**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that facility staff failed to provide treatment and care in accordance with professional standards of practice after a resident fall that resulted in serious injury, resulting in death. Resident #2 died from the injuries sustained from the fall. This was evident for 1 (#2) of 3 residents reviewed for falls with serious injury.As a result of these findings, a state of immediate jeopardy (IJ) was declared on [DATE] at 3:55 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on [DATE] at 5:30 PM and it was not accepted. The facility submitted a second draft at 5:55 PM, and it was not accepted. The third draft was submitted at 6:09 PM and the facility ' s written plan to remove the immediacy was accepted on [DATE] at 6:20 PM with an alleged date of compliance of [DATE].The findings include:On [DATE] at 3:22 PM a medical record review for Resident #2 revealed the attending physician ' s history and physical note dated [DATE]. Resident #2 was hospitalized for infections and after treatment the resident was sent to the facility for rehabilitation services because s/he was weak. The resident was diagnosed with advanced dementia and anxiety especially at night.On [DATE] at 6:43 AM, a review of the video recording from the facility ' s surveillance camera located at the [NAME] wing nurses ' station was conducted. The video recorded that on [DATE] at 12:08 AM, Resident #2 was sitting in a reclined geriatric chair (referred to as a geri chair, it is a padded chair that reclines and is on wheels) in the nurses ' station unsupervised. The resident stood up and attempted to walk out of the nurses ' station without assistance. The resident was observed falling on their right side, making no attempts to catch themselves. The resident laid motionless on the floor then at 12:10 AM, Geriatric Nursing Assistant (GNA) #6 was observed back at the nurses ' station, without taking a moment to check the resident, she started waving her arms towards the central nurses ' station as if she was trying to get someone ' s attention. Then she walked down to the central nurses ' station. GNA #6 then returned to the resident, who was still lying on the floor and started pulling on the resident ' s left arm as if to roll the resident over before a nurse was able to assess the resident. It was observed the resident had a pool of blood on the floor next to his/her head. The GNAs were placing pads under the resident ' s head.Registered Nurse (RN) #7 and RN #8 were observed walking down the hallway from the central nurses ' station. There was no sound available, but RN #7 was observed leaning over the resident ' s face and head. The nurse was not observed conducting a thorough assessment such as checking for signs of an injury to ensure it was safe to move the resident and conducting a neurological exam (referred to as a neuro check, blood pressure, pulse, respirations, temperature, and level of oxygen in the blood, hand grips, foot pushes, pupil size and reaction.). Neuro checks should have been obtained at the time of the fall and every 15 minutes for the first hour or until Emergency Medical Services (EMS) personnel arrived. She indicated to the GNAs and RN #8 to help her get the resident back into the chair. Once the resident was back in the chair, RN #7 leaned over the resident for a few minutes and moved the resident ' s hands. When the resident was placed back in the chair, resident #2 was observed to have a round knot on the right temple and his/her nose was bloody. Without conducting a thorough assessment, a neuro check, and/or rendering first aid to the resident, At 12:15 AM RN #7 and RN #8 left the resident with the GNAs and walked back towards the central nurses ' station. It was observed on the video that the knot on the resident ' s temple grew into an oval shape, however the nurses left so they were unaware that this was happening. RN #8 came back at 12:25 AM and wrote down a few things then left at 12:27 AM. She failed to assess the resident for changes or conduct a neuro check. EMS arrived at 12:46 AM, 35 minutes after staff were aware the resident had fallen. RN #7 came back at 12:51 AM, after EMS arrived.A review of the EMS Comprehensive Report on [DATE] at 3:45 PM, revealed 911 was called on [DATE] at 12:41 AM, 31 minutes after the resident fell. EMS was dispatched at 12:43 AM. Per the report the residents ' blood oxygen level decreased and the resident needed supplemental oxygen. EMS staff were unable to get the oxygen back to a normal level before arriving at the nearest hospital. The resident was deemed a level 3 priority resident. On [DATE] at 8:24 AM the emergency room report read that Resident #2 had a computerized tomography (CT) scan of the head which showed s/he suffered from hemorrhaging on the left side of the brain to include bleeding at the site of the hematoma on the resident ' s head that could be viewed in the video. The injury warranted surgical intervention; however, the family chose not to put the resident through the surgical procedure. The resident was given medications to reverse the bleeding, however, subsequently died [DATE] at 9:16 AM. The physician documented the cause of death was due to an accident at the nursing home.A telephone interview with the resident ' s family member and their spouse on [DATE] at 11:55 AM revealed they watched the video recording of the surveillance camera. They stated they were appalled by the lack of concern and care provided by the facility staff at the time their family member fell. An interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:57 AM revealed that they had a Nurse ' s How to Book at the central nurses ' station. There was a procedure for sending residents to the hospital via 911. Review of the procedure with LPN #2 revealed the following: Step 1 stated to obtain an order from the doctor to send the resident out 911 unless a real emergency, Step 2 prepare the paperwork for transfer, Step 3 was to call 911. When LPN #2 was asked if a resident had an unwitnessed fall and had a large hematoma on their temple would a nurse wait until Step 3 to call 911, she reported she would call 911 first. Furthermore, she stated in that case (a head injury) this procedure goes out the window. She reported she would stay with the resident or ask another nurse to stay with them. When asked if the fall occurred at the [NAME] wing nurses ' station, she reported she could stay with the resident and get all the paperwork ready at that nurses ' station.On [DATE] at 11:05 AM a telephone interview with RN #7 revealed she failed to stay with the resident, conduct neuro checks, and render first aid because she wanted to send the resident to the hospital as soon as possible after she saw the injuries. However, she failed to call 911 for 31 minutes after the resident fell. The nurses ' station where the resident fell had a phone, computer, and printer. In addition, she had RN #8 and RN #10 on duty but failed to ask for assistance to ensure the resident was transferred for emergency care safely and quickly. An interview with RN #8, who was being oriented to the facility by RN #7 when the accident occurred, revealed that she was concerned by the lack of monitoring and response to the resident's needs, however she failed to take action. A telephone interview with the Director of Nursing (DON) on [DATE] at 8:41 AM revealed she had concerns about RN #7 ' s lack of immediacy during the incident. She stated that the assessment could have been better. When asked what action she took to address her concerns she stated that she had a conversation with RN #7. However, there was no documented evidence of training, or counseling regarding the concerns.During an interview with the Medical Director on [DATE] at 11:10 AM, he reported he had not watched the surveillance video footage of the fall. The content was reviewed with him. He stated that based on the content reviewed, there were errors made. He reported that if a resident had a head injury, he would expect the nurse to call 911 immediately before calling him. He stated that the nurse should have obtained a set of vital signs immediately to ensure no cardiac issues caused the fall. Then the nurse should have conducted the neuro checks to determine if the resident had any deficits. He stated that when a resident has a rapidly growing hematoma on their head, pressure should be applied to stop possible bleeding. Especially when the resident was on an anticoagulant and showing signs of active bleeding from the fall.The provisions of the plan to remove the immediacy included the following:1.a. RN #7 and RN #8 are suspended immediately for not following facility policy and procedure; not performing a thorough assessment including a neuro check and vital signs; and moving the resident prior to performing a proper assessment.b. The results of the investigation will determine progressive disciplinary action up to and including termination and if warranted a report to the Board of Nursing.c. If RN #7 and RN #8 return to work they will be educated before they work the shift.d. The investigation will be concluded by [DATE].2.a. Licensed Nurses (facility, contract, and agency) will be in-serviced on the following policies and procedures: Assessment of the Resident Post Fall Notification of 911 in Emergency Situations Without Notifying the Physician First Observation of Neurological Signs Bleeding.b. In-services will be provided by the DON and Infection Preventionist.c. New agency staff will receive a packet containing these policies and procedures when they arrive at the facility at the front desk and/or given by the charge nurse on the unit.d. The agency nurse will sign a receipt roster that they have received the information.3. The facility will be in compliance by [DATE].On [DATE] at 8:15 AM, an onsite visit was conducted. After validation of the implementation of the facility ' s plan of removal, which included staff interviews and record reviews, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on [DATE] at 9:50 AM.Cross Reference: F689 and F726

Based on observation, record review and interview, it was determined that facility staff failed to ensure that residents had adequate supervision to prevent falls with serious injury. As a result of this deficient practice Resident #2 died due to the injuries sustained from a fall. This was evident for 1 (#2) of 3 residents reviewed for falls. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 6/20/25 at 4:55 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on 6/20/25 at 6:40 PM and it was not accepted. The facility submitted a second draft at 7:52 PM, and it was not accepted. The third draft was submitted at 8:02 PM and the facility ' s written plan to remove the immediacy was accepted on 6/20/25 at 8:30 PM with an alleged date of compliance of 6/23/25.The findings include:A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 6/18/25 at 3:22 PM a medical record review for Resident #2 revealed the attending physician ' s history and physical note dated 4/8/25. Resident #2 was hospitalized for infections and after treatment the resident was sent to the facility for rehabilitation services because s/he was weak. The resident was diagnosed with advanced dementia and anxiety especially at night. Review of the progress notes revealed the resident frequently tried to get out of bed without assistance. A review of the baseline care plan revealed that staff noted the resident had a risk for falls, however, failed to implement resident-centered interventions to address the level of supervision the resident required to prevent accidents. Facility staff checked that the resident needed floor mats.On 6/20/25 at 6:43 AM a review of the video recording from the facility ' s surveillance camera at the [NAME] wing nurses ' station was conducted. The video was time stamped for 4/19/25 at 11:36 PM, and showed Resident #2 was brought to the nurses ' station by GNA #5 and GNA #6. The resident was in a reclined geri-chair, covered with a blanket and sheet. At 11:45 PM GNA #5 left the nurses station and then at 11:56 PM GNA #6 left the nurses ' station and Resident #2 was left unsupervised. At 12:06 AM on 4/20/25, Resident #2 was observed throwing the covers back and attempting to stand up. The resident attempted to push the reclined footrest down, but could not. The gerichair started moving back as the resident continued to try to stand. Then GNA #5 returned to the nurses ' station and attempted to get the resident to scoot back in the chair but was unsuccessful. When GNA #6 returned a few seconds later, they both repositioned the resident in the reclined gerichair. The GNAs failed to offer the resident to walk, go to the bathroom, food or a drink to determine the possible reason the resident was trying to get up. GNA #6 wrapped the resident ' s feet with the blankets as they both left the nurses ' station at 12:08 AM. After attempting to get out of the reclined geri chair without assistance the GNAs left the resident unsupervised a second time. After the GNAs left, The resident got out of the chair, threw the covers up, and after unwrapping his feet from the blanket, stood up. The resident used furniture in the nurses ' station to hold on to, made their way to the counter height portion of the desk and fell. The resident fell on the right side and made no attempts to catch themselves. The resident laid motionless on the floor and at 12:10 AM, GNA #6 was observed back at the nurses ' station, and she started waving her arms. Then without checking to see if the resident was ok, she walked down to the central nurses ' station. GNA #6 returned to the resident, who was still lying on the floor and started pulling on the resident ' s left arm as if to roll the resident over before a nurse was able to assess the resident. It was observed the resident had a pool of blood on the floor next to his/her head. The GNAs were placing pads under the resident ' s head.RN #7 and RN #8 were observed walking down the hallway from the central nurses ' station area. Upon arrival, there was no sound available, but RN #7 was observed to lean over the resident near his/her head and shoulders for a few seconds. The nurse was not observed conducting a thorough assessment such as checking for signs of an injury to ensure it was safe to move the resident and conducting a neurological exam (referred to as a neuro check, blood pressure, pulse, respirations, temperature, and level of oxygen in the blood, hand grips, foot pushes, pupil size and reaction.). Staff were observed picking up the resident and sitting the resident back in the reclined geri chair. Once back in the geri chair a large knot was observed on resident #2 ' s right temple and the resident ' s nose was bleeding. RN #7 leaned over the resident for a few seconds and left the nurses ' station without rendering first aid. Further review of the video revealed that RN #7 did not go back to the nurses ' station to check on the resident, until EMS arrived 35 minutes later. The GNAs wiped the resident ' s nose and the resident wiped his/her nose. However, at no time did staff apply pressure to the top of the nose to stop the bleeding. The GNAs changed the blankets because they were soiled with blood. EMS arrived at 12:50 AM and took the resident to the local acute care hospital where the resident subsequently passed away. A review of the EMS Comprehensive Report on 6/20/25 at 3:45 PM, revealed 911 was not called until 4/20/25 at 12:41 AM, 31 minutes after the resident fell. EMS was dispatched at 12:43 AM. Per the report the residents ' blood oxygen level decreased and the resident needed supplemental oxygen. EMS staff were unable to get the oxygen back to a normal level before arriving at the nearest hospital.On 7/2/25 at 8:24 AM the emergency room report read that Resident #2 had a computerized tomography (CT) scan of the head which showed s/he suffered from hemorrhaging on the left side of the brain to include bleeding at the site of the hematoma on the resident ' s head that could be viewed in the video. The injury warranted surgical intervention; however, the family chose not to put the resident through the surgical procedure. The resident was given medications to reverse the bleeding, however, subsequently died 4/20/25 at 9:16 AM. The physician documented the cause of death was due to an accident at the nursing home.Review of the facility ' s investigation file on 6/18/25 at 2:17 PM a review of the facility ' s investigation file revealed an email dated 4/23/25 at 4:24 PM, written by GNA #6 (agency staff) on 4/23/25. The statement read that when she came on duty and during her first rounds, Resident #2 was trying to get up and wander around. She stated that she and GNA #5 transferred the resident to the gerichair and reclined the chair. She wrote that the resident was brought to the nurses station so they could watch the resident. After a while the resident seemed to calm down, so she went to answer a call light, she heard Resident #2 ' s chair alarm so she came out to check on him. She found the resident on the floor and went to the nurse for assistance. GNA #6 was not available for an interview. A review of the statement written by GNA #5 (agency staff) noted that she had heard the resident ' s chair alarm and when she came back to the nurses ' station the resident was on the floor.On 6/18/25 at 5:16 PM during a telephone interview with GNA #5 she reported that on 4/19/25, when she and GNA #6 came on duty they were told that the resident had been trying to get out of bed. She reported that the 3-11 PM supervisor (she did not know the name of the supervisor) told her and GNA #6 that they should get Resident #2 up in a recliner because s/he was a fall risk. She reported that she had not been assigned to the resident that night, but she was working with the GNA who was assigned to the resident in the west hallway. She reported that she assisted GNA #6 to get the resident out of bed and into the recliner geri chair. She reported that she knew that when a resident was up in a geri chair for behaviors they were supposed to have eyes on them at all times. When asked why this was not the case for Resident #2, she stated that they [GNAs] needed to make their rounds and there was no one to watch the resident. During the investigation it was determined that there were 3 nurses sitting at the central nurses ' station at the time of the fall.An interview with GNA #13 revealed that staff would bring a resident who was a fall risk to the nurses ' station at night when they were concerned about the resident ' s safety. She reported, when we get them up we are supposed to keep eyes on them at all times. She reported this was the facility ' s policy. When asked what she does if she needs to tend to another resident, she stated the nurse would watch them. An interview with RN #7 revealed she was sitting in the central nurses ' station and was unaware that the resident was up in the recliner. She stated that she failed to do a thorough assessment because when she observed the resident head injury she wanted to call 911 and get the paperwork ready to go out. She reported was aware there were 2 other nurses on duty that evening RN #8 [orientee] and RN #10. However, review of the EMS report revealed she failed to call 911 until 12:41 AM, 31 minutes after the resident fell. During an interview with the DON she was asked what she expected staff to do when they had a resident who was trying to get out of bed. She stated staff should check to see if the resident needed anything such as toileting, food, and or drink. Then if they continue to try to get up they may place them in a chair at the nurses ' station. However, if they get them out of bed then they need to have eyes on the resident at all times. When asked if she watched the surveillance video for this incident on 4/20/25. She stated she had and her concerns were the lack of urgency when staff responded to the fall. She stated that the assessment was not thorough. She reported that she had an extensive talk with RN #7 regarding the response to the incident. Additionally, she educated staff regarding the need to provide supervision for residents who were a fall risk. An interview with the Nursing Home Administrator (NHA) on 6/20/25 at 8:27 AM revealed she had reviewed the video with the DON while investigating the fall. She was unable to recall when she reviewed it and reported she would look back on her notes and get back to the surveyor. However, she failed to do so by the end of the survey. The provisions of the plan to remove the immediacy included the following:1. In-service on Fall Precautions and 1:1 Supervision Policy and Procedure- will be completed by 06/23/2025 by the Director of Nursing and Unit Manager.2. New Policy and Procedure on Fall Risk Identification and 1:1 Supervision Protocol-see attached will be in-serviced by the Director of Nursing and Unit Manager by 06/23/2025.3. [NAME] dots placed on resident name door plates for high risk of falls on 6/20/2025 with staff education on Fall Alerts/Green Dots completed by 06/23/2025 by Unit Manger and Director of Nursing4. New Policy and Procedure for educating agency nursing staff developed on 06/20/25. Agency staff will receive the in-service at the time they report on duty through the front desk staff and/or charge nurse and it will be made part of the orientation packet for new agency nursing staff. The facility will use the agency roster in Kronos to assure compliance. -See attached policy. Compliance date of 06/23//2025. 5. Overall compliance date of 06/23/2025.On 6/24/25 at 9:30 AM, an onsite visit was conducted. After validation of the implementation of the facility ' s plan of removal, which included staff interviews and record reviews, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on 6/24/25 at 3:45 PM.Cross Reference: F684, F726, and F940