**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to develop and implement a baseline care plan to address resident safety needs for 7 (#11, #25, #60, #66, #69, #75, and #276) of 24 residents who were identified on admission to be at risk for falls. The facility's noncompliance placed Resident #276 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) when the resident sustained a femur fracture as the result of a fall and also had the potential to place Residents #11, #25, #60, #66, #69, and #75 in Immediate Jeopardy. The Administrator was informed of the Immediate Jeopardy (IJ) on 11/18/19 at 1:20 PM in her office. F-655, and F-689 were cited at a scope and severity of J. An extended survey was conducted from 11/18/19 to 11/19/19. The Immediate Jeopardy was effective from 9/23/19 through 11/18/19. A Removal Plan which removed the immediacy of the jeopardy was received on 11/19/19 at 9:00 PM and corrective actions were validated on site by the surveyors on 11/19/19. The facility's noncompliance at F-655 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The findings include: Facility policy review, Baseline Care Plan, dated 11/2017, revealed .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident .Be developed within 48 hours of a resident's admission .Interventions shall be initiated that address the resident's current needs including: safety concerns to prevent decline or injury, such as .fall . Medical record review revealed Resident #276 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Repeated Falls, Fracture of Right Femur, Difficulty Walking and Aftercare Following Joint Replacement Surgery. Further review revealed the resident was readmitted on [DATE] with a new diagnosis of Fracture of Left Femur. Medical record review of the 5-day Minimum Data Set, dated [DATE] revealed Resident #276 had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with bed mobility, transfer, dressing, toileting, personal hygiene and total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance; moving from seated to stand position, moving on and off toilet and surface to surface transfer. Further review revealed Resident #276 had a fall prior to admission with a fracture of the right femur . Medical record review of Resident #276's Fall Risk Assessment, dated 9/10/19 revealed .Multiple falls in past 90 days .oriented to person only .Alzheimer's or other dementia .Total Score:12-Moderate risk for falls . Medical record review revealed a baseline care plan was not developed or implemented within 48 hours of admission for Resident #276. Further review revealed a fall care plan was not developed until after Resident #276 had fallen on 9/24/19 and sustained a fractured left femur. The Comprehensive Care Plan was developed at the same time. Review of Resident #276's fall investigation dated 9/24/19 revealed .fall unwitnessed .resident was walking to the restroom unassisted with oxygen tubing on .resident found sitting upright in front of restroom floor . Continued review of the investigation revealed the resident stated she got out of bed and was walking to the bathroom but forgot her nasal cannula was still on causing her to fall. Review of the Emergency Department record dated 9/24/19 revealed .She accidentally choked herself with her nasal cannula and fell on left side. Review of a Nurse's Note dated 9/24/19 at 10:07 AM revealed, .Left hip is positive for fracture. NP [Nurse Practitioner] notified .Order received to send to ER [Emergency Room], POA [Power of Attorney] notified . Medical record review of a Physician's Order dated 9/24/19 at 10:16 AM revealed .Send to ER for left hip fracture . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Altered Mental Status, Repeated Falls, Muscle Weakness and Difficulty in Walking. Medical record review of Resident #11's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review revealed no baseline care plan was developed for Resident #11 within 48 hours of admission to address immediate safety needs. Medical Record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses which included Cognitive Communication Deficit, Repeated Falls and Altered Mental Status. Medical record review of Resident #25's Fall Risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Medical record review revealed no baseline care plan was developed for Resident #25 within 48 hours of admission to address immediate safety needs. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Dementia Without Behavioral Disturbance and Alzheimer's Disease. Medical record review of Resident #60's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review revealed no baseline care plan was developed for Resident #60 within 48 hours of admission to address immediate safety needs. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses which included Rheumatoid Arthritis, Muscle Weakness, Pain, Morbid Obesity and Cerebral Infarction. Medical record review of Resident #66's Fall Risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Medical record review revealed no baseline care plan was developed for Resident #66 within 48 hours of admission to address his immediate safety needs. Medical record review revealed Resident #69 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Muscle Weakness, Pressure Ulcer of Right Heel and Difficulty in Walking. Medical record review of Resident #69's Fall Risk assessment dated [DATE] revealed the resident was at high risk for falls. Medical record review revealed no baseline care plan was developed for Resident #69 within 48 hours of admission to address his immediate safety needs. Medical record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses which included Lateral Subluxation of Left Patella, Muscle Weakness, Difficulty in Walking and Pain. Medical record review of Resident #75's Fall Risk assessment dated [DATE] revealed the resident was at moderate risk for falls. Medical record review revealed no baseline care plan was developed for Resident #75 within 48 hours of admission to address his immediate safety needs. Interview with the Administrator and the Interim Director of Nursing in the fine dining room on 11/19/19 at 7:05 PM confirmed Resident #'s 11, #25, #60, #66, #69, #75 and #276 did not have a baseline care plan. Continued interview confirmed all residents were to have a baseline care plan in place within 48 hours of admission. Further interview confirmed if a baseline care plan had been completed for Resident #276 monitoring and better interventions would have been implemented to prevent the fall. The surveyors verified the Removal Plan by: 1. The surveyors reviewed and verified Resident #276's updated care plan for the development and revision to provide adequate supervision and interventions to prevent accidents and injuries. 2. The surveyors reviewed and verified the facility's 100% audit of residents' care plans to ensure interventions for adequate supervision and interventions to prevent accidents and injuries were implemented. The surveyors reviewed the facility's 100% audit of resident current fall risk assessments. 3. The surveyors reviewed and verified the education and training on facility policy and procedure to develop a baseline care plan for the Interim Director of Nursing, the Assistant Director of Nursing, Staffing Coordinator, Minimum Data Set Coordinator and Medical Records Personnel. The surveyors reviewed and verified the facility's staff education for developing baseline care plans. The licensed staff was educated on 11/19/19 on baseline care plans and the CNAs were educated on 11/19/19 on communicating resident needs. New orientees will be educated on baseline and comprehensive care plans during orientation. The surveyors validated the facility's resource materials for determination of root cause analysis for falls/accidents and fall intervention tips were placed at each nurses' station. 4. The surveyors verified the facility's QAPI meeting held on 11/19/19 to discuss the Corrective Action Plan for the deficiencies and the Medical Director was in agreement with the plan. The audits on admission/readmission care plans and falls for implementation of a baseline and/or comprehensive care plan to include supervision and interventions to prevent accidents and injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation and interviews, the facility failed to provide adequate supervision to prevent falls for 2 (#276, #39) of 24 residents who were assessed at risk for falls. The facility's noncompliance placed Resident #276 and #39 in Immediate Jeopardy (IJ) When Resident #276 sustained a femur fracture from a fall and resident #39 sustained skin tears to her head and forearm from a fall. The Administrator was informed of the Immediate Jeopardy (IJ) on 11/18/19 at 1:20 PM in her office. F-655, and F-689 were cited at a scope and severity of J. The facility was cited F-689 J which was Substandard Quality of Care. An extended survey was conducted from 11/18/19 to 11/19/19. The Immediate Jeopardy was effective from 9/23/19 through 11/18/19. A Removal Plan which removed the immediacy of the jeopardy was received on 11/19/19 at 9:00 PM and corrective actions were validated on site by the surveyors on 11/19/19. The facility's noncompliance at F-689 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction. The findings include: Facility policy review, Accidents and Supervision, dated 11/2017, revealed .The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: Identification of Hazards and Risk .All staff are to be involved in observing and identifying potential hazards in environment .Implementing interventions to reduce hazard(s) and risk(s) .as part of the plan of care .Monitoring is the process of evaluating the effectiveness of the care plan interventions . Medical record review revealed Resident #276 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Repeated Falls, Fracture of the Right Femur, Difficulty Walking, and Aftercare Following Joint Replacement Surgery. Further review revealed the resident was readmitted on [DATE] with a new diagnoses of Fracture of the Left Femur. Medical record review of the 5-day MDS dated [DATE] revealed Resident #276 had a BIMS score of 3, indicating severe cognitive impairment; required extensive assistance with bed mobility, transfer, dressing, toileting and personal hygiene and total dependence for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance; moving from seated to standing position, moving on and off toilet and surface to surface transfer. Further review revealed Resident #276 had a fall with a right femur fracture prior to admission. Medical record review of Resident #276's Fall Risk assessment dated [DATE] revealed .Multiple falls in past 90 days .oriented to person only .Alzheimer's or other dementia .Total Score:12-Moderate risk for falls . Medical record review revealed Resident #276 did not have a baseline care plan. Further review revealed a fall care plan with interventions was not initiated until after the resident sustained a fall resulting in a Left hip fracture on 9/24/19. Medical record review of Resident #276's Nurse's Note dated 9/24/19 at 6:59 AM revealed .summoned to resident room by loud noise and residents yell at 0300 [3:00 AM] .[Named Resident] was found sitting upright in front of the bathroom door . Medical record review of the Interdisciplinary Team Occurrence Investigation Worksheet for Resident #276, dated 9/24/19 revealed .c/o [complained of] leg pain . Further review revealed the MD [Medical Doctor] was notified of the incident. Review of Resident #276's fall investigation dated 9/24/19 revealed .fall unwitnessed .resident was walking to the restroom unassisted with oxygen tubing on .resident found sitting upright in front of restroom floor . Continued review of the investigation revealed the resident stated she got out of bed and was walking to the bathroom but forgot her nasal cannula was still on causing her to fall. Review of the Emergency Department record dated 9/24/19 revealed .She accidentally choked herself with her nasal cannula and fell on left side. Review of Resident #276's medical record revealed her care plan was not developed until 9/24/19, after the fall had occured. Further review revealed intervention added on 9/24/19 to .Change 02 tubing [oxygen tubing] to shorter tubing . Medical record review of Resident #276's Physician's Order dated 9/24/19 at 7:03 AM revealed, .BIL [bilateral] Hip x-ray . Review of Resident #276's Nurse's Note dated 9/24/19 at 10:07 AM revealed, .Left hip is positive for fracture. NP [Nurse Practitioner] notified .Order received to send to ER [Emergency Room], POA [Power of Attorney] notified . Medical record review of Resident #276's Radiology Report dated 9/24/19 at 10:45 AM revealed, .left sub capital femoral neck fracture with mild impaction .Left hip fracture . Telephone interview with CNA #3 on 11/19/19 at 10:05 AM revealed, We were told to keep an eye on her because she was a high fall risk. Medical record review revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which included Repeated Falls, Psychotic Disorder with Delusions, Anxiety, Difficulty in Walking and Muscle Weakness. Medical record review of Resident #39's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 staff for transfers and toileting. Medical record review of Resident #39's Fall Risk Assessments dated 1/14/19, 1/17/19, 2/3/19, 2/12/19, 2/24/19, 4/15/19, 6/4/19 and 8/10/19 revealed the resident was a moderate fall risk. Medical record review of Resident #39's Nurse's Event Note dated 9/23/19 revealed .Resident was in bathroom sitting on toilet. Tech [Certified Nurse Aid (CNA)] left room for a brief moment and resident got up and attempted to pull pants up and walk to w/c [wheelchair]. Was observed on floor with ST [skin tear] to R [right] eyebrow and a small ST to L [left] forearm by elbow. Instructed tech about not leaving residents who are fall risk alone in bathroom . Telephone interview with CNA #4 on 11/19/19 at 11:47 AM revealed she assisted Resident #39 to the bathroom on 9/23/19. She stated, I sat her on the toilet and walked out of the room to the hallway to the Kiosk [computer where staff charts]. I heard her fall and went back into the room and she was lying on the floor by the bathroom door. I stepped outside the room to get assistance. The nurse came to her room to assess her, we got her clothes on her and she had a 'gash' on her head. I was told by the nurse after the fall that [Named Resident #39] was a fall risk and I was to never leave her by herself. Telephone interview with the Licensed Practical Nurse (LPN) #2 on 11/19/19 at 12:18 PM confirmed CNA #4 left Resident #39 alone in the bathroom on 9/23/19 and the resident had a fall resulting in skin tears to her right eyebrow and left forearm. Interview with Administrator and Interim Director of Nursing in the fine dining room on 11/19/19 at 7:05 PM confirmed we should never leave any resident who needs assistance in the bathroom by themselves. Continued interview confirmed leaving her [Resident #39] in the bathroom alone resulted in an injury. Further interview confirmed if a baseline care plan had been completed for Resident #276 monitoring and better interventions would have been implemented to prevent the fall. The surveyors verified the Removal Plan by: 1. The surveyors reviewed and verified Resident #39's and Resident #276's updated care plan for the development and revision to provide adequate supervision and interventions to prevent accidents and injuries. 2. The surveyors reviewed and verified the facility's 100% audit of resident's care plans to ensure interventions for adequate supervision and interventions to prevent accidents and injuries were implemented. The surveyors reviewed the facility's 100% audit of resident current fall risk assessments. 3. The surveyors reviewed and verified the education and training for the Interim Director of Nursing, the Assistant Director of Nursing, Staffing Coordinator, Minimum Data Set Coordinator and Medical Records Personnel. The surveyors reviewed and verified the facility's staff education for developing and implementing baseline care plans. The surveyors validated the facility's resource materials for determination of root cause analysis for falls/accidents and fall intervention tips were placed at each nurse's station. The surveyors reviewed and verified all on duty licensed nurses education on developing baseline and/or comprehensive care plans. The surveyors verified the facility's QAPI meeting held on 11/19/19.