**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07/31/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure Res #1, who was at risk for elopement, did not elope from the facility. Res #1 admitted to the facility on [DATE] with diagnoses including dementia. Res #1 eloped from the facility on 06/29/24 without staff knowledge and was returned to the facility by a community member. The facility did not complete one-on-one monitoring upon the Res #1's return or initiate environmental interventions for prevention. The care plan was not revised for the Res #1 and staff did not have a consistent plan to monitor and prevent elopement for the resident. On 07/31/24 at 3:00 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to elopement for Res #1. On 07/31/24 at 3:12 p.m., the administrator was notified of the IJ situation. On 08/01/24 at 12:11 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Corrective Action: Plan of Removal On 07/31/24, elopement risk assessments were initiated on all residents with care plans updated to identify any at risk residents. 1. A notification sign will be placed on front door and service door to alert visitors and vendors to not let anyone out without notifying/asking facility staff first. 2. All staff In-Serviced on elopement risk policy, ensuring that identified elopement risk residents are redirected away from doors, properly performing 1:1 monitoring, and location of list of wandering/elopement risk residents and to check list at beginning of shift. 3. MDS Coordinator in-serviced on completion of 48-hour care plans on all new admissions to include but not limited to potential for risk of elopement. 4. HR/BOM in-serviced on all newly hired personnel will be educated on elopement policy, location of list of at risk for elopement residents with an acknowledgement page. 5. Nursing Administration In-Serviced on reviewing elopement risk resident list/any new admissions and updating list accordingly 5 times weekly during clinical meeting. 6. DON/Designee will report any negative findings quarterly to QAPI. 7. Any employee that can't be reached for In-Service will be inactive and taken off of schedule until education is provided. Completed by 10 a.m. 8/1/2024 The IJ was lifted, effective 08/01/24 at 10:00 a.m., when all components of the plan of removal had been completed. The deficiency remained at a level of potential for more than minimal harm. Based on observation, record review, and interview, the facility failed to ensure a resident at risk for elopement did not elope from the facility for one (#1) of three sampled residents reviewed for elopement and failed to ensure treatment carts were locked. The facility assessment documented four residents who were at risk for elopement and five residents who wander. Findings: A Safety and Supervision of Residents policy, revised July 2017, documented in part Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring that interventions are implemented; and e. Documenting interventions. A Wandering and Elopement policy, revised March 2019, documented in part If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 1. Res #1 admitted to the facility on [DATE] with diagnoses including dementia. A baseline care plan was not completed. A wander risk assessment, dated 06/21/24 documented the resident was at risk for elopement. The 72 hour portion of the wander risk assessment was not completed to include history of wandering prior to admission. A progress note, dated 06/22/24 at 2:32 p.m., documented Res #1 was exit seeking. A progress note, dated 06/23/24 at 5:50 p.m., documented Res #1 was trying to get out of the facility. A progress note, dated 06/24/24 at 8:30 a.m., documented an interview with the Res #1's daughter in which the daughter notified the facility Res #1 was a flight risk. A progress note, dated 06/25/24 at 4:23 a.m., documented Res #1 continued to attempt to get out of the facility. A progress note, dated 06/25/24 at 9:51 a.m., documented Res #1 was attempting to leave the facility. The note documented the staff would continue to check on the Res #1 every two hours. A progress note, dated 06/26/24 at 7:28 p.m., documented Res #1 was attempting to get out the front door. A progress note, dated 06/27/24 at 2:25 a.m., documented Res #1 was attempting to get out the front door. An incident report, dated 06/29/24, documented the Res #1 eloped from the facility because a family member let them out. The incident report documented a sign would be placed on the door to alert visitors to not let anyone out, and the resident would be placed on one-on-one monitoring until a new wander risk assessment was completed. A witness statement, dated 06/29/24, documented the Res #1 was observed outside the facility at 1:55 p.m. A progress note, dated 06/29/24, at 2:54 p.m., documented the Res #1 had left the facility without staff knowledge and had been returned by a community member. The high temperature for the facility's location on 06/29/24 was 97 F. No wander risk assessment was documented after 06/29/24. A care plan, dated 07/03/24, documented Res #1 was at risk for elopement. The interventions documented included: Assess for fall risk, distract Res #1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Res #1 prefers: (not completed), monitor for fatigue and weight loss, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. A HOURLY RESIDENT CHECKS form, dated 06/29/24, documented a single check at 3:07. It did not document a.m. or p.m. There were no other documented checks for 06/29/24. A HOURLY RESIDENT CHECKS form was not provided for 06/30/24 from midnight to 6:15 p.m. A HOURLY RESIDENT CHECKS form was not provided for 07/02/24 from 6:00 a.m. to 6:00 p.m. A HOURLY RESIDENT CHECKS form was not provided for 07/04/24 from 6:00 a.m. to 6:30 p.m. A HOURLY RESIDENT CHECKS form was not provided for 07/05/24 from 6:00 a.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/06/24. A HOURLY RESIDENT CHECKS form was not provided for 07/08/24 from 6:00 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/09/24 from midnight to 6:00 a.m. and 6:00 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/10/24 from midnight to 6:00 a.m. and 4:30 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/11/24 from midnight to 6:00 a.m., from 10:30 a.m. to 3:00 p.m., and from 6:00 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/12/24. A HOURLY RESIDENT CHECKS form was not provided for 07/13/24. A HOURLY RESIDENT CHECKS form was not provided for 07/14/24 from midnight to 6:00 a.m. and from 6:00 p.m. to midnight. A HOURLY RESIDENT CHECKS form was not provided for 07/15/24 from midnight to 6:00 a.m. and from 6:00 p.m. to midnight. No additional forms were provided after this date. On 07/29/24 at 12:00 p.m., the outer front door of the entrance to the facility was observed missing. The hinge was observed hanging from the top of the door frame. A green button to the right of the door granted entry to the facility. No signs for visitors regarding letting anyone out was observed. On 07/29/24 Res #1 was observed wandering the halls and approaching the front door several times from 12:44 p.m. to 1:25 p.m. Staff are not observed redirecting or interacting with Res #1 during this time. On 07/29/24 at 1:07 p.m., staff #1 stated Res #1 was on 15 minute visuals and was supposed to wear bright colors so they can be spotted easily. On 07/29/24 at 1:31 p.m., staff #2 stated Res #1 was reoriented, the staff check the doors to make sure they are locked, and the Res #1 is checked every 2 hours for safety. On 07/31/24 at 11:26 a.m., the staff #3 stated they knew Res #1 was at risk for elopement because they had eloped from their apartment twice before admission. They stated the 15 minute checks were only supposed to be completed during the day because Res #1 was asleep at night. When asked why some of the staff completed them at night they stated they did not have an answer for that. On 07/31/24 at 11:48 a.m., staff #5 stated there were no residents on one-on-one monitoring. They stated the 15 minute checks were not the same as one-on-one monitoring. They stated the 15 minute checks were supposed to be documented 24 hours per day. On 07/31/24 at 12:30 p.m. the staff #3 stated one on one monitoring was not completed. They stated they did not have an answer as to why the other interventions listed were not completed. On 07/31/24 at 12:56 p.m., the staff #3 stated a member of the community was the one who returned the resident to the facility. On 07/31/24 at 1:02 p.m., the staff #3 stated the baseline care plan was not completed. 2. On 07/29/24 at 12:16 p.m., the treatment cart parked on the south side of the nurses station was observed unlocked and unsupervised. The cart remained unlocked and unsupervised until 1:31 p.m. On 07/29/24 at 12:59 p.m., the treatment cart parked on the north side of the nurses station was observed unlocked and unsupervised. On 07/29/24 at 1:31 p.m. staff #2 stated the treatment carts should be locked when they are left. They stated they thought their cart was locked. They were observed locking the medication cart. On 08/01/24 at 11:04 a.m., the treatment cart parked on the south side of the nurses station was observed unlocked and unsupervised. On 08/01/24 at 11:41 p.m., the treatment cart parked on the north side of the nurses station was observed unlocked and unsupervised. On 08/01/24 at 1:00 p.m., the treatment cart parked on the south side of the nurses station was observed unlocked and unsupervised. On 08/01/24 at 1:05 p.m., staff #4 stated treatment carts should be locked when staff walk away from the cart or it is not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure staff were available 24 hours a day who had current certification in CPR for Healthcare Providers (training to include hands-on practice and in-person skills) and maintain their certifications to be able to provide CPR until emergency medical services arrived. The facility failed to have a CPR policy and ensure staff were familiar with facility policies related to CPR. Three of the facility's 15 nurses had CPR certification, one night shift nurse who worked three shifts a week, one weekend nurse, who worked the day shift, and the administrator/RN, who was not on the schedule. No CMAs or CNAs had evidence of CPR certification. On [DATE] at 3:35 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. On [DATE] at 3:41 p.m., the administrator was notified of the IJ situation. On [DATE] at 12:14 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: Haskell County Nursing Center February 23, 2023 On February 22, 2023 State Surveyors entered the facility to conduct a complaint survey and also an annual survey. Prior to leaving the facility on February 23, 2023 the survey team initiated an IJ template for the facility for failure to ensure that there was a system in place to ensure that there were an adequate number of staff in the facility that were healthcare provider CPR certified for each shift. The facility also failed to ensure that there was a CPR policy in place and to ensure that staff were familiar with the protocols related to providing CPR. 3 of 15 nurses were certified with only part of the facility being covered with at least one CPR certified employee in the facility at all times. All staff were required to be CPR certified upon hire and the instructor that was performing the CPR classes for the facility relocated to a job that did not allow her to continue to train our staff in CPR, therefore most staff CPR certifications expired in [DATE]. We have a nurse on staff that has completed the book work training to be certified as a CPR instructor but we have had difficulty locating an instructor to check her off for her skills and hands on training therefore we have difficulty finding someone to certify our staff in CPR. On February 23, 2023 from 1600 to 1800 Upon being given the IJ template all staff on shift were immediately inserviced by the administrator and the Director of Nursing on what to do in the event someone went into cardiac arrest, the new policies and procedures implemented by the facility regarding protocols for performing CPR, CPR certification requirements and the proper way to determine the residents code status. On February 23, 2023 from 1600 until 1800 by the assistant DON and the infection control preventionist, the remaining nursing staff were called and in serviced by phone on the proper protocols to follow regarding the proper procedures in the event a resident went into cardiac arrest, the new policy and procedures regarding CPR and CPR certification as well as the proper way to determine a residents code status. A Policy regarding CPR was immediately put into place and approved by the medical director administrator and the DON. During the Survey Process we had practical nursing students in the facility doing clinicals and their instructor informed us that she was in fact certified as a CPR instructor and that she was willing to come in on February 24, 2023, to certify the remaining nurses on staff that were not CPR certified. Therefore, All Nurses employed with our facility were instructed to present to the facility on February 24, 2023, for CPR certification from 11 am to 2 pm. This will allow there to be a minimum of 2 Certified staff on shift at night and more than 5 certified staff on shift on days. We also scheduled all CNAs and CMAs to attend CPR training for those that just needed to renew their certification on Saturday and Sunday February 25th and 26th with classes being held from 8 am to 12 pm and 1 pm until 5 pm both days. And the following weekend from 8 am until 4 pm both with classes on both Saturday and Sunday for all staff that have not been certified previously. Another CPR certified employee was called into the facility to work tonight so that affective immediately there would not be any time that there is not several CPR certified staff on shift working ensuring that we had 24-hour coverage of staff that were CPR certified. These steps that were put into place will ensure that the 30 residents who currently reside in the facility that are full codes will be able to be provided care appropriately according to their wishes and code status ensuring that there will be staff always trained in CPR on shift. From this point forward and following the policy that the facility implemented all staff will be required to attend CPR certification with hands on training every 2 years and will be required to obtain or have their CPR certification prior to starting work or within 90 days from their hire date. The facility will comply and will have the immediacy of the deficiency of having numerous CPR certified staff on at all times twenty-four hours a day with all nurses CPR Certified and all remaining staff in-serviced, this correction will be completed by February 24, 2023, at 4pm. After completion of the correction of the immediate jeopardy, all CNAs and CMAs will attend CPR training in the weeks ahead to ensure that all nursing staff are certified. A CPR policy and Procedure was developed and implemented on February 23, 2023, and approved by the medical director, Administrator, and the DON. All staff were in-serviced and educated on the policies and protocols of the new policy by the administrator and the Director of Nurses. All staff verbalized understanding and importance of knowing the policy and procedure for the facility. All resident records also reviewed and updated with code status and if a DNR ensured a DNR was scanned into the medical record. The immediate Jeopardy will be corrected on February 24, 2023, by 4 pm. The IJ was lifted, effective [DATE] at 4:00 pm., when all the components of the plan of removal had been completed. The deficient practice remained at a pattern with potential for harm to Residents. Based on record review, observation, and interview, the facility failed to: a. ensure the availability of staff present 24 hours a day who had current certification in CPR for Healthcare Providers (training to include hands-on practice and in-person skills) and maintained their certifications to be able to provide CPR until emergency medical services arrived and b. have a CPR policy and ensure staff were familiar and trained in basic life support. The administrator identified 30 residents whose code status was full code. Findings: Upon entrance to the facility, on [DATE] at 10:30 a.m., no staff were present in the building who had certification in CPR for Healthcare Providers. On [DATE] at 10:45 a.m., the DON stated the facility did not have a policy related to CPR or CPR certification. She stated, No one is required to be CPR certified. On [DATE] at 4:25 p.m., LPN #1 stated her CPR certification had expired. She stated she was told by administration that she did not need to be certified. LPN #2 stated hers had also expired. LPN #1 and LPN #2 were the only nurses assigned to work the floor that shift. On [DATE] at 5:23 p.m., the IP/LPN stated she had completed her online training but still needed to find a trainer to do the hands on skills part. On [DATE] at 5:27 p.m., the administrator stated she had ACLS, BLS, and PALS certification which expires 11/2023. On [DATE], during record review, the IP/LPN provided the CPR for Health Care Providers certifications for the administrator/RN, LPN #3, and RN #1. She stated those were the only staff who were CPR certified. On [DATE] at 12:48 p.m., the DON and ADON were asked how the staff know the code status of a resident. The DON stated there was a list at the nurse station. She went and brought back the list of residents who had DNR status. She stated the list had not been updated. She stated it was dated back in 2021. The ADON stated she looked at the top right hand corner of the residents' EHR. During record review there were several residents' EHRs that did not have the code status at the top of their chart. The residents' code status was observed near the door of each resident. On [DATE] from 12:57 p.m. to 2:00 p.m., interviews where conducted with all staff on the halls. There were no staff who voiced they had CPR certification at this time except for two CNAs. The CNAs stated they thought their certification was still good but did not have their card with them. They said the facility had not asked them for their CPR certification card. [DATE] at 3:41 p.m., the administrator stated she did not realize CPR certification was a regulation. She stated the person who had been doing their CPR classes had stopped doing classes last year in June.

2. Res #24 had diagnoses which included after care following joint replacement surgery and arthritis in the left knee. A care plan, dated 07/06/22, documented Res #24 was at risk for falls. The care plan documented interventions of keep the call light within reach and encourage the resident to use it; promptly answer all requests for assistance; and educate the resident, family, and care givers about safety reminders and what to do if a fall occurs. The care plan also documented to transfer the resident to the emergency room for a CT scan of the head and left shoulder and an x-ray of the scapula. An incident report, dated 11/06/22, documented the resident fell in the bathroom after the resident's legs gave out. The report documented the resident had not been injured and did not document interventions to prevent recurrence. The care plan was not updated at that time. An incident report, dated 11/08/22, documented the resident fell in the bathroom when his legs gave out. The report documented the resident had a skin tear to the upper right arm measuring 7 x 5 cm, a skin tear to the left hand on the index and middle finger, and a skin tear to the upper back measuring 3 x 4 cm. The report did not document interventions to help prevent future falls and the care plan was not updated. A quarterly assessment, dated 12/03/22, documented the resident was moderately impaired in cognition, independent with bed mobility, walking, locomotion, and toilet use; and limited assistance with transfer, dressing, and hygiene. The assessment documented the resident had fallen with a minor injury. An incident report, dated 12/13/22, documented the resident fell in his room sustaining a skin tear to the right forearm measuring 6 cm and skin tears to three fingers on the left hand. The entry documented the resident could not focus for neuro checks and was sent to the emergency room. The report did not document interventions and the care plan was not updated. An An incident report, dated 01/10/23, documented the resident fell in his room, fractured his hip, and pulled off a toe nail. The report documented the resident was educated to use the call light and wait for assistance prior to getting up. No care plan updates were documented. A discharge with return anticipated assessment, dated 01/10/23, documented the resident had fallen with a minor injury and a fall with a major injury. A medicare 5 day PPS assessment, dated 01/22/23, documented the resident was moderately impaired in cognition and required limited to total assistance with ADLs. An incident report, dated 01/24/23, documented the resident fell in his room while attempting to transfer himself to his wheel chair. The entry documented the resident sustained an abrasion to the left knee. The report did not document any interventions to prevent falls and the care plan was not updated. On 02/28/23 at 9:50 a.m., the resident was observed in his bed sleeping. An unidentified hospice aide was present in the room and stated she had just finished with his cares and the resident was worn out. The call light was observed on the resident's abdomen, the wheel chair was placed at the foot of the bed, a recliner was next to the bed, and a walker was placed on the other side of the recliner. An over the bed table with a urinal placed on it was out of reach of the resident. On 02/28/23 at 9:52 a.m., CNA #1 reported the resident had broke his hip from falling. The CNA stated the resident did not have any interventions to prevent falls prior to the hip fracture. The CNA stated the previous night a bed alarm was put on the resident as he kept trying to get out of bed. The CNA stated they felt the resident needed a fall mat but had not been approved for one yet. On 02/28/23 at 9:56 a.m., the MDS coordinator reported she completed this resident's care plan. She reviewed the resident's falls in November and December of 2022, and January of 2023 and agreed no new interventions to prevent the reoccurrence of falls had been documented on the care plan for Res #24. 3. Res #34 had diagnoses which included dementia, long term use of anticoagulants/antiplatelet, and persistent mood disorder. A care plan, dated 12/21/21, documented the resident was at risk for falls. The care plan documented interventions of anticipate and meet the resident's needs; keep the call light in reach and encourage the resident to use it; encourage the resident to participate in activities which promoted exercise or physician activity for strengthening and improved mobility; and ensure the resident was wearing appropriate foot wear. An annual assessment, dated 07/06/22, documented Res #34 was severely impaired in cognitive skills for daily decision making and was independent with most ADLs but required limited assistance with dressing and extensive assistance with toilet use and personal hygiene. The assessment documented the resident had a fall with minor injury. The only update to the fall care plan was dated 07/22/22. It documented the resident preferred not to wear any type of foot wear including non skid socks or shoes. An incident report, dated 10/07/22, documented the resident had fallen in her room. The report documented as a CNA stood her up to assist her to change her clothing, the resident walked away and tripped over the leg of the bedside table sustaining a 2.5 x 1.5 cm skin tear to the right elbow. There were no documented interventions and the care plan was not updated. An incident report, dated 11/21/22, documented the resident was found uninjured and sitting on the floor in her room calling mama mama after rolling out of bed. The report documented the resident was educated on not lying on the edge of the bed to avoid falling out and the resident voiced understanding. The care plan was not updated. An incident report, dated 11/27/22, documented the resident was lying on her back on the floor. The report documented the resident had become tangled in her catheter tubing and fell. The report did not document any injuries. The report documented the catheter bag was changed to a leg bag. The care plan was not updated. An incident report, dated 12/13/22, documented the staff heard the resident calling out and found the resident on the floor with a 2.5 x 1.5 cm abrasion to the left knee. No interventions were documented and the care plan was not updated. An incident report, dated 12/24/22, documented the resident had been found in the floor with her clothing down around her thighs. The report documented the resident sustained a 1 cm skin tear below the left elbow. The report documented staff were educated to ensure no slip socks were on the resident. The care plan was not updated. An incident report, dated 01/08/23, documented the resident was found in the floor on her back with redness to both knees and the right shoulder. Interventions to help prevent recurrence were not documented and the care plan was not updated. An incident report, dated 01/08/23, documented the resident was found on the floor under her bed with no injuries. The report documented the resident was instructed to use the call light when she needed help. The care plan was not updated. An incident report, dated 01/13/23, documented the resident fell in her room onto a fall mat and was not injured. The report did not document interventions for falls and the care plan was not updated. A quarterly assessment, dated 01/23/23, documented Res #34 was severely impaired in cognitive skills for daily decision making and remained mostly independent with ADLs but required limited assistance with transfer, eating, and toileting; and extensive assistance with dressing. The assessment documented Res #34 had fallen two or more times resulting in injury except major injury. An incident report, dated 01/24/23, documented the resident fell half in and out of her room and received a 2 cm laceration above her right eye, a 2 x 1 cm skin tear to the right elbow, and a 17.5 x 2 cm skin tear from her right shoulder to her right elbow. The report documented the staff were educated on non slick socks and the care plan was not updated. On 02/23/23 at 11:54 a.m., the resident was observed in the dining room at the assistive feeding table. The staff member attending to the resident was observed to leave the dining room briefly and asked another staff member to keep an eye on her. During the time the attending staff member was gone, the resident attempted to rise from her seat several times and was observed to be very unsteady. The other staff member was observed to have the resident sit back down and reassure her. On 02/27/23, between 2:44 p.m. and 2:49 p.m., three CNA's were interviewed regarding fall interventions for Res #34. All three stated the only interventions they were aware of was the fall mat beside the bed and to use a gait belt when ambulating with the resident. On 02/28/23 at 9:15 a.m., the resident was observed to get out of bed, cross her fall mat, and enter the bathroom without staff assistance. A short time later, the resident was observed back in bed. On 02/28/23 at 9:57 a.m., the MDS coordinator stated the nursing staff were to put interventions in to prevent future falls when they completed the incident reports. She stated the DON and IP received the incident reports and then brought them to her to update the care plans. On 02/28/23, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; monitor and evaluate the effectiveness of the interventions; modify the care plan with each fall; conduct a root cause analyses for each fall; and communicate the interventions with all staff. Res #41 had 16 falls in four months with one fall resulting in a fractured hip. Res #41 had sustained a broken hip after six falls and only two falls had steps to prevent recurrence. Res #41 had nine falls after a hip fracture with only two of those falls having interventions to prevent recurrence. The last fall was 02/26/23. Res #24 had five falls in four months, with the forth fall resulting in a fractured hip. Res #34 had eight falls in the last four months with the last fall resulting in a 17 x 2 cm skin tear to arm. The facility failed to consistently put interventions in place to prevent falls for these residents. On 02/28/23 at 1:59 p.m., the Oklahoma State Department of Health verified the existence of the IJ situation. On 02/28/23 at 2:07 p.m., the administrator was notified of the IJ situation. On 02/28/23 at 3:58 p.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: February 28, 2023 On February 28, 2023, surveyors were here for annual survey and issued an IJ template regarding falls. The facility failed to ensure that residents who had fallen had fall interventions put into the resident ' s care plan to prevent the recurrence of falls. The facility failed to monitor the effectiveness of the interventions and modify the care plan with each fall. They also failed to conduct a root cause analyses for each fall and communicate the intervention with all staff. The residents affected were resident #41, 24, and 34, with the potential for all remaining residents to be at risk. The facility will correct this deficient practice by 02/28/2023 at 6 pm by in servicing all nursing staff, RNs, LPNs, CMAs, and CNAs regarding: · The facility falls prevention policy. · The facility Accident and Incident Policy · Newly implemented fall intervention book · The importance of reporting changes in resident conditions · The facility incident reporting system · How to review and update a care plan · Perform a new fall risk assessment for all residents in the facility. · Updating fall care plans for the 3 residents affected. The facility has implemented a system to consistently ensure interventions are put into place following resident falls. A root cause analyses will be performed on all 3 residents affected. From this day forth the administrator and the Director of Nurses and Compliance Officer will review all incident/accident reports daily to ensure completion with a root cause analysis established. The facility will ensure that all risk management reports have appropriate interventions added after every fall, updating care plans and fall risk assessments when needed if a resident has a fall. This monitoring will be continuous without a stop date. The IJ was lifted, effective 02/28/23 at 6:00 pm., when all the components of the plan of removal had been completed. The deficient practice remained at a pattern with for actual harm to the residents. Based on record review, observation, and interview, the facility failed to: a. ensure residents who had fallen had interventions put in place to prevent the recurrence of falls; b. monitor and evaluate the effectiveness of the interventions; c. modify the care plan with each fall; d. conduct a root cause analyses for each fall; and e. communicate the interventions with all staff for three (#41, 24, and #34) of three sampled residents reviewed for falls. The IP/LPN identified 21 residents who had fallen in the last four months. Findings: 1. Res #41 had diagnoses which included unspecified injury of left hip, Parkinson's disease, dementia, anxiety disorder due to known physiological condition, and pain. An annual MDS assessment, dated 10/25/22, documented the resident's cognition was severely impaired; was independent with bed mobility, transfers, walking, dressing, and toileting; and required limited assistance with hygiene and bathing. The assessment documented the resident's balance was not steady but was able to stabilize without staff assistance. The assessment documented the resident had no impairment in ROM; used a walker and a wheelchair; was always continent of urine and bowel; did not have pain; and had one fall with no injury. The care plan interventions, dated 11/02/21, documented the following: a. Be sure resident's call light is within reach and encourage the resident to use it for assistance as needed. b. The resident needs prompt response to all requests for assistance. c. The resident needs a safe environment with floors free from spills and/or clutter; adequate, glare-free light; the bed in low position at night; side rails as ordered, handrails on walls, and personal items within reach. d. Ensure that the resident was wearing appropriate footwear, non-skid socks when ambulating or mobilizing in w/c. A facility incident report, dated 11/21/22 at 3:30 p.m., documented the resident was on his knees in the shower room and wheelchair was not in sight. The resident stated he wanted to use the toilet. The report documented no injuries and the intervention was for the resident to be educated to use wheelchair or when walking to use his walker during ambulation. A facility incident report, dated 11/22/22 at 10:08 p.m., documented the resident was lying on the floor beside his bed. The report documented no injuries and no interventions to prevent recurrence. A facility incident report, dated 12/05/22 at 7:50 a.m., documented the resident was sitting on floor near toilet in the common bathroom. The report documented the resident said his knees gave out when using wheeled walker. The report documented no injuries and no updated interventions. A facility incident report, dated 01/02/23 at 5:05 a.m., documented the resident was sitting on the floor near the foot of his bed. The resident stated he missed a step while walking to the bathroom. The report documented no injuries and no interventions to prevent recurrence. The resident's medical record documented the resident received Part B therapy from 01/06/23 to 01/20/23. A facility incident report, dated 01/18/23 at 12:40 a.m., documented the resident was lying on the floor in his room and the resident said he must have fallen. The report documented no injuries and no interventions to prevent recurrence. A facility incident report, dated 01/21/23 at 9:30 a.m., documented the resident was sitting in his wheelchair in the dayroom; was observed attempting to stand and walk to a recliner; and leaned forward and went to his knees. The report documented no injuries and no updated interventions. A facility incident report, dated 01/23/23 at 11:44 a.m., documented the resident was observed standing up from his w/c while in the dining room, fell backward to floor onto his left side, was sent to the hospital, and sustained a left trochanter hip fracture. The report did not documented any interventions to prevent recurrence. A discharge with return anticipated MDS assessment, dated 01/23/23, documented the resident had two or more falls with no injury and one fall with major injury. The resident's medical record documented the resident received Part A therapy from 01/27/23 to the present time. A facility incident report, dated 01/31/23 at 9:00 p.m., documented the resident was on his knees beside his bed, with no injury, and no interventions to prevent recurrence. A facility incident report, dated 02/02/23 at 4:32 a.m., documented the resident was on his knees on the fall mat, alarm in place but did not go off, and the resident had only been in bed for 10 minutes when found. The report documented no injuries and no steps to prevent recurrence. A facility incident report, dated 02/04/23 at 3:30 p.m., documented the resident was lying on his left side on the fall mat, said he rolled off the bed, with no injuries, and no interventions to prevent recurrence. The care plan intervention, dated 02/06/23, documented the resident needed to use a personal alarm on his bed and chair for personal safety precautions. A quarterly MDS assessment, dated 02/06/23, documented the resident's cognition was severely impaired; had no rejection of care behaviors; required the extensive assistance of two people with bed mobility, transfers, dressing, toileting, and bathing; did not walk; required extensive assistance of one person with mobility in a wheelchair and hygiene; and the assistance of one person with eating. The assessment documented the resident's balance was not steady and required staff assistance to stabilize; had impaired ROM on one lower extremity; was frequently incontinent of urine and bowel; had pain and received PRN pain medication; and had one fall with no injury and one fall with minor injury. A facility incident report, dated 02/07/23 at 6:01 a.m., documented the resident yelled for help, was on his left side next to bed on the mat, and stated his left hip hurt. The report documented the resident's alarm string was attached to the resident but not to the alarm box. The report documented the intervention was to wrap the call light in bright pink tape. The care plan intervention, dated 02/07/23, documented the resident had a current left hip fracture which required surgery and currently attended therapy. A facility incident report, dated 02/10/23 at 6:28 p.m., documented the resident was on knees beside his bed, removed the alarm before getting out of bed, and no injury. The report documented the intervention was to place the body alarm in a place on his clothing where he could not reach and place the resident on one on one. There was no documentation of one on one supervision. The next three facility incident reports, dated 02/12/23, 02/14/23, and 02/22/23, documented the resident was on his knees on the fall mat beside his bed, stated he rolled out of bed with no injuries, and no interventions to prevent recurrence. On 02/24/23 at 3:54 p.m., the resident was observed sitting in a recliner in lobby with feet elevated and grip socks on. The resident stated he had not fell, had not broken anything, was not in therapy, and had no pain. A facility incident report, dated 02/26/23 at 11:30 p.m., documented the nurse was answering the resident's call light and upon entering the room, the resident was sitting on his buttocks with arm upon the recliner and knees up by his chest. The report documented the resident stated he was trying to go to the bathroom and when he stood up he fell and hit his head. The report did not document updated interventions to prevent recurrence. On 02/27/23 at 2:54 pm, an observation was made of the resident's room. The resident was not in his room. The resident's twin bed was in low position with a mat on the floor at bedside. There was a bubbled air mattress overlay on top of the flat mattress. The edges of the overlay tapered off to the edge of the mattress. On 02/27/23 at 2:56 p.m., CNA #3 was asked what interventions she used to keep res from falling. She stated she took the resident to the bathroom every hour. She was asked if that intervention was communicated to her from another staff member. She stated, ''No, It was just something that she did. On 02/27/23 at 4:11 p.m., the DON was asked what the facility was doing to help prevent falls for the resident. She stated the resident was told to use his call light and we try to keep an eye on him. She stated, There is not a lot we can do. She stated it was the nurse's responsibility to came up with an intervention for a fall. She stated the nurse should document the interventions on the incident reports. She was asked about the process of the interventions getting on the care plans. She stated she was not sure and should ask the MDS coordinator for that answer. On 02/27/23 at 4:19 p.m., the MDS coordinator stated the nurses documented the interventions on the incident reports. She stated all falls should have an intervention to help prevent another fall. She stated the nurse also documents the interventions in the residents' progress notes. The MDS coordinator stated the IP/LPN goes through the nurse notes and up- dates the care plans with the interventions. On 02/28/23 at 10:38 a.m., the IP/LPN stated she had recently started to update the plans. She stated they should have an intervention for each fall. She stated if an intervention was documented in the nurse notes, then she added it to the care plan. She said it was the nurse on duty responsibility, when the resident fell, to come up with an intervention. She stated an inservice was conducted in January over falls. She stated a root cause analysis was not being conducted. On 02/28/23 at 11:32 a.m., the administrator stated she did not realize there had not been interventions for most of the falls. She stated the resident was on Part B therapy before he broke his hip and Part A after the hip fracture. She said they had removed his w/c and walker so he would not to get to them without help. She said they had done one on one with him and kept the alarm out of his reach. She stated the nurses were supposed to add an intervention with each fall. The administrator stated they had went over interventions for falls at a recent in-service. She stated the facility had not been doing a root cause analysis.