will review resident interviews, staff interviews, and resident observations by [DATE] to ensure the physician is notified of any change in condition. The DON/ADON/ MDS nurse will review current resident and staff interviews to ensure that appropriate interventions were placed based on falls root cause analysis. 10. On [DATE], the DON/ADON and/or designee will review fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. By [DATE], the MDS Coordinator will review nursing notes for the past 30 days to ensure physician notification and care plan revision to reflect any change, including falls and behaviors. One resident was identified to not have a care plan related to a skin tear; however, the physician had been notified with orders for treatment. 12. By [DATE], the DON and/or the ADON will review the Twenty-Four hour reports to ensure any change in a resident's condition has been addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. The Nurse Consultant/DON/ADON/SDC/RN Charge Nurse will review care plans on current residents to ensure appropriate documentation related to change in conditions, including but not limited to: pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. The reviews were completed by [DATE]. Five resident care plans were revised. 14. By [DATE], the Nurse Consultant educated the ED/DON/ADON/SDC on utilizing Stop and Watch forms, a communication form developed by CMS to communicate changes related to change of condition. Education will include giving the completed Stop and Watch to the nurse and making a copy and leaving for the DON/ADON. The DON/ADON will review Stop and Watches and follow up on possible change of condition during the daily clinical meeting and was completed as appropriate. By [DATE], the ED/DON/ADON/SDC will educate current staff regarding utilizing Stop and Watch forms for any change in condition, giving the completed form to the nurse, and making a copy for the DON. 15. The Nurse Consultant educated the ED/DON/ADON/SDC the DON/ADON on [DATE] to review Stop and Watches forms to ensure they were acted upon appropriately to include physician notification for changes in condition, They were also educated to ensure appropriate interventions were implemented for falls based on root cause analysis of the fall, which includes the 5 Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention at time of fall. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. The SDC/DON/ADON/ED then educated licensed staff by [DATE] regarding the utilization of the 5 Why's tool to determine the root cause of a fall to assist in determining the most appropriate intervention. In addition, current licensed nurses will be educated to notify the on-call Nurse Manager after a fall to review the root cause and the intervention for appropriateness. 16. By [DATE], the ED/DON/ADON/SDC will educate current licensed staff on appropriate documentation including, but not limited to: changes in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or needing increased help from staff. 17. By [DATE], the Nurse Consultant will educate the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and the Wound Care Nurse (LPN) on assuring that residents are assessed for potential medication side effects; to ensure a monitoring order is placed on the MAR to monitor for potential side effects of psychoactive medication; to review medication for necessity, including an appropriate diagnosis; and to ensure a medication review request is sent to the consultant pharmacist following a resident fall and upon admission/re-admission. Education included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate diagnosis for any psychotropic medication. The review will be conducted during the daily clinical meeting and will be followed-up by the Pharmacy Consultant. Any new medication orders will be reviewed by the DON/ADON/SDC for necessity to include appropriate diagnosis and or indication for the medication. 18. The Nurse Consultant will educate the DON/ADON/SDC on ensuring pharmacy reviews have occurred monthly and ensuring timely follow up of recommendations per facility policy, which states the recommendations will be received by the DON within 3 days of completion of review. The recommendations will be sent to the physician and the DON will verify the physician and Medical Director has received the review within 3 days. The DON should receive a response from the physician within 7 days. If a response is not received in 7 days, the DON/ADON will notify the physician for acceptance and/or a response to the recommendations that require action. If no response is received in 14 days, the DON/ADON will notify the Medical Director for further action. The DON/ADON will also notify the Executive Director and the Nurse Consultant. This education will occur on [DATE]. The DON, ADON, or Staff Development Coordinator will then will educate current licensed staff by [DATE] on assuring that residents are assessed for potential side effects of medications, ensuring a monitoring order is placed on the MAR to monitor for potential side effects of psychoactive medication, reviewing medication for necessity to include appropriate diagnosis, and ensuring a medication review request will be sent to the consultant pharmacist following any resident fall. 19. The Pharmacy Director will re-educate the Registered Pharmacist by [DATE] on accurately completing a Medication Regimen Review, which will include a supporting diagnosis for psychoactive medications, reviewing for necessity/indication for the medication, and reviewing for psychoactive medications that may be contributing to falls. The Pharmacist assigned to the facility at the time of the IJ has been removed as the Pharmacy Consultant. The current Pharmacy Consultant has been educated on the concerns related to regimen reviews, appropriate diagnoses related to psychoactive medications, and indication for necessity of medications by the ED on [DATE]. 20. For all education, a post education test will be administered by the Nurse Consultant/DON/ADON/SDC following education. If a score of 100% is not obtained, re-education will be completed until proficiency is obtained and their score is 100%. Five tests will be administered daily by ED/Assistant Administrator/ DON/ADON/SDC to ensure retention of education, until IJ is removed and approved through QAPI process. Current staff who have not received education by [DATE] will be mailed a certified letter informing them to contact the Executive Director/DON/SDC prior to working the floor. Staffing Agencies currently being utilized will be mailed a certified letter on [DATE] of the need to contact the ED/DON/SDC for education prior to working. The Executive Director/SDC or designee will ensure all newly hired staff and agency staff will receive education during New Hire Orientation or prior to working the floor. 21. The IDT will review in the daily clinical meeting (Monday through Friday) each fall and nursing shift reports to ensure the following is completed for any resident who sustained a fall: Falls Risk evaluation, to include the 5 Why's; physician notification; and care plan revision. In addition, the IDT will review Stop and Watch forms, progress notes, and physician orders to ensure care plans have been updated appropriately and physicians have been notified. 22. The Executive Director/Assistant Administrator/DON will conduct daily post clinical IDT meetings Monday-Friday for two weeks to review all identified Change of Condition and the effectiveness of medication to ensure notification of residents' physician as required. In addition, the Executive Director/Assistant Administrator/DON will review five (5) random resident records to ensure proper documentation has been completed related to any change in condition, physician notification, and the care plans are appropriate. Any issues identified will be corrected immediately and reported to the QAPI Committee for 3 months for further review and recommendations. 23. The facility will conduct weekly monitoring to evaluate psychoactive medication on residents, residents new prescribed psychoactive medications, and residents that have had medication dose adjustment. This psychoactive meeting will be conducted weekly by the facility IDT, (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and Pharmacist to review appropriate utilization of psychoactive medications which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 24. Beginning [DATE], the Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at facility to monitor processes related to supervision to prevent accidents, care plan development/revision, and physician notification until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. An AD-HOC QAPI meeting is held at least bi-weekly and as needed to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 25. Beginning [DATE], The Director of Nursing, Assistant Director of Nursing, or the Staff Development Nurse will review MAR's daily (Monday through Friday), during the Clinical Meeting, for two weeks, for documentation of side effect monitoring of psychotropic medication and appropriate diagnosis to support the necessity for newly ordered medication, new admissions, and readmissions. The Director of Nursing will also review falls to ensure the Medication Regimen Review has been sent to the consultant pharmacist daily (Monday through Friday) during the clinical meeting. The Director of Nursing will contact the Pharmacy Director, in 72 hours, if no communication from the review is received from the consultant pharmacist. Any concerns identified will be corrected immediately, and reported to QAPI committee for further review and recommendations. 26. The Executive Director will ensure the facility has conducted weekly monitoring, month over month, for 3 months to evaluate psychoactive medication on residents newly prescribed psychoactive medications, and residents that have had medication dose adjustments. This psychoactive meeting will be conducted weekly, by the facility IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and the Pharmacist to review appropriate utilization of psychoactive medications, which includes; antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 27. The Nurse Consultant or Director of Nursing will be in the center daily to monitor residents with new psychotropic medication orders to ensure side effect monitoring is completed. 28. Beginning [DATE], Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at the facility to monitor process, related to psychotropic medications, until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. AD-HOC QAPI meeting is held at least bi-weekly, and as needed, to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 29. The Executive Director will review 5 random Admissions/Readmissions/Falls/New Medication Orders/ Monthly Pharmacy Reviews for timeliness, and to ensure proper documentation has occurred daily. Any issues identified will be corrected immediately, and reported to QAPI Committee for 3 months for further review and recommendations. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on [DATE], as alleged: 1. Review of documentation revealed Resident #259 no longer resided at the facility. 2. Interview with the Administrator on [DATE] at 5:15 PM and review of documentation revealed by [DATE], the Pharmacist completed a Medication Regimen Review for current residents on psychoactive medications, to ensure there was supporting diagnosis, and necessity and indication for the use of the medication. The Pharmacist also reviewed psychoactive medications that could have contributed to falls. Further review of documentation and interview with the Administrator confirmed one-hundred and eleven (111) residents were reviewed by the Pharmacist. Review of facility documentation revealed the Pharmacist made recommendations to the Medical Director on 63 residents reviewed and six (6) of those recommendations were for gradual dose reductions of psychoactive medications. 3. Interview with the Director of Nursing (DON) on [DATE] at 3:30 PM and review of documentation revealed she and Assistant Director of Nursing (ADON) #1 assessed current residents for potential side effects from psychoactive medication on [DATE]. The DON and ADON #1 reviewed the residents' Medication Administration Records (MAR)'s to ensure it reflected monitoring for potential side effects for residents that received psychoactive medications in the facility. 4. Interview with the DON on [DATE] at 3:30 PM and review of facility documentation revealed a meeting occurred at the facility on [DATE], which evaluated residents that received psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. Review of documentation also revealed The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) attended the meeting, as well as the Medical Director, which attended the meeting, by phone. Continued interview with the DON and further review of documentation revealed the meeting was conducted to review appropriate utilization of psychoactive medications, antipsychotic medications, hypnotic medications, antianxiety medications, and mood-altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive medications was achieved. 5. Review of documentation and an Interview with ADON #1 on [DATE] at 3:15 PM revealed she and the DON as well as the Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on [DATE]. Further interview and review of documentation also revealed The Nurse Consultant, the DON, ADON, and the Wound Nurse reviewed resident falls for[TRUNCATED]