**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the provider failed to implement a comprehensive person-centered care plan to meet the needs of 2 (#61 and #84) of 25 sampled residents. The facility failed to ensure: 1. Staff consistently implemented an intervention of sitters at bedside for supervision for Resident #61; and 2. Staff scheduled an order neurology consultation for Resident #84. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. Resident #61 was sent to the emergency room for evaluation and head CT revealed a new subacute subdural hematoma. Resident #61 was then admitted to the neurological Intensive Care Unit through 05/27/2025. When Resident #61 returned to the facility, he only received staff supervision at bedside as the staffing schedule would allow which placed the resident at a likelihood to fall again and sustain serious injury, harm, impairment, or death. The Resident had another unwitnessed fall on 05/29/2025. S1ADM was notified of the Immediate Jeopardy on 06/12/2025 at 2:51 p.m. This deficient practice continued at the potential for more than minimal harm for the current 109 residents residing in the facility whom required a comprehensive person-centered care plan to meet their needs. The Immediate Jeopardy was removed on 06/13/2025 at 4:17 p.m., as confirmed by onsite verification through record review and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: 1. Review of Resident #61's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included an admitting diagnosis of Traumatic Subdural Hemorrhage with Loss of Consciousness, Repeated Falls, Fracture of Unspecified Part of Neck of Right Femur, and Cerebral Edema. Review of Resident #61's 5 Day MDS with an ARD of 06/03/2025 revealed a BIMS of 9, which indicated the resident was moderately cognitively impaired. Further review revealed he was coded for history of falls and required moderate assistance with mobility. Review of Resident #61's most recent Care Plan revealed in part, the following: Problem: I am at risk for falls related to recent fall and history of subdural hematoma. Interventions: 05/03/2025 Fall - No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 Fall - No injuries observed. Non-skid footwear placed on resident, brought to hospital. 05/13/2025 Fall - Sitter at bedside for supervision. Educated staff on fall prevention. 05/18/2025 Fall - Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks every 1 hour monitoring to be initiated upon return. 05/29/2025 Fall - Neurological checks every 1 hour monitoring to be initiated upon return. 1:1 at bedside. 1:1 not present during fall, staff education on 1:1 protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Helmet as per order and non-skid footwear. Review of the Incident Log revealed Resident #61 had 4 unwitnessed falls and 1 witnessed fall since admission on [DATE]. Unwitnessed falls: 05/03/2025, 05/12/2025, 05/18/2025, and 05/29/2025. Witnessed falls: 05/13/2025. Review of Resident #61's Nurse's Notes dated 05/02/2025 revealed in part, the following: 5:39 p.m., Resident discharged from a prior rehab facility because resident had a recent subdural hematoma status post craniotomy with evacuation March 2025. Review of Resident #61's Incident Reports revealed in part, the following: 05/03/2025 Resident #61 found on floor. No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 CNA outside of room, heard thump. Resident #61 slid out of bed onto mattress. Non-skid footwear placed on resident. 05/13/2025 Resident #61 had a witnessed fall in his bathroom while getting assistance to use the toilet. Resident lost his balance, stumbled and fell backwards and hit his head. Resident was alert and noted to be bleeding from the back of his head. Resident was assessed and sent to hospital for further treatment. Neurological checks, 1 hour monitoring initiated. Fall mat placed back at bedside. Sitter at bedside for supervision. Staff educated on importance of fall prevention. 05/18/2025 S22CNA stated she had just stepped away from the room and returned less than a minute and Resident #61 was on floor. Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks, 1 hour monitoring to be initiated upon return. Review of hospital records for Resident #61 dated 05/18/2025 revealed in part, the following: [AGE] year old male patient with a past medical history of recent subdural hematoma (post craniotomy with subdural hematoma evacuation 03/22/2025) presented to hospital after being found down next to his bed sustaining an unwitnessed fall. Patient does have a hematoma and bruising on his right side of head. Compared to the prior study, CT of the head shows there is interval development of a subacute subdural hemorrhage with minimal acute component along the right cerebral convexity measuring 8 mm with subtle effacement of the adjacent right cerebral convexity sulci. The resident will be placed in the neurological Intensive Care Unit and admitted to neurosurgery for a higher level of care and closer neurological monitoring. Review of hospital Physical Therapy Evaluation and Treatment for Resident #61 dated 05/20/2025 revealed in part, the following: Assessment: [AGE] year old male admitted with a medical diagnosis of subdural hematoma. He presents with the following impairments/functional limitations: weakness, impaired endurance, impaired self-care skills, impaired functional mobility, gait instability, impaired balance, impaired cognition, decreased coordination, decreased safety awareness, impaired cardiopulmonary response to activity. Required consistent cueing for safety throughout session. Recommending moderate intensity therapy on discharge to increase safety and maximize functional outcomes. If patient does not discharge to moderate intensity therapy, patient will need 24/7 supervision due to frequent falls and decreased safety awareness/cognitive impairment. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/28/2025. Evaluation status post hospital stay at local hospital. Diagnosis: subdural hematoma. Plan: Subdural hematoma with recurrent falls and history of craniotomy: Readmit for skilled nursing services. Continue with safety helmet and sitter at bedside. Fall precautions. Review of Resident #61's Incident Reports revealed in part, the following: 05/29/2025 Resident #61 discovered on floor in room. NP instructed to continue monitoring as per protocol and report any changed from baseline. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Neurological checks, 1 hour monitoring initiated. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/31/2025. Patient just returned back to facility from the acute setting diagnosed with subdural hematoma. Yesterday, patient sustained a fall unwitnessed. Patient was observed crawling around on the floor in his room. Plan: Recurrent falls: continue fall precautions. Monitor vital signs and neurological checks, continue safety helmet and sitter at bedside. Review of Resident #61's Nurse's Notes dated 05/29/2025 revealed in part, the following: 11:37 p.m. Resident discovered on floor in room. 1:1 staff supervision not present during fall, staff education on 1:1 protocol given. On 06/11/2025 at 10:53 a.m., an interview was conducted with S19ADON. She stated she was responsible for reviewing resident's falls, and adjusting or implementing care plan interventions after the falls. She stated Resident #61 had several falls since admission to the facility. She stated because of Resident #61's history of a subdural hematoma with craniotomy, after his fall on 05/03/2025, a helmet was ordered and sitter at bedside was initiated on his care plan. She reviewed the incident logs and confirmed for the falls dated 05/12/2025, 05/18/2025, and 05/29/2025, a sitter was not at the bedside. She stated the facility was not obligated to provide sitters at all times, only when extra staff was available. She stated the intervention added to the care plan on 05/03/2025 regarding a sitter at the bedside was an immediate intervention implemented by the nurse after the fall, and was not intended to be an ongoing intervention. She explained after a fall, she would copy the Immediate Action Taken section in the incident report and paste it into the resident's care plan as the intervention. She confirmed the sitter at bedside intervention did not have an end date or duration. She said if staff was available the facility would assign a staff member to sit with Resident #61 to assist with fall prevention. She said if an assigned staff member needed to take a break, they were entitled to their break and did not need to find a replacement to supervise Resident #61. She stated staff was doing the best they could to prevent Resident #61 from falling. On 06/11/2025 at 11:28 a.m., an interview was conducted with S20CNA. She stated she worked on Resident #61's hall on the night of 05/18/2025. She stated she did not recall anyone being assigned 1:1 staff supervision to Resident #61 when he fell that night. She stated on 05/18/2025, S22CNA walked out of Resident #61's room and he fell. She stated staff got him to his wheelchair and put him at the nurse's station. She stated he started complaining of his neck hurting, she reported it to S23LPN and he was sent out to the ER. She stated when he first admitted to the facility, she was told he had a history of a brain bleed. She stated he was very active and constantly wanted to get out of bed. She stated staff sat with him when extra staff was available, but not every shift. On 06/11/2025 at 11:35 a.m., an interview was conducted with S21CNA. She stated Resident #61 attempted to get out of bed constantly. She stated she had worked 1:1 staff supervision with him a few times. She stated when she sat with him, she had to keep eyes on him at all times as he was very impulsive and fell often. She stated she couldn't leave the room unless the resident was with her or someone else was watching him or he would try to get up and fall. On 06/11/2025 at 1:15 p.m., an interview was conducted with S2DON. She stated after a resident had a fall, she expected S19ADON to follow up with the resident or nurse to find out what happened, then enter appropriate interventions in the care plan. She stated S19ADON should not have copied and pasted part of the incident report into the resident's care plan as the interventions. She stated when 'verbiage such as sitters at bedside was placed in the care plan, there should be a duration or timeframe documented. S2DON reviewed Resident #61's care plan and confirmed sitter at bedside was listed as an intervention with no duration or end date. S2DON explained Resident #61 was never supposed to have ongoing 1:1 staff supervision and it was just something we are doing to try to prevent him from falling. She stated she did not know S19ADON and S24CNA were scheduling sitters to supervise Resident #61 when extra staff was available. She stated she was aware Resident #61 was impulsive at times. She stated since Resident #61 had not sustained a fall recently, she would be discontinuing the staff sitting with him. She stated she was not aware S25NP recommended 1:1 staff supervision for Resident #61. On 06/11/2025 at 1:48 p.m., an interview was conducted with S25NP. She stated she was familiar with Resident #61. She stated her main concerns with the resident was lack of sleep and agitation at night. She stated having sitters at bedside has been the most effective intervention for fall prevention for him. She stated Resident #61 was impulsive, unsteady, and a fall risk. She stated staff should have eyes on him at all times. She stated her concern with him being left unsupervised for any period of time would be him falling and sustaining another head injury. On 06/11/2025 at 1:57 p.m., an interview was conducted with S24CNA. He stated he was familiar with Resident #61. He stated Resident #61 would only sleep in 20 minutes increments, then wake up and try to get up. He stated Resident #61 was impulsive. He stated most nights, someone was assigned to sit with him, but not always. He stated he was sitting with Resident #61 on 05/29/2025, and stepped out of his room thinking the resident was asleep. He stated Resident #61 fell and was found right beside the mattress on the floor with no injuries. He confirmed when staff was in the room with Resident #61, it prevented him from falling. He stated the resident was sleeping when he left the room, and confirmed if he wouldn't have left the room, he could have prevented the resident from getting out of the bed and falling. On 06/13/2025 at 9:08 a.m., an interview was conducted with S23LPN. She stated she was working on 05/18/2025 when Resident #61 fell. She stated S22CNA informed her she had just stepped away from the resident's room when he fell. She stated she could not remember if someone was assigned to sit with him that night. She stated if there was extra staff, someone was assigned to him, but if there was only 1 CNA scheduled on the hall, the CNA would sit outside of his room and try to watch him and the call lights. She stated if that CNA had to assist another resident or answer a call light, no one would watch Resident #61. She stated Resident #61 slept for very short periods of time, in 10-15 minute increments, and was pretty impulsive. She stated the resident did not have an order for 1:1 staff supervision, and the facility tried to put extra staff with him to prevent falls. On 06/13/2025 at 9:27 a.m., an interview was conducted with S22CNA. She stated she was familiar with Resident #61. She stated sometimes he was oriented, but he was also forgetful and confused. She stated he constantly got up and down out of bed. She stated she had been assigned to sit with him at times, but sometimes he did not have a sitter when she worked the hall. She stated the night of 05/18/2025, he did not have 1:1 staff supervision. She stated she found the resident on the floor in front of the fall mat. She stated he complained of neck pain and was sent to the hospital. She stated the intervention of sitters at bedside was put in place to help prevent Resident #61 from falling, but sitters were not at the bedside every night. On 06/13/2025 at 9:46 a.m., an interview was conducted with S26LPN. She stated she was familiar with Resident #61. She stated Resident #61 was impulsive, and would not wait for help when he needed it. She stated she was working on 05/29/2025 when Resident #61 was found on his floor. She stated Resident #61 was found on the floor at about 11:37 p.m. She stated she was shocked the resident fell because he had an assigned sitter that night. She stated the assigned sitter, S24CNA, stepped out of his room and did not notify her. She stated the resident woke up and got out of bed during that time. She stated if the sitter needed to leave, the nurse should have been notified or the other CNA could have sat with him. She stated Resident #61 was very quiet and very fast. She stated having 1:1 staff supervision for the resident prevented him from falling. On 06/13/2025 at 3:35 p.m., staff interviews revealed Resident #61 was admitted to the hospital on [DATE] after a follow-up head CT for further evaluation. 2. Review of Resident #84's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Cerebral Palsy, Extrapyramidal and Movement Disorder, and Other Seizures. Review of Resident #84's current Physician's Orders revealed the following: Start date: 04/02/2025 Schedule neurology appointment secondary to seizure-like activity. Review of Resident #84's current Care Plan revealed in part, the following: Problem: I have a seizure diagnosis and am at risk for injury. Interventions: Follow-up with neurology related to seizure-like activity. Review of Resident #84's Nurse Practitioner's notes revealed, in part: Created By: S25NP Created Date: 04/02/2025 at 11:04 a.m. Chief Complaint / Nature of Presenting Problem: Evaluation status post ER visit for seizure-like activity. 1. Seizure-like activity: Workup per ER unremarkable. Please consult neurology for evaluation and treatment. On 06/11/2025 at 9:01 a.m., an interview was conducted with S17TS. S17TS confirmed she was responsible for scheduling follow up appointments. S17TS reviewed her files and calendar. S17TS confirmed no neurology consult appointment had been made for Resident #84 and should have been. S17TS stated she was not aware of this appointment. S17TS stated the process is for an appointment slip to be placed on her door so she would follow-up with scheduling the appointments. On 06/12/2025 at 11:28 a.m., an interview was conducted with S2DON. S2DON reviewed Resident #84's physician orders and care plan. S2DON was made aware, as of 06/11/2025, Resident #84's neurology consult from 04/02/2025 had not been scheduled. S2DON confirmed staff failed to implement the appropriate intervention per the comprehensive resident centered care plan. S2DON stated the process is for an appointment slip to be placed on S17TS's door so she would follow-up with scheduling the appointments. The facility had implemented the following actions to correct the deficient practice: 1. On 06/11/2025, the sitter at bedside/l:1 monitoring was discontinued on the fall care plan. 2. On 06/12/2025, 100% review of the current fall care plans revealed no other resident had a fall care plan with sitter at bedside/on 1:1 monitoring. 3. On 06/12/2025, Resident #61 was admitted to the hospital following a medical appointment. In the event Resident were to return to the facility, 1:1 monitoring would be initiated. Resident #61 will be reassessed by the nursing staff and NP to determine the continuation of the 1:1 monitoring based on his needs. 4. If Resident #61 returns to the facility, he will receive a fall risk assessment to determine the appropriate interventions to be implemented. 5. Regional nurse provided education on 06/12/2025 to nursing administrative team, including the ADON, regarding fall prevention including adding, implementing, and monitoring effectiveness of appropriate interventions consistent with current professional standards. 6. The clinical staff received in-servicing by nursing administration on not leaving the room without relief when scheduled for 1:1 monitoring beginning on 06/12/2025 and will be completed 06/13/2025. Clinical staff will not be scheduled until receiving this in-service. 7. On 06/13/2025, the DON/designee reviewed recent fall care plans in the daily weekday morning meetings. DON/designee will continue to monitor care plans for appropriate interventions on weekdays for 4 weeks. 8. Any findings and plan will be taken through the facilities Quality Assurance Performance Improvement (QAPI) Process for review and revision as needed. The facility asserts the likelihood for serious harm to any resident with a care plan of sitter at bedside/l:1 monitoring no longer exists as of 06/13/2025. 9. The facility will ascertain substantial compliance by 06/13/2025. Throughout the survey from 06/12/2025 to 06/13/2025, interviews and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on proper 1:1 monitoring and how to identify what residents required monitoring while following care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents received adequate supervision to prevent avoidable falls for 1 (#61) of 4 (#6, #61, #85, and #103) residents reviewed for falls. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. Resident #61 was sent to the emergency room for evaluation and head CT revealed a new subacute subdural hematoma. Resident #61 was then admitted to the neurological Intensive Care Unit through 05/27/2025. When Resident #61 returned to the facility, he only received staff supervision at bedside as the staffing schedule would allow which placed the resident at a likelihood to fall again and sustain serious injury, harm, impairment, or death. The Resident had another unwitnessed fall on 05/29/2025. S1ADM was notified of the Immediate Jeopardy on 06/12/2025 at 2:51 p.m. This deficient practice continued at the potential for more than minimal harm for any resident residing in the facility whom required increased supervision. The Immediate Jeopardy was removed on 06/13/2025 at 4:17 p.m., as confirmed by onsite verification through record review and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross Reference F656 Review of Resident #61's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included an admitting diagnosis of Traumatic Subdural Hemorrhage with Loss of Consciousness, Repeated Falls, Fracture of Unspecified Part of Neck of Right Femur, and Cerebral Edema. Review of Resident #61's 5 Day MDS with an ARD of 06/03/2025 revealed a BIMS of 9, which indicated the resident was moderately cognitively impaired. Further review revealed he was coded for history of falls and required moderate assistance with mobility. Review of Resident #61's most recent Care Plan revealed in part, the following: Problem: I am at risk for falls related to recent fall and history of subdural hematoma. Interventions: 05/03/2025 Fall - No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 Fall - No injuries observed. Non-skid footwear placed on resident, brought to hospital. 05/13/2025 Fall - Sitter at bedside for supervision. Educated staff on fall prevention. 05/18/2025 Fall - Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks every 1 hour monitoring to be initiated upon return. 05/29/2025 Fall - Neurological checks every 1 hour monitoring to be initiated upon return. 1:1 at bedside. 1:1 not present during fall, staff education on 1:1 protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Helmet as per order and non-skid footwear. Review of the Incident Log revealed Resident #61 had 4 unwitnessed falls since admission on [DATE]. Unwitnessed falls: 05/03/2025, 05/12/2025, 05/18/2025, and 05/29/2025. Review of Resident #61's Nurse's Notes dated 05/02/2025 revealed in part, the following: 5:39 p.m., Resident discharged from a prior rehab facility because resident had a recent subdural hematoma status post craniotomy with evacuation March 2025. Review of Resident #61's Incident Reports revealed in part, the following: 05/03/2025 Resident #61 found on floor. No injuries observed. Fall mat at bedside. Sitters initiated at bedside. 05/12/2025 CNA outside of room, heard thump. Resident #61 slid out of bed onto mattress. 05/18/2025 S22CNA stated she had just stepped away from the room and returned less than a minute and Resident #61 was on floor. Send to hospital for evaluation and treatment. Review of facility's Emergency Transfer Log revealed Resident #61 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Review of hospital records for Resident #61 dated 05/18/2025 revealed in part, the following: [AGE] year old male patient with a past medical history of recent subdural hematoma (post craniotomy with subdural hematoma evacuation 03/22/2025) presented to hospital after being found down next to his bed sustaining an unwitnessed fall. Patient does have a hematoma and bruising on his right side of head. Compared to the prior study, CT of the head shows there is interval development of a subacute subdural hemorrhage with minimal acute component along the right cerebral convexity measuring 8 mm with subtle effacement of the adjacent right cerebral convexity sulci. The resident will be placed in the neurological Intensive Care Unit and admitted to neurosurgery for a higher level of care and closer neurological monitoring. Review of hospital Physical Therapy Evaluation and Treatment for Resident #61 dated 05/20/2025 revealed in part, the following: Assessment: [AGE] year old male admitted with a medical diagnosis of subdural hematoma. Recommending moderate intensity therapy on discharge to increase safety and maximize functional outcomes. If patient does not discharge to moderate intensity therapy, patient will need 24/7 supervision due to frequent falls and decreased safety awareness/cognitive impairment. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/28/2025. Evaluation status post hospital stay at local hospital. Diagnosis: subdural hematoma. Plan: Subdural hematoma with recurrent falls and history of craniotomy: Readmit for skilled nursing services. Continue with sitter at bedside. Fall precautions. Review of Resident #61's Incident Reports revealed in part, the following: 05/29/2025 Resident #61 discovered on floor in room. NP instructed to continue monitoring as per protocol and report any changed from baseline. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/31/2025. Patient just returned back to facility from the acute setting diagnosed with subdural hematoma. Yesterday, patient sustained a fall unwitnessed. Plan: Recurrent falls: continue sitter at bedside. Review of Resident #61's Nurse's Notes dated 05/29/2025 revealed in part, the following: 11:37 p.m. Resident discovered on floor in room. 1:1 staff supervision not present during fall, staff education on 1:1 protocol given. On 06/11/2025 at 10:53 a.m., an interview was conducted with S19ADON. She stated Resident #61 had several falls since admission to the facility. She stated because of Resident #61's history of a subdural hematoma with craniotomy, after his fall on 05/03/2025, a sitter at bedside was initiated on his care plan. She reviewed the incident logs and confirmed for the falls dated 05/12/2025, 05/18/2025, and 05/29/2025, a sitter was not present at the bedside. She said if staff was available the facility would assign a staff member to sit with Resident #61 to assist with fall prevention. She said if an assigned staff member needed to take a break, they were entitled to their break and did not need to find a replacement to supervise Resident #61. She stated the facility was not obligated to provide sitters at all times, only when extra staff was available. On 06/11/2025 at 11:28 a.m., an interview was conducted with S20CNA. She said staff were assigned to supervise Resident #61 when enough staff was available to help prevent him from falling. She stated on the night of 05/18/2025, no one was assigned 1:1 staff supervision to Resident #61. She stated S22CNA walked out of Resident #61's room and he fell. She stated he started complaining of his neck hurting, she reported it to S23LPN and he was sent out to the ER. She stated he was very active and constantly attempted to get out of bed. On 06/13/2025 at 9:27 a.m., an interview was conducted with S22CNA. She stated she was familiar with Resident #61. She stated he constantly got up and down out of bed. She stated she had been assigned to sit with him at times to prevent falls, but sometimes he did not have a sitter when she worked the hall. She stated the night of 05/18/2025, he did not have 1:1 staff supervision. She stated she found the resident on the floor in front of the fall mat. She stated he complained of neck pain and was sent to the hospital. She stated the intervention of sitters at bedside was put in place to help prevent Resident #61 from falling, but sitters were not at the bedside every night. On 06/13/2025 at 9:08 a.m., an interview was conducted with S23LPN. She stated she was working on 05/18/2025 when Resident #61 fell. She stated S22CNA informed her she had just stepped away from the resident's room when he fell. She stated Resident #61 slept for very short periods of time, in 10-15 minute increments, and was pretty impulsive. She stated if there was only 1 CNA scheduled on the hall, no one would be assigned at bedside to supervise Resident #61. On 06/11/2025 at 1:57 p.m., an interview was conducted with S24CNA. He stated he was familiar with Resident #61. He stated Resident #61 would only sleep in 20 minutes increments, then would wake up and try to get up. He stated Resident #61 was impulsive. He stated he was sitting with Resident #61 on 05/29/2025 while the assigned sitter was on break. She stated he stepped out of Resident #61's room thinking the resident was asleep. He stated Resident #61 fell and was found right beside the mattress on the floor with no injuries. He stated the resident was sleeping when he left the room, and confirmed if he wouldn't have left the room, he could have prevented the resident from getting out of the bed and falling. He stated when staff was in the room with Resident #61, it prevented him from falling. On 06/13/2025 at 9:46 a.m., an interview was conducted with S26LPN. She stated she was familiar with Resident #61. She stated Resident #61 was impulsive, and would not wait for help when he needed it. She stated she was working on 05/29/2025 when Resident #61 was found on his floor. She stated she was shocked the resident fell because he had an assigned sitter that night. She stated the assigned sitter, S24CNA, stepped out of his room and did not notify her. She stated if the sitter needed to leave, the nurse should have been notified so the other CNA could have sat with him for supervision. She stated staff should not have left him since he was 1:1. She stated Resident #61 was very quiet and very fast. She stated having 1:1 staff supervision for the resident prevented him from falling. On 06/11/2025 at 1:48 p.m., an interview was conducted with S25NP. She stated she was familiar with Resident #61. She stated she could not recall the date sitters at bedside were implemented for Resident #61, but it had been a while. She stated having sitters at bedside had been the most effective intervention for fall prevention for him. She stated Resident #61 was impulsive, unsteady, and a fall risk. She stated she expected staff to keep eyes on him at all times. She stated her concern with him being left unsupervised for any period of time would be him falling and sustaining another head injury. On 06/11/2025 at 1:15 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #61's care plan and confirmed sitter at bedside was listed as an intervention for fall prevention with no duration or end date. S2DON stated Resident #61 was never supposed to have ongoing 1:1 staff supervision and stated it was just something we are doing to try to prevent him from falling when extra staff was available. She stated she was not aware S25NP recommended 1:1 staff supervision for Resident #61. She stated she was not aware S19ADON and S24CNA continued to schedule 1:1 supervision for Resident #61 when staff were available to prevent falls. On 06/13/2025 at 3:35 p.m., staff interviews revealed Resident #61 was admitted to the hospital on [DATE] after a follow-up head CT for further evaluation. The facility had implemented the following actions to correct the deficient practice: 1. On 06/11/2025, the sitter at bedside/l:1 monitoring was discontinued on the fall care plan. 2. On 06/12/2025, 100% review of the current fall care plans revealed no other resident had a fall care plan with sitter at bedside/on 1:1 monitoring. 3. On 06/12/2025, Resident #61 was admitted to the hospital following a medical appointment. In the event Resident were to return to the facility, 1:1 monitoring would be initiated. Resident #61 will be reassessed by the nursing staff and NP to determine the continuation of the 1:1 monitoring based on his needs. 4. If Resident #61 returns to the facility, he will receive a fall risk assessment to determine the appropriate interventions to be implemented. 5. Regional nurse provided education on 06/12/2025 to nursing administrative team, including the ADON, regarding fall prevention including adding, implementing, and monitoring effectiveness of appropriate interventions consistent with current professional standards. 6. The clinical staff received in-servicing by nursing administration on not leaving the room without relief when scheduled for 1:1 monitoring beginning on 06/12/2025 and will be completed 06/13/2025. Clinical staff will not be scheduled until receiving this in-service. 7. On 06/13/2025, the DON/designee reviewed recent falls in the daily weekday morning meetings. DON/designee will continue to monitor recent falls for appropriate interventions on weekdays for 4 weeks. 8. If the facility identifies a resident requiring sitter at bedside/1:1 monitoring this will be monitored by DON/designee weekly until this monitoring is no longer needed. 9. Any findings and plan will be taken through the facilities Quality Assurance Performance Improvement (QAPI) Process for review and revision as needed. 10. The facility asserts the likelihood for serious harm to any resident with a care plan of sitter at bedside/l:1 monitoring no longer exists as of 06/13/2025. 11. The facility will ascertain substantial compliance by 06/13/2025. Throughout the survey from 06/12/2025 to 06/13/2025, interviews and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on proper 1:1 monitoring and how to identify what residents required monitoring while following care plan intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure it was administered in a manner that effectively used its resources for 1 (#61) of 4 (#6, #61, #85, and #103) residents reviewed for falls. The facility failed to have an effective system in place to ensure a care plan intervention of sitter at bedside was continuously implemented for Resident #61 to prevent falls. This deficient practice resulted in an Immediate Jeopardy situation on 05/12/2025 when Resident #61, a cognitively impaired resident with a history of falls, recent brain bleed, poor safety awareness, and impulsiveness, had an unwitnessed fall when staff left him unsupervised. Resident #61 was assessed to need staff supervision at bedside on 05/03/2025. On 05/18/2025, the resident had another unwitnessed fall when S22CNA left his bedside leaving the resident unsupervised. Resident #61 was sent to the emergency room for evaluation and head CT revealed a new subacute subdural hematoma. Resident #61 was then admitted to the neurological Intensive Care Unit through 05/27/2025. When Resident #61 returned to the facility, he only received staff supervision at bedside as the staffing schedule would allow which placed the resident at a likelihood to fall again and sustain serious injury, harm, impairment, or death. The Resident had another unwitnessed fall on 05/29/2025. S1ADM was notified of the Immediate Jeopardy on 06/12/2025 at 2:51 p.m. This deficient practice continued at the potential for more than minimal harm for any residents residing in the facility whom required increased supervision. The Immediate Jeopardy was removed on 06/13/2025 at 4:17 p.m., as confirmed by onsite verification through record review and interviews. The facility implemented an acceptable Plan of Removal (POR) prior to survey exit. Findings: Cross Reference F656 and F689 Review of Resident #61's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included an admitting diagnosis of Traumatic Subdural Hemorrhage with Loss of Consciousness, Repeated Falls, Fracture of Unspecified Part of Neck of Right Femur, and Cerebral Edema. Review of Resident #61's 5 Day MDS with an ARD of 06/03/2025 revealed a BIMS of 9, which indicated the resident was moderately cognitively impaired. Further review revealed he was coded for history of falls and required moderate assistance with mobility. Review of Resident #61's most recent Care Plan revealed in part, the following: Problem: I am at risk for falls related to recent fall and history of subdural hematoma. Interventions: 05/03/2025 Fall - No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 Fall - No injuries observed. Non-skid footwear placed on resident, brought to hospital. 05/13/2025 Fall - Sitter at bedside for supervision. Educated staff on fall prevention. 05/18/2025 Fall - Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks every 1 hour monitoring to be initiated upon return. 05/29/2025 Fall - Neurological checks every 1 hour monitoring to be initiated upon return. 1:1 at bedside. 1:1 not present during fall, staff education on 1:1 protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Helmet as per order and non-skid footwear. Review of the Incident Log revealed Resident #61 had 4 unwitnessed falls and 1 witnessed fall since admission on [DATE]. Unwitnessed falls: 05/03/2025, 05/12/2025, 05/18/2025, and 05/29/2025. Witnessed falls: 05/13/2025. Review of Resident #61's Nurse's Notes dated 05/02/2025 revealed in part, the following: 5:39 p.m., Resident discharged from a prior rehab facility because resident had a recent subdural hematoma status post craniotomy with evacuation March 2025. Review of Resident #61's Incident Reports revealed in part, the following: 05/03/2025 Resident #61 found on floor. No injuries observed. Fall mat at bedside. Bed currently against wall. Sitters at bedside. Helmet ordered for fall protection. 05/12/2025 CNA outside of room, heard thump. Resident #61 slid out of bed onto mattress. Non-skid footwear placed on resident. 05/13/2025 Resident #61 had a witnessed fall in his bathroom while getting assistance to use the toilet. Resident lost his balance, stumbled and fell backwards and hit his head. Resident was alert and noted to be bleeding from the back of his head. Resident was assessed and sent to hospital for further treatment. Neurological checks, 1 hour monitoring initiated. Fall mat placed back at bedside. Sitter at bedside for supervision. Staff educated on importance of fall prevention. 05/18/2025 S22CNA stated she had just stepped away from the room and returned less than a minute and Resident #61 was on floor. Send to hospital for evaluation and treatment. Bolster mattress ordered. Neurological checks, 1 hour monitoring to be initiated upon return. Review of hospital records for Resident #61 dated 05/18/2025 revealed in part, the following: [AGE] year old male patient with a past medical history of recent subdural hematoma (post craniotomy with subdural hematoma evacuation 03/22/2025) presented to hospital after being found down next to his bed sustaining an unwitnessed fall. Patient does have a hematoma and bruising on his right side of head. Compared to the prior study, CT of the head shows there is interval development of a subacute subdural hemorrhage with minimal acute component along the right cerebral convexity measuring 8 mm with subtle effacement of the adjacent right cerebral convexity sulci. The resident will be placed in the neurological Intensive Care Unit and admitted to neurosurgery for a higher level of care and closer neurological monitoring. Review of hospital Physical Therapy Evaluation and Treatment for Resident #61 dated 05/20/2025 revealed in part, the following: Assessment: [AGE] year old male admitted with a medical diagnosis of subdural hematoma. If patient does not discharge to moderate intensity therapy, patient will need 24/7 supervision due to frequent falls and decreased safety awareness/cognitive impairment. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/28/2025. Evaluation status post hospital stay at local hospital. Diagnosis: subdural hematoma. Plan: Subdural hematoma with recurrent falls and history of craniotomy: Readmit for skilled nursing services. Continue sitter at bedside. Review of Resident #61's Incident Reports revealed in part, the following: 05/29/2025 Resident #61 discovered on floor in room. NP instructed to continue monitoring as per protocol and report any changed from baseline. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Neurological checks, 1 hour monitoring initiated. 1:1 staff supervision not present during fall, staff education on 1:1 staff supervision protocol given. Staff educated on importance of notifying another care partner if leaving the hall for breaks/lunches. Review of Resident #61's Nurse Practitioner's Notes revealed in part, the following: Date of Service 05/31/2025. Patient just returned back to facility from the acute setting diagnosed with subdural hematoma. Yesterday, patient sustained a fall unwitnessed. Plan: Recurrent falls: continue sitter at bedside. Review of Resident #61's Nurse's Notes dated 05/29/2025 revealed in part, the following: 11:37 p.m. Resident discovered on floor in room. 1:1 staff supervision not present during fall, staff education on 1:1 protocol given. On 06/11/2025 at 10:53 a.m., an interview was conducted with S19ADON. She stated she was responsible for reviewing resident's falls, and adjusting or implementing care plan interventions after the falls. She explained after a fall, she would copy the Immediate Action Taken section in the incident report and paste it into the resident's care plan as the intervention. She stated after Resident #61's fall on 05/03/2025, the nurse implemented an intervention immediately after of sitter at bedside. S2ADON said post fall she copied that intervention from the incident report onto the current care plan as the implemented intervention. She stated this intervention was not intended to be ongoing, but she did not put an end date or duration to indicate that it should be stopped. She reviewed the incident logs and confirmed for the falls dated 05/12/2025, 05/18/2025, and 05/29/2025, a sitter was not at the bedside. She stated the facility was not obligated to provide sitters at all times, only when extra staff was available. She said if staff was available the facility would assign a staff member to sit with Resident #61 to assist with fall prevention. She said if an assigned staff member needed to take a break, they were entitled to their break and did not need to find a replacement to supervise Resident #61. She stated staff was doing the best they could to prevent Resident #61 from falling. On 06/11/2025 at 11:28 a.m., an interview was conducted with S20CNA. She stated she worked on Resident #61's hall on the night of 05/18/2025. She stated she did not recall anyone being assigned 1:1 staff supervision to Resident #61 when he fell that night. She stated on 05/18/2025, S22CNA walked out of Resident #61's room and he fell. She stated he started complaining of his neck hurting, she reported it to S23LPN and he was sent out to the ER. She stated when he first admitted to the facility, she was told he had a history of a brain bleed. She stated he was very active and constantly wanted to get out of bed. She stated staff sat with him when extra staff was available, but not every shift. On 06/11/2025 at 11:35 a.m., an interview was conducted with S21CNA. She stated Resident #61 attempted to get out of bed constantly, was impulsive, and fell often. She stated she had worked 1:1 staff supervision with him a few times, but someone was not always assigned to sit with him. She stated he would try to get up and fall if someone wasn't watching him. On 06/11/2025 at 1:15 p.m., an interview was conducted with S2DON. She stated after a resident had a fall, she expected S19ADON to follow up with the resident or nurse to find out what happened, then enter appropriate interventions in the care plan. She stated S19ADON should not have copied and pasted part of the incident report into the resident's care plan as the interventions. She stated when 'verbiage such as sitters at bedside was placed in the care plan, there should be a duration or timeframe documented. S2DON reviewed Resident #61's care plan and confirmed sitter at bedside was listed as an intervention with no duration or end date. S2DON explained Resident #61 was never supposed to have ongoing 1:1 staff supervision and it was just something we are doing to try to prevent him from falling. She stated she did not know S19ADON and S24CNA were scheduling sitters to supervise Resident #61 when extra staff was available. She stated she was aware Resident #61 was impulsive at times. She stated she was not aware S25NP recommended 1:1 staff supervision for Resident #61. On 06/11/2025 at 1:48 p.m., an interview was conducted with S25NP. She stated she was familiar with Resident #61. She stated her main concerns with the resident was lack of sleep and agitation at night. She stated having sitters at bedside has been the most effective intervention for fall prevention for him. She stated Resident #61 was impulsive, unsteady, and a fall risk. She stated staff should have eyes on him at all times. She stated her concern with him being left unsupervised for any period of time would be him falling and sustaining another head injury. On 06/11/2025 at 1:57 p.m., an interview was conducted with S24CNA. He stated Resident #61 was impulsive and would only sleep in 20 minutes increments, then wake up and try to get up. He stated most nights, someone was assigned to sit with him, but not always. On 06/13/2025 at 9:08 a.m., an interview was conducted with S23LPN. She stated she was working on 05/18/2025 when Resident #61 fell. She stated she could not remember if someone was assigned to sit with him that night. She stated if there was extra staff, someone was assigned to him, but if there was only 1 CNA scheduled on the hall, the CNA would sit outside of his room and try to watch him and the call lights. She stated if that CNA had to assist another resident or answer a call light, no one would watch Resident #61. She stated Resident #61 slept for very short periods of time, in 10-15 minute increments, and was pretty impulsive. She stated the resident did not have an order for 1:1 staff supervision, and the facility tried to put extra staff with him to prevent falls. On 06/13/2025 at 9:27 a.m., an interview was conducted with S22CNA. She stated Resident #61 was oriented sometimes, but he was also forgetful and confused. She stated he constantly got up and down out of bed. She stated she had been assigned to sit with him at times, but sometimes he did not have a sitter when she worked the hall. She stated when the resident fell the night of 05/18/2025, he did not have 1:1 staff supervision. She stated the intervention of sitters at bedside was put in place to help prevent Resident #61 from falling, but sitters were not at the bedside every night. On 06/13/2025 at 9:46 a.m., an interview was conducted with S26LPN. She stated Resident #61 was impulsive, and would not wait for help when he needed it. She stated on 05/29/2025, Resident #61 had an assigned sitter. She stated the assigned sitter, S24CNA, stepped out of his room and the resident fell. She stated Resident #61 was very quiet and very fast. She stated having 1:1 staff supervision for the resident prevented him from falling. On 06/13/2025 at 3:35 p.m., staff interviews revealed Resident #61 was admitted to the hospital on [DATE] after a follow-up head CT for further evaluation. The facility had implemented the following actions to correct the deficient practice: 1. On 06/11/2025, the sitter at bedside/l:1 monitoring was discontinued on the fall care plan. 2. On 06/12/2025, 100% review of the current fall care plans revealed no other resident had a fall care plan with sitter at bedside/on 1:1 monitoring. 3. On 06/12/2025, Resident #61 was admitted to the hospital following a medical appointment. In the event Resident were to return to the facility, 1:1 monitoring would be initiated. Resident #61 will be reassessed by the nursing staff and NP to determine the continuation of the 1:1 monitoring based on his needs. 4. If Resident #61 returns to the facility, he will receive a fall risk assessment to determine the appropriate interventions to be implemented. 5. Regional nurse provided education on 06/12/2025 to nursing administrative team, including the DON, ADON, Infection Preventionist/QA, and MDS, regarding fall prevention including adding, implementing, and monitoring effectiveness of appropriate interventions consistent with current professional standards. 6. Regional Nurse will monitor for compliance weekly for 4 weeks. 7. Any findings and plan will be taken through the facilities Quality Assurance Performance Improvement (QAPI) Process for review and revision as needed. 8. The facility asserts the likelihood for serious harm to any resident with a care plan of sitter at bedside/l:1 monitoring no longer exists as of 06/13/2025. 9. The facility will ascertain substantial compliance by 06/13/2025. Throughout the survey from 06/12/2025 to 06/13/2025, interviews and record review revealed the above listed actions were implemented. Random staff interviews revealed staff received training on proper 1:1 monitoring and how to identify what residents required monitoring while following care plan interventions.