**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record review, observations, and interviews, the facility failed to identify causal factors for falls and failed to implement interventions for the prevention of new falls following each new incident. This affected 3 (Residents 3,7, and 11) of 3 sampled residents. The facility census was reported to be 60. The facility Administrator was notified on 3/17/2025 at 5:44 PM of an Immediate Jeopardy (IJ) which began on 12/01/2024. The IJ was removed on 3/17/2025, as confirmed by surveyor onsite verification. Findings are: Record review of the facility policy Fall Risk and Prevention Guidelines revised October 2024 revealed that a resident's fall risk begins pre-admission. Upon admission, the plan of care should be ready to incorporate the fall prevention measures based on information gathered. The Morse Fall Scale is completed with each admission, readmission and with quarterly, annual and significant changes when completing the minimum data set (MDS, a standardized assessment tool used in Medicare and Medicaid certified nursing homes to collect comprehensive, standardized data on residents' health status and functional capabilities). Intervention and prevention measures of falls were to include use of: 1.) the resident care plan to identify history, risks, and resistance or refusal of interventions, 2.) incident analysis to identify trends and patterns for prevention. 3.) customer service rounds (nursing rounds), 4.) resident information sheets or the use of a [NAME], 5.) information gathered post fall, 6.) use of the reference Suggested Interventions to Manage Falls, 7.) immediate assessment and treatment of any injuries, 8.) complete set of vital signs, 9.) make appropriate notifications to Director of Nursing, hospital, family, etc. At this point the root cause analysis could be conducted by: 1.) interviewing any witnesses, 2.) making notes of the resident's surroundings, 3.) interviewing staff about the last time cares were provided to the individual, 4.) recording reviews of the medications and any recent lab work and revisit the plan of care, and 5.) nursing reviews of the post data collected and initiating a plan of care. Record review of the facility policy Risk Management updated on 09/27/2025 revealed all accidents/incidents involving residents must be reported, investigated, and reviewed through the facility's quality improvement program to ensure residents are receiving the highest quality of care. Each nurse who identified an incident would be responsible for completing the incident report. The incidents reportable included witnessed and unwitnessed falls, new skin issues, elopements, medication errors, abuse, resident to resident interactions, any unusual event, and smoking or burn injuries. The completed report would include details and descriptions of the incident as well as any immediate action taken; list any injuries, pain level, mobility and any confusion: identify predisposing factors for the incident including environmental, physiological, situation, or other causative factors; list any witnesses; describe actions taken (called family, director of nursing, ER), document in the electronic medical record; and finally, the nurse's signature. Neurological assessments were to take place if there were any unwitnessed falls or head injuries and to continue assessing for potential or further injuries. Record review of the facility policy Person Centered Care Plan revised January 2024 revealed the care plans are developed within 7 days after the completion of the comprehensive MDS assessment, and reviewed annually, quarterly and with significant changes as needed. The comprehensive person centered care plan contains measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that are identified. The overall person centered care plan should be oriented towards 1.) preventing avoidable declines, 2.) managing risk factors, 3.) preserving and building on the resident's strengths, 4.) respecting personal preferences and the right to decline treatments, 5.) include specific goals, treatment preferences and desired outcomes of care, and 6.) Include resident strengths and care needs. The care plans should be clear and concise, include personal strengths, include refusals of care, and show the risk versus the benefits. A. Record review of the annual MDS assessment dated [DATE] revealed Resident 7 had a Brief Interview for Mental Status (BIMS score-a 15-point cognitive screening tool used in long-term care facilities to assess a resident's cognitive function) score of 9 indicating the resident is moderately cognitively impaired, used a walker, needed standby assistance with dressing but substantial assistance when toileting or bathing, was occasionally incontinent of bowel and/or bladder, had no skin conditions, used a pressure reducing device in her chair, had diagnoses of arthritis, hypertension, and non-Alzheimer's dementia as well as other diagnoses. Resident 7's medications included the use of anti-psychotics, diuretics, antiplatelets, a hypoglycemic, and anticonvulsants. Resident 7 did not receive any physical therapy or occupational therapy in the 7 days used to prepare the annual MDS assessment. Record review of the working Care Plan (a structured approach to address an individual's healthcare and personal care needs) for Resident 7, printed and reviewed on 03/17/2025, revealed Resident 7 used an anticoagulant with a goal to remain free of complications and injuries (bleeding, bruising, swelling, hypotension and hospitalizations) through the next review of date of 07/06/2025. Resident 7's Protime/INR (a test that measures how quickly ones blood clots, helping to assess the effectiveness of blood-thinning medications like Warfarin) was to be checked per the physician orders. Resident 7 was at high risk of falling related to gait and balance problems, incontinence, and hypotension. New care plan interventions were initiated on 02/26/2025 for the following: -call light within reach and encourage use, -educate resident, staff, and family about safety reminders, -ensure proper footwear, -fax meds to physician for review, -follow facility fall protocol, -review information on past falls and attempt to determine cause of falls, -record possible root causes. -Alter remove any potential causes if possible. Educate resident/family/caregivers/Interdisciplinary team as to causes. Care plan interventions were also updated on 03/03/2025 when staff were to request a physical therapy and occupational therapy evaluation and obtain a urine analysis (UA) due to recent falls report and send results to provider. The resident started an antibiotic for a urinary tract infection. The last update was initiated on 03/10/2025 which stated the resident needs a safe environment with, even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach. Record review of the facility incidents by incident types for the month of February 2025 revealed eight witnessed falls, eight unwitnessed falls, two unusual event incidents, and two observed on the floor incidents of which Resident 7 had two unwitnessed falls (02/23/2025 and 02/26/2025). Record review of the facility incidents by incident types for March 1 to March 17, 2025, revealed five witnessed falls, nine unwitnessed falls, and one unusual event incidents of which Resident 7 had one witnessed fall (03/08/2025) and 3 unwitnessed falls (03/01/2025, 03/02/2025, and 03/10/2025). Record review of the post Fall Report from 02/26/2025 at 7:10 AM revealed Resident 7 was alert and oriented to person, place, and thing and had fallen in the hallway on the way back to the resident's room. Resident 7 stated they had fallen in the hallway when they lost their balance. Vital signs were reported to be stable. The resident reported dizzy feeling prior to falling. Interventions put into place by facility included need to tighten the laces on the shoes when tied, possible need for new shoes, and need to change pull-up when getting dressed in the morning. No injuries noted. Record review of the post Fall Report from 03/01/2025 at 6:55 AM revealed Resident 7 had been found on the floor of the resident's room with no apparent injuries noted. Resident 7 was alert and oriented to person, place and thing, but was found to be incontinent of both bowel and bladder. Interventions on the fall report but not the care plan stated to keep the call light within reach of Resident 7. No injuries noted. Record review of the post Fall Report from 03/02/2025 at 11:30 PM revealed Resident 7 was found on the floor of the resident's bathroom. Resident 7 reportedly lost balance and fell due to weakness and being alone. Resident 7 was reported to be alert and oriented to person, place and thing, wore only socks without grippers, and had changes in gait and balance over the last 2 weeks. When found Resident 7 was incontinent of urine. Resident 7 had started a new medication for a urinary tract infection the same date. Interventions put into place were to obtain a physical therapy and occupational therapy referral. No injuries noted. Record review of the post Fall Report from 03/08/2025 at 6:45 PM revealed Resident 7 tried to get out of the wheelchair without assistance and fell in the presence of a roommate. Neurological checks were initiated because it was unknown if Resident 7 hit (gender) head. Resident 7 was moved near the nurses station until it was time for bed for that single evening episode. There was no update to Resident 7's care plan. No injuries noted. Record review of the post Fall Report from 03/10/2025 at 4:03 PM revealed Resident 7 lost (gender) balance when getting out of the wheelchair, was disoriented x 2, had changes in gait, mobility, and balance over the past 2 weeks, and had a change in mental condition. At the time of the fall, Resident 7 wasn't using the walker for ambulation and had not used the call light. No injuries noted. Record review on 03/17/2025 of the Progress Notes of Resident 7 revealed that the Healthcare Power of Attorney (HPOA) had been contacted by nursing staff about the fall that occurred on 03/10/2025 at 3:15 PM. The HPOA asked that the resident be sent to the emergency room for further evaluation. This was further ordered by Resident 7's primary healthcare physician as noted in the progress notes. Interview on 03/17/2025 at 1:20 PM with the MDS, revealed that since Resident 7 had been placed in the hospital on [DATE]. The MDS had not gotten any updates about Resident 7 but did know the hospital admission diagnosis included a diagnosis of urinary tract infection. The MDS, further revealed that generally, the next day the care plans are updated with the new interventions because there must be a new intervention with each incident. The nurses and charge nurses may come to me or to the DON to ask about adding something to the care plan and then the DON and I meet to add what is needed. The DON and I have weekly meetings. We also have monthly meetings to discuss the high fall risk residents and make sure there are interventions in place. Interview on 03/17/2025 at 1:25 with the DON in the office of the DON, revealed that there is a Performance Improvement Project (PIP) in place for falls. We have seen some trends and made some improvements. After an incident, the MDS, the Assistant Director of Nursing (ADON), and I all meet to discuss what staff put into place in the fall report at the time of the incident. We let the staff know right away by going out to the floors and visiting with the staff when we have changed the care plan. We also use a white board to share updates. I think the staff use a small binder at the nurses' station to track these changes as well. But a lot of the updates are done by word of mouth at the time of report. Interview on 03/17/2025 at 3:45 PM with the DON confirmed that not all information identified for care plan interventions, found on the fall reports, get added to the care plans after each incident. DON confirmed that some of the updates to care plan interventions did not show on the care plans until a few days after the incidents and at times another incident had already taken place. DON further confirmed some interventions are not appropriate because staff cannot assist with interventions such as physical therapy and occupational therapy referrals, asking physician for orders for biopsies, and single occurrence interventions. The DON also confirmed the fall reports are used to identify issues and follow trends, but the root cause of many of the fall issues is not found. B. Record review of the Resident 11 quarterly MDS dated [DATE] revealed this resident had a BIMS Score of 12 indicating the resident was moderately cognitively impaired, did not wander or refuse cares, used a walker and wheelchair, is independent in activities of daily living except for supervision at bathing time, is occasionally incontinent of urine, and had diagnoses of hypertension, hypokalemia, diabetes, and seizure disorder. Resident 11 also took the following types of medications: Antipsychotics, antidepressants, hypnotics, and anticonvulsant's. Record review of the care plan for Resident 7 revealed the resident had idiopathic epilepsy and was a high risk for falls. The care plans were updated for falls on 12/13/2024, 01/06/2025, 01/30/2025, 3/7/2025, and 3/10/2025. The care plan update on 3/7/2025 stated staff were to rearrange the room. The update on 3/10/2025 occurred while the resident was in the hospital and revealed the facility had added siderail's to Resident 11's bed to promote independence with transfers and repositioning, and to promote safety. Record review of the facility incidents by incident types for the month of January 2025 revealed Resident 11 had two unwitnessed falls (1/1 and 1/28/2025). Record review of the facility incidents by incident types for the month of February 2025 revealed Resident 11 had one witnessed fall (2/21/2025) Record review of the facility incidents by incident types for March 1 to March 17, 2025, revealed Resident 11 had 2 unwitnessed falls (3/5 and 3/7/2025). Record review of the Progress notes reviewed on 03/17/2025 revealed a health status note written on 03/07/2025 at 5:09 AM revealed Resident 11 was having urgency and frequency with urination and when asked about the symptoms denied burning or pain with urination. Resident 11 was assisted to the bathroom and voided small amounts and was having incontinence issues post voiding with no strong odors or cloudiness observed while voiding but needed to have assistance to the bathroom every hour through the night. The resident remained on Neuro checks from a fall that occurred on 03/05/2025. On 03/07/2025 at 5:34 AM a change of condition notification was faxed to the Resident 7's doctor and staff awaited a response. On 03/07/2025 at 6:33 AM the staff found Resident 7 on the floor in the bathroom with back resting against the wall. Resident 11 was confused and after a quick assessment by staff was ambulated and found to be unsteady and shaky. Resident 11's primary care physician sent an order to have to have Resident 11 sent to the emergency room for evaluation and treatment. Record review of the Hospital Discharge paperwork for Resident 11 dated 03/13/2025 revealed that upon admission to the emergency room the resident had chills, an altered mental status changes. His blood work revealed a white count of 20,000 (Normal is 3000 to 11,000) which indicated a bacterial infection, a lactic acid of 2.0 and procal of 5.5 (Both lactic acid and procalcitonin are indicators used to determine whether a patient has sepsis of the blood). Resident 11's urine was positive for bacteria that was positive for nitrates, 3+ leukocyte esterase, cloudy, many bacteria, and a white count that was too numerous to mention (nitrates, leukocyte esterase, cloudiness, bacteria and white counts are all used to determine if there is an infection in the urine). Prior to discharge Resident 11 was diagnosed with a urinary tract infection and sepsis due to E.coli (a bacteria) without acute organ dysfunction. The reason for his referral to the hospital had been weakness. Interview with MDS Coordinator on 03/17/2025 at 3:45 PM who revealed that updates to the care plan did not occur with each incident and were not added immediately after the incidents that occurred. Interview with the DON on 03/17/2025 at 3:45 PM who confirmed that updates to the care plan did not flow over from the progress notes and were not added to the care plan. C. Record Review of the MDS dated [DATE] for Resident 3 revealed the BIMS had not been conducted for this resident as Resident 3 is rarely understood or never understood. Resident 3 does have behavioral issues 1 to 3 times per week, and occasional rejects cares, is unable to ambulate 10 feet, and uses a motorized electric wheelchair. Resident 3 needs assistance with eating and toileting, and is dependent with cares related to dressing and bathing. Resident 3 is occasionally incontinent of urine, frequently incontinent of bowel, and has ongoing pain. Resident 3's diagnoses include atrial fibrillation (abnormal beating of the heart), osteoporosis (weakened bones), anxiety, depression, schizophrenia, and a fractured right patella. Resident 3 takes medications for anxiety, depression, opioid for pain, and an anticonvulsant. Record review of the Care Plan printed on 3/17/2025 for Resident 3 revealed this resident was at high potential for falls. There were no updates to the care plan for falls during the month of December 2024. During the month of January 2025, there were updates to the care plan on 01/06, 01/08, 01/10, 01/28 and 01/29/2025. During the month of February 2025 there was a single update to the care plan pertaining to falls on 2/26/2025. There were no updates to the fall area of the care plan during the month of March 2025. Record review of the Progress Notes for Resident 3 which revealed falls occurred on 12/01/2024 at 10:16 PM, 12/22/2024 at 11:45 AM, and 12/28/2024 at 5:39 PM during the month of December 2025. The progress notes further revealed that Resident 3 was educated about carrying too many things at one time. This was not included in the care plan. Record review of Resident 3's progress notes also revealed that on 12/23/2024 the resident was given gripper socks, educated about wearing proper footwear, and to not wash things in the sink. This was not added to the care plan. Resident 3 did have pain in the right knee following the accident on 12/28/2024 at 5:39 PM. A change of condition report was called to the Primary care provider and the resident was sent to the emergency room at 11:45 PM. The resident returned to the facility on [DATE] at 1:30 AM diagnoses with a right patellar fracture of the right knee, wearing an ace wrap and an immobilizer to the right knee. Record review of the facility incidents by incident types for the month of January 2025 revealed Resident 3 had four unwitnessed falls (1/12, 1/17, 1/26 and 1/27/2025) and one observed on the floor incident (1/2/2025). Record review of the facility incidents by incident types for the month of February 2025 revealed Resident 3 had one witnessed fall (2/26/2025). Record review of the facility incidents by incident types for March 1 to March 17, 2025, revealed Resident 3 had one unwitnessed fall (3/13/2025). Interview with the MDS Coordinator on 03/17/2025 at 3:45 PM revealed that Resident 3 is able to get out the wheelchair to sit on the floor for prayers. We encourage Resident 3 to ask for assistance, but oftentimes (gender) doesn't remember to use the call light. Resident 3 is a High Potential Fall Risk per (gender) care plan but we really didn't have any issues until December. There were no care plan updates added to Resident 3's care plan until that fractured patella occurred. MDS Coordinator confirmed that new interventions should have been added with each incident. Interview with the DON on 03/17/2025 at 3:34 PM confirmed no new updates to the care plan concerning fall risks were added until January. Also confirmed that some of the interventions need to be revised so that they are pertinent to the staff. D. Interview on 03/17/2025 at 1:15 PM with the charge nurse Licensed Practical Nurse (LPN-C) who has worked at the facility for the past 3 years, explained that the current process following incidents in the facility is to call the Director of Nursing (DON) and family as well as sending a change of condition report to the physician to let them know about the occurrences. The DON will then update the care plan and let us as staff know right away what changes have been added. LPN-C admitted to not reviewing the care plan itself and just gets the care plans by word of mouth from the DON or the MDS. Charge nurses do not update the care plans. Charge nurses will fill out the fall reports and do the neuro checks when needed such as unwitnessed falls and when a resident hits their head. Interview on 03/17/2025 at 1:20 PM with the MDS in the office of the MDS, revealed that generally, the next day the care plans are updated with the new interventions because there must be a new intervention with each incident. The nurses and charge nurses may come to me or to the DON to ask about adding something to the care plan and then the DON and I meet to add what is needed. The DON and I have weekly meetings. We also have monthly meetings to discuss the high fall risk residents and make sure there are interventions in place. Interview on 03/17/2025 at 1:25 with the DON in the office of the DON, revealed that there is a Performance Improvement Project (PIP) in place for falls. We have seen some trends and made some improvements. After an incident, the MDS, the Assistant Director of Nursing (ADON), and I all meet to discuss what staff put into place in the fall report at the time of the incident. We let the staff know right away by going out to the floors and visiting with the staff when we have changed the care plan. We also use a white board to share updates. I think the staff use a small binder at the nurses' station to track these changes as well. But a lot of the updates are done by word of mouth at the time of report. Interview on 03/17/2025 at 3:25 PM with Nurse Aide (NA-A) revealed the nurses will tell the nurse aides at the beginning of the shift if there are any changes to the way care is provided for residents. Or there is a book we can look in at the desk too. NA-A revealed [gender] does not review the care plans for any residents and instead relies on word of mouth. Interview on 03/17/2025 at 3:28 PM with NA-B revealed to have no knowledge of a book at the front desk to obtain updates. NA-B stated the nursing staff let the nurse aides know about changes at the beginning of the shift about care changes. NA-B does not review the care plans for any residents. Interview on 03/17/2025 at 3:30 PM with LPN-C who confirmed that most staff including LPN-C rely on the word of mouth to get the information about care updates on residents in house. Interview on 03/17/2025 at 3:45 PM with the MDS Coordinator in office of the DON who stated that the care plans are updated with each incident, however, MDS was unable to identify the updates for each incident on the care plans for sampled residents after incidents in question. MDSC also identified the care plan interventions that do not actually assist the residents at the time of the incidents. MDS did identify that some residents are non-compliant with interventions and so these are just not added to the care plans. Interview on 03/17/2025 at 3:45 PM with the DON confirmed that not all information identified for care plan interventions, found on the fall reports, get added to the care plans after each incident. DON confirmed that some of the updates to care plan interventions did not show on the care plans until a few days after the incidents and at times another incident had already taken place. DON further confirmed some interventions are not appropriate because staff cannot assist with interventions such as physical therapy and occupational therapy referrals, asking physician for orders for biopsies, and single occurrence interventions. The DON also confirmed the fall reports are used to identify issues and follow trends, but the root cause of many of the fall issues is not found. E. An abatement statement was presented and approved on 03/17/2025 at 9:34 PM by the Administrator. The Abatement statement read as follows: -On 3/17/2025, Administrator, Director of Nursing and MDS were educated on the Accura Risk Management process by Chief Clinical Officer. -On 3/17/2025, staff education was initiated to ensure all licensed staff understand the Accura risk management process. Any licensed staff not currently working will be educated prior to the start of their next shift. -On 3/17/2025. All NA's through evening shift into night shift were educated on the communication plan for care plan changes and intervention updates. -On 3/17/2025, Care Plan updates were initiated on Resident 3 and Resident 11. Resident 7 remains out of the facility and the care plan will be updated upon return. Audit: All residents who have had two or more galls within 30 days in the last 60 days will have care plan reviews for causative factors and appropriate interventions. The communication board will be audited daily for the next 4 days to ensure all updated care plan changes and new interventions are communicated to the NAs. We will move to auditing 3x weekly starting 3.24.2025. Any concerns will be reported to the administrator immediately and addressed in facility Quality Assurance. After consideration, it was determined that the facility put the facility residents in a situation of immediate jeopardy by not assessing the fall situations, identifying the causal factors for the fall incidents, and for failing to add interventions that staffing knew about immediately following the incidents, and to make changes to care plans using a process that was known to all staff members. The Immediate Jeopardy started with the fall that took place on 12/01/2024 at 10:16 PM. At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on Observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. After receiving the abatement statement, the severity was changed to a D.