**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Res #30 had diagnoses which included dementia with behavioral disturbance, bladder cancer, and diabetes. A quarterly resident assessment, dated 02/11/22, documented the resident was moderately cognitively impaired, required total assistance for bed mobility, transfers, toileting, and personal hygiene, had limited range of motion in both lower limbs, and had one fall with minor injury since the last assessment. An incident report, dated 03/21/22, documented Res #30 had a fall from bed without injury. An intervention of a fall mat was documented. The care plan was not updated with STPR. A fall risk assessment, dated 03/29/22, documented a score of 18 which placed the resident at high risk for falls. A nurse progress note, dated 04/17/22 at 3:00 p.m., documented Res #30 had a fall from the bed without injury. No intervention was documented for this fall. A nurse progress note, dated 04/18/22, at 3:15 p.m., documented Res #30 had a fall from bed which resulted in a 3 x 4 cm abrasion to the right knee. No intervention was documented for this fall. An incident report, dated 04/24/22, documented Res #30 had a fall from the bed which resulted in swelling and bleeding to the left eyebrow. No intervention was documented for this fall. A nurse progress note, dated 04/30/22 at 10:20 a.m., documented Res #30 was sent to the emergency room for evaluation due to seizure-like activity. A nurses progress note, dated 04/30/22 at 1:30 p.m., documented Res #30 was sent via life-flight to a different hospital. A hospital discharge record, dated 05/09/22, documented Res #30 was to return to the facility with hospice to provide terminal care. A care plan, reviewed 05/20/22, documented Res #30 was at risk for falls. The interventions included: remind resident to ask for staff assistance with transfers and monitor for changes which may warrant increased supervision or assistance. An incident report, dated 05/21/22, documented Res #30 had a fall from the bed without injury. No intervention was documented for this fall. A significant change assessment, dated 05/23/22, documented Res #30 was severely cognitively impaired, required extensive assistance with bed mobility, required total assistance with transfers, dressing, toileting, personal hygiene and bathing, and had one fall without injury since last assessment. An incident report, dated 05/31/22, documented Res #30 had a fall from the bed resulting in a hematoma to the right eyebrow. No interventions were documented for this fall. On 07/05/22 at 2:34 p.m., Res #30 was observed in bed with a fall mat pushed underneath the bed. On 07/06/22, at 10:17 a.m., CNA #1 stated the fall precautions for Res #30 was a fall mat, and that she could ask the nurse for access to the care plan to see what interventions were required. On 07/06/22 at 10:18 a.m., CNA#2 stated she asked the nurse what to do for each patient and did what the nurse asked. She could not state any specific interventions for resident #30. On 07/06/22 at 10:22 a.m., the MDS coordinator stated she did not care plan any fall interventions after each of the falls. 2. Res #24 was admitted to the facility on [DATE] with diagnoses which included acute cystitis with hematuria, unspecified dementia with behavioral disturbance, and psychotic disorder. A Fall Risk assessment, dated 12/17/21, documented the resident was at high risk for falls. An incident report, dated 01/12/22, documented the resident attempted to sit in a geri-chair and missed the chair without injury. No new STPR were added to the care plan. A quarterly assessment, dated 02/21/22, documented the resident was severely impaired with cognition, required supervision and limited assistance of one person physical assistance with transfers and locomotion. An incident report, dated 03/04/22, documented the resident was walking and lost his balance without injury. No new STPR were added to the care plan. A nurse's note, dated 03/31/22, documented the resident stumbled on a wheelchair that had a resident in it and fell face first. The note documented the resident received a large bump to the upper right forehead. The note documented the resident refused neuro checks. The note documented an hour later the resident found in a women's room face down in the floor in the corner of the room. The note documented the resident was sent to the emergency room due to not responding to voice normally, and had to shake him or other stimuli for him to respond. No new STPR were added to the care plan. No incident or state reportable reports were found. An incident report, dated 04/05/22, documented the resident was sitting on his bottom just inside his room without injury. The report documented to add the resident to the restorative program. No new STPR were added to the care plan. A nurse note, dated 04/27/22, documented the staff went to check the resident to see if he was dry and found him in the floor without injury. No new STPR were added to the care plan. An incident report, dated 05/21/22, documented the resident was wandering and ambulating independently about the day room in front of the desk when he suddenly became weak and fell backwards. The report documented he did not hit his head and to continue neuro checks. No new STPR were added to the care plan. An incident report, dated 06/05/22, documented the resident was wandering around facility into the dining room and tripped over a wet floor sign without injury. The report documented to redirect when ambulating close to an area where signs are being utilized. STPR were not added to the care plan. A Fall Risk Assessment, dated 06/13/22, documented the resident was a high risk for falls. An incident report, dated 06/22/22, documented the resident was laying on his back on the floor with a small abrasion to his left arm and neuro checks were initiated. No new STPR were added to the care plan. On 07/06/22 at 1:57 p.m., the MDS coordinator stated the last review of resident's care plan was 02/28/22. The MDS coordinator reported the care plan should have been revised and interventions put in place after each fall. 4. Res #21 was admitted to the facility with diagnoses which included Parkinson's Disease and bipolar disorder. A care plan, dated 01/26/22, documented Res #21 had a history of falls with interventions in place. A quarterly assessment, dated 04/29/22, documented Res #21 was cognitively intact and required assistance with ADLs. A nurse progress note, dated 05/03/22, read in parts, .at approx 6 pm this evening .fell as leaving the dining room .C/o head pain and shoulder and arm pain. sent to er. family notified.'' A nurse progress note, dated 05/16/22, read in part, .res cont to c/o arm pain. Sent to ER for xray. reveals fx of humerous [sic] . A physician progress note, dated 6/21/22, read in part, '' .she sustained a fall last month and C/O Right arm pain. The initial xray was negative for fracture: however, per the staff, she eventually went to the ER where a Right humeral fracture was identified . On 07/06/22 at 4:30 p.m., the MDS coordinator reported the resident did have a care plan for falls but it had not been revised since 01/26/22. The MDS coordinator stated the care plan should have been revised with interventions after the resident fell. On 07/06/22 at 4:38 p.m., the administrator reported the care plan had not been updated since 01/26/22 and the care plan should have been updated on 05/03/22 with additional interventions for falls. On 07/06/22 an immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to prevent falls and to consistently identify and implement interventions to prevent falls for Res #15, 24, and #30. Resident #15 fell multiple times including one where the Res had sustained a laceration to the right leg which required sutures and subsequently became infected and required further hospitalization. Res #24 fell multiple times and with one fall received a large bump to the upper right forehead and was later found face down in the floor of another resident's room. Res #24 was not responsive and subsequently sent to the hospital for evaluation. Res #24 continued to fall. Res #30 had fallen multiple times with different injuries including one where the Res had sustained a hematoma to his right eyebrow. A week later Res #30 was sent to the hospital for evaluation of seizure like activity. On return from the hospital, Res #30 continued to fall. On 07/06/22 at 2:10 p.m., OSDH verified the existence of the IJ situation in regard to the failure of the facility to provide interventions and supervision to prevent falls. On 07/06/22 at 2:19 p.m., the administrator was notified of the IJ situation. On 07/06/22 at 6:12 p.m., a plan of removal was accepted. The plan of removal read in part, Plan of Removal: On July 6th, 2022 at 2:19pm [sic], fall assessments initiated and will be completed on 50 of 50 residents residing in facility with the potential to fall (to be completed by 11am on 7/7/2022[)] Immediate interventions put in place for residents #15, #24, and #30 as well as interventions for residents who's [sic] assessment place them at high-risk for falls (to be completed by 2pm on 7/7/2022[)] Fall Interventions care planned on residents #15, #24, and #30 as well as others who are at high-risk for falls (to be completed by 2pm on 7/7/2022) Direct care staff in serviced on reporting falls, incident/fall scene investigations, interventions, fall policies and procedures, location of quick reference fall guide (completed by 2pm on 7/7/2022[)] Non-direct care staff in serviced on preventing and identifying fall hazards (to be completed by 12pm on 7/7/2022) Quick reference guide with fall policy & Procedure placed at nurse's station (to be completed by 7pm on 7/6/2022) On 07/07/22 in-services were provided by the DON/designee to all staff. Topics of the in-service included reporting falls, incidents, accidents, fall scene investigation, witness statements, interventions, a review of the fall policy and procedure, and quick reference guide for falls. On 07/07/22 at 11:45 a.m., the IJ was removed when all components of the plan of removal had been completed. The deficient practice remained at an actual harm at a pattern. Based on record review, observation, and interview, the facility failed to ensure each resident received supervision and interventions to prevent falls for four (#15, 21, 24, and #30) of four residents reviewed for accident hazards. The administrator identified 29 residents had fallen in the previous six months. Findings: A facility protocol, titled Falls - Clinical Protocol revised in September 2012, read in parts: .Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .Monitoring and Follow-Up a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall .If a resident continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (bedsides those that have already been identified) and will re-evaluate the continued relevance of current interventions . A facility policy, titled Accidents and Incidents - Investigating and Reporting, revised February 2014, read in parts, .1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: .k. Any corrective action taken; .6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence . 1. Resident #15 had diagnoses which included osteoarthritis, embolism of deep veins of the lower extremities, pulmonary embolism, and morbid obesity. A care plan, dated 12/03/20, documented Res #15 was at risk for falls. The plan of care did not document a goal or interventions to prevent falls. An incident report, dated 07/22/21, documented Res #15 had attempted to transfer from bed to BSC and appeared to have lost her balance. The report documented Res #15 hit her head on the bathroom door, sustained a small knot to crown of her head, and a small abrasion to left inner eye from her glasses. The incident report did not document any STPR of falls. A care plan, dated 08/02/21, documented Res #15 had a history of falling, with a goal of falls will not cause injury through the next review date, and interventions that read in part, .Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician Remind to use call light for assistance . An incident report, dated 09/12/21, documented the staff found Res #15 sitting on the floor up against the wall. The incident report documented Res #15 stated she hit the top of her head and neuro checks were started. A STPR was documented as to move the BSC closer and to encourage Res #15 to use the call light. The care plan for Res #15 did not document the intervention. An incident report, dated 10/12/21, stated the staff were called to Res #15's room and found her on the floor near her bed. The report documented Res #15 stated she was getting off the bed to use commode and fell. The report documented Res #15 was not injured. The STPR was to instruct Res #15 to use her call light and staff were to make sure it was in reach. A fall risk assessment form, dated 12/16/21, documented Res #15 scored 14. The form documented a score of ten or more indicated a high risk for falls. A quarterly assessment, dated 02/14/22, documented the resident was intact in cognition and required extensive assistance with most ADLs. The assessment did not document Res #15 had fallen. An x-ray report, dated 12/14/21, read in part, .marked lateral displacement of patella . No incident report or documentation was found related to injury was provided by the facility. A fall risk assessment for Res #15, dated 03/12/22, documented Res #15 scored 14. The form documented a score of ten or more indicated a high risk for falls. An incident report, dated 03/19/22, documented Res #15 was laying on the floor beside the bed face down. The report documented Res #15 complained of pain to her face, right leg, neck pain, and sustained a laceration to her right leg. The incident report documented CNA #3 had attempted to provide a bed bath to Res #15 without assistance. The form documented when the CNA attempted to turn Res #15 she rolled off the bed. The report documented Res #15 was sent to the hospital via EMS. The STPR were documented as address to Res #15's safety needs on return from the hospital, to make sure the wheels of the bed were locked, and staff were to be in-serviced on care plans. The care plan was not updated related to this fall. An entry to a sheet on the Res #15's care plan, dated 03/19/22, documented Fall with Laceration. The entry did not include new interventions to prevent falls. A nurse note, dated 03/24/22, documented Res #15 was given antibiotics and was to be transferred to the hospital for wound treatment related to laceration sustained on 03/19/22. A staff in-service, dated 04/12/22, was conducted and staff members were instructed to follow residents' care plans or ask a nurse if there were any questions. A hospital discharge record, dated 04/13/22, documented Res #15 had been admitted from the nursing home due to right lower extremity cellulitis after having a laceration on the leg which was caused from a fall. A quarterly assessment, dated 05/11/22, documented Res #15 was cognitively intact, required two plus person physical assist for bed mobility, and had no falls. On 06/29/22 at 9:54 a.m., Res #15 was observed in her bed. The bed was in a high position. Res #15 stated she had fallen several times. On 07/06/22 from 9:45 a.m., to 9:55 a.m., four CNA's and CMA's were interviewed regarding the fall prevention for Res #15. They stated the only intervention was is 4 person assist, one CNA added to keep the call light close. On 07/06/22 at 10:35 a.m., the MDS coordinator was asked how the facility notified her of resident falls and for any new interventions. The MDS coordinator stated she was getting copies of incident reports for a time. The MDS coordinator reviewed Res #15's care plan and stated it did not have the appropriate interventions to prevent falls for this resident. The MDS coordinator stated she did add Res #15 required a four person assist under the ADL care plan however this intervention should have been added to the fall care plan as well.