**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of facility documentation, observation, and interview, the facility failed to revise 7 residents' (#119, #28, #34, #39, #40, #47, and #80) care plans after falls with effective interventions to prevent further falls of 52 sampled residents, placing residents #119, #28, #34, #39, #40, #47, and #80 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). The facility's failure is likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17, and is ongoing. The findings include: Review of the facility policy Care Planning-Interdisciplinary Team dated 1/1/17 revealed .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .which includes, but is not limited to the following personnel: a. The resident's Attending Physician; b. The Registered Nurse who has responsibility for the resident; c. The Dietary Manager/Dietician; d. The Social Services Worker responsible for the resident; e. The Activity Coordinator; f. Therapists (speech, occupational, recreational, etc.), as applicable; g. Consultants (as appropriate); h. The Director of Nursing (as applicable); i. The Charge Nurse responsible for resident care; j. Nursing Assistants responsible for the resident's care; and k. Others as appropriate or necessary to meet the needs of the resident .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan .The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan .is at the discretion of the Care Planning Committee . Medical record review revealed Resident #119 was admitted to the facility on [DATE] with diagnoses including History of Falling, Dementia, Anxiety, Muscle Weakness, Abnormalities of Gait and Mobility, and Lack of Coordination. Medical record review of Resident #119's ongoing care plan revealed the resident was at risk for falls and interventions implemented included on 12/24/15: non-slick footwear that fits and assist with transfers as needed; instruct on safety measures to reduce the risk of falls (posture, changing positions, use of handrails); keep areas free of obstructions; keep personal items within easy reach; bed to be in lowest position with wheels locked; call light within reach when in room; invite/escort to activities of choice; instruct/remind to call for assist with mobility/transfers; use of proper assistive device wheelchair/walker. On 1/8/16 a sensor alarm in chair was added; on 2/5/16 a bed sensor was added; on 4/15/16 floor mat due to resident transfers self to from wheel chair was added; on 5/9/16 posey grip in wheelchair due to increased falls was added; 10/14/16 toileting as needed and Call Before You Fall signs was added; and on 5/30/17 anti-tip bars and anti-lock brakes to wheelchair was added. Medical record review revealed Resident #119 had 9 falls from 7/1/17 - 7/10/18 with dates of falls 7/1/17, 8/20/17 (resulting in a laceration to the forehead requiring sutures), 10/15/17, 11/10/17 (resulting in a bone fracture of the lower leg), 11/16/17, 11/19/17, 4/13/18 (resulting in a femur fracture), 6/27/18, and 7/10/18. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #119 required extensive assistance with bed mobility, transfers, dressing, personal hygiene, and was dependent for toileting. Continued review revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Medical record review of the Care Plan dated 12/24/15 and revised 7/10/18 revealed the care plan was not revised with the interventions indicated by falls investigations including to toilet every 2 hours (10/15/17 fall), toilet more frequently and utilize bean bag (11/16/17 fall), and for Velcro noodles to mattress rail (7/10/18 fall). Interview with Nurse Mentor (nurse Unit Manager) #1 on 8/18/18 at 9:25 AM in the Mentor's office, confirmed .All of us are responsible to make sure the intervention is to be implemented [revised] on the care plan .Ultimately the mentor is responsible . Interview with the Director of Nursing (DON) on 8/18/18 at 10:36 AM in the conference room, confirmed the care plan had not been revised to include new interventions for toileting interventions (10/15/17 fall and 11/16/17 fall) and Velcro noodles to the mattress (7/10/18 fall) . Medical record review revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Dementia, Heart Disease, Previous Myocardial Infarction, Osteoporosis, Anemia, and Osteoarthritis. Medical record review of the quarterly MDS dated [DATE] revealed Resident #28 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #28's current care plan, not dated revealed, [Resident #28] is at risk for falls d/t [due to]: Decreased mobility, LT [left] hip fracture s/p [status post] ORIF [Open Reduction Internal Fixation], dementia . Actual Falls: 5/19/17, 6/17/17, 2/15/18 with FX [fracture] L [left] distal femur (resolve) Interventions: Assist [Resident #28] to wear non-slick footwear that fits. Attempt to engage [Resident #28] in ADL's [Activities of Daily Living] that improve strength, balance and posture. Instruct [Resident #28] on safety measures to reduce the risk of falls (posture, changing positions, use of handrails.) Keep areas free of obstructions to reduce the risk of falls or injury. Keep nurse call light within reach, Instruct [Resident #28] to use call bell or call out of assistance. Keep personal items within easy reach; bed to be in lowest position with wheels locked. Review of an Incident/Accident Report revealed Resident #28 had a fall on 2/15/18 at 9:45 AM, in the resident's room with injury. Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: Ensure w/c [wheelchair] is within reach while in bed . Medical record review revealed the resident's care plan was not revised to include the intervention to keep the wheelchair within reach while the resident was in bed. Review of an Incident/Accident Report revealed Resident#28 had a fall on 6/7/18 at 2:00 PM in the dining room, CNA [Certified Nurse's Assistant] observed res. [resident] topple forward from her w/c to the floor. Res. remained alert. Skin tear noted to left forearm. Res. did hit her head on right forehead. No bruising @[at] this time . Additional comments and/or steps taken to prevent recurrence: Res. cautioned re: leaning forward in w/c . Medical record review of the resident's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 6/7/18. Interview with Licensed Practical Nurse (LPN) #4 on 8/17/18 at 4:36 PM, in the secure unit, revealed the Household Nurse Mentor for each unit was responsible for updating a resident's care plan after a fall. Interview with Household Nurse Mentor #1 on 8/17/18 at 5:05 PM, in the secure unit nurse's office, revealed the Mentor was responsible for updating Resident #28's care plan with new fall interventions. Continued interview and review of the resident's care plan with the Nurse Mentor confirmed the resident's care plan had not been revised after the resident's fall on 2/15/18 to keep the resident's wheelchair within reach, and confirmed the facility failed to update the resident's care plan after the resident's fall on 6/7/18. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder, Presence of Left Artificial Hip, Lumbago with Sciatica, Scoliosis, and Chronic Kidney Disease. Medical record review of the quarterly MDS dated [DATE] revealed Resident #34 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #34's current care plan, not dated, revealed, [Resident #34] is at risk for falls related to Decreased Mobility, Scoliosis, Narcotic and Psychotropic Medication Use . Continued review revealed the following interventions: .Assist with toileting as needed. Attempt to engage [Resident #34] in ADL's that improve strength, balance and posture. Fall risk assessment as indicated. Keep call light within reach and remind how to use as needed. Keep room free from clutter, walkways clear. Keep frequently used items within reach. Monitor medications for changes that may effect falls. Footwear will fit properly and have non-skid soles. Instruct [Resident #34 on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .Goals: Resident #34 will have no falls this review period . Review of an Incident/Accident Report revealed Resident #34 had a fall on 2/25/18 at 4:30 AM in the resident's room .Heard someone crying and found pt [patient] on the floor in her room. She states she was going to BR [bathroom] and fell. C/O [complain of] lt [left] hip pain. Skin tear to Lt elbow . Continued review revealed, Additional comments and/or steps taken to prevent recurrence: Call before you fall posted . Medical record review of the resident's care plan revealed Resident #34's care plan was not revised to reflect the resident's fall on 2/25/18 or the new intervention to post the call before you fall sign. Review of an Incident/Accident Report revealed the resident had a fall on 6/16/18 at 9:55 PM in the resident's room .I was told by CNA [Certified Nurse Assistant] that resident was on the floor in her room, went to assess resident, she had skin tear to lt. hand, bump on left side of head and was c/o lt hip pain . Further review revealed, .Additional comments and/or steps taken to prevent recurrence .Call before you fall, posey grip [rubberized mat for resident to sit on while in wheelchair to prevent sliding from chair] . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall the resident had on 6/16/18 or the new intervention to add the posey grip to the wheelchair. Review of an Incident/Accident Report revealed the resident had a fall on 7/14/18 at 7:05 PM in the resident's room .Resident's roommate was calling for help [staff] and I went to the room and resident was on the floor in front of the sink and blood was pooled around her head . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: Call before you fall. Encourage out of room more . Medical record review of Resident #34's care plan revealed the care plan was not revised to reflect the fall on 7/14/18 or the intervention to .encourage out of room more . Interview and review of the resident's care plan on 8/18/18 at 12:08 PM with the DON, in the conference room, revealed the Household Nurse Mentors on the units were responsible for ensuring revisions to the care plan were completed after a fall. Continued interview confirmed Resident #34's care plan had not been revised to reflect any of the resident's falls, and did not accurately reflect the fall interventions. Medical record review revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction with Hemiplegia and Hemiparesis Left side, Contracture of Lower Extremity, Atrial Fibrillation, Dementia, and Pressure Ulcer. Medical record review of the quarterly MDS dated [DATE] revealed Resident #39 required extensive assistance with bed mobility and 1 person assistance for transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 7, indicating severe cognitive impairment. Medical record review of Resident #39's care plan with a goal date of 6/10/18, revealed the resident was .at risk of falls d/t [due to] weakness, Left sided weakness s/p [status post] CVA [Cerebrovascular Accident], Dementia . Review of the facility documentation revealed the resident had a total of 9 falls between 4/3/18 and 8/11/18. Medical record review revealed Resident #39's care plan was updated to reflect 5 dates the resident had falls: 4/3/18, 4/15/18, 6/7/18, 6/27/18 (fall was actually 6/26/18 according to Icident/Accident Report) and 6/30/18. Continued review revealed the only times the resident's care plan was revised to reflect a new intervention after a fall were 6/7/17 - Call before you fall sign; 6/27/18 (for the 6/26/18 fall) - Pool noodles to bed; 6/30/18 - Frequent rounds; and 7/2/18 - Scoop mattress ordered. Interview with Household Nurse Mentor #2 on 8/15/18 at 7:40 AM, on the 400 unit confirmed the resident's care plan was not revised to reflect new or effective interventions to address Resident #39's continued falls. Interview with the DON on 8/16/18 at 9:30 AM, in the conference room confirmed the facility failed to revise the resident's care plan and failed to implement new or effective interventions to address the resident's continued falls. In summary, Resident #39 had 9 falls between 4/3/18-8/11/18. Interventions on the falls investigation were not consistently placed on the care plan. There were 6 falls with no intervention added to the care plan. Medical record review revealed Resident #40 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Kidney Disease, Hypertension and a History of Falls. Medical record review of the admission MDS dated [DATE] revealed Resident #40 required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #40's care plan dated 5/23/18, revealed Resident #40 is at risk of falls due to weakness, History of Falls, Dementia and Hypertension. Interventions including wear non-slick footwear that fits; instruct the resident on safety measures to reduce risk of falls; attempt to engage in activities of daily living (ADL's) that improve strength; balance and posture, and keep areas free of obstacles to reduce the risk of falls or injury Medical record review of facility documentation revealed the resident had a total of 4 falls between 6/27/18 and 8/2/18. Medical record review of Resident #40's care plan dated 8/6/18 revealed the care plan was not updated to reflect the resident had falls on the following dates: 6/27/18, 7/16/18, 7/30/18 and 8/2/18. Continued review revealed the resident's care plan was not revised to reflect new or effective interventions to address the resident's continued falls resulting in the resident sustaining a head injury. Observation and interview with LPN Nurse Mentor #2 on 8/17/18 at 10:00 AM, in the resident's room, confirmed the resident was in bed with the head of the bed up, fall mats to both sides of the bed were without alarms, and the call light was out of reach of the resident. Further observation revealed the Nurse Mentor took the Call Before You Fall sign off the closet door and asked the resident to read the sign. Continued observation revealed Resident #40 held the sign in her hand, smiled, and stated nice. The resident was not able to read the Call Before You Fall sign. Further interview confirmed .She doesn't use the call bell, she hollers for us . Continued interview confirmed the Call Before You Fall sign was not an appropriate intervention for Resident #40 and re-education on the use of a call light for a severely cognitively impaired resident was not an appropriate fall prevention intervention. Interview with the DON on 8/20/18 at 11:15 AM, in the conference room confirmed the resident had multiple falls without appropriate interventions put in place. In summary, Resident #40 had 4 falls between 6/27/18 and 8/2/18. Interventions on the falls investigation were not placed on the care plan. There were no new interventions added to the care plan after each fall. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Dementia, Cerebral Vascular Accident, Schizoaffective Disorder, and Bipolar Disorder. Medical record review of the admission MDS dated [DATE] revealed Resident #47 required extensive assistance of I person with bed mobility, transfers, dressing, toileting and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of Resident #47's comprehensive care plan with an effective date of 4/5/18 revealed, .at risk for falls d/t weakness, RT [related to] acetabular fracture [a break in the socket portion of the hip joint] s/p [status/post] fall, vision impairment, encephalopathy, dementia, anxiety, schizoaffective disorder, myasthenia gravis and psychotropic med use . Continued review of the care plan revealed, .Actual falls 4/9/18, 4/10/18, 4/11/18, 4/14/18, 4/23/18, 4/25/18, 4/26/18, 4/27/18, 5/6/18 .Goals .will maintain current level of mobility with no increase in the incidence of falls/injuries .Interventions .Assist .to wear non-slick footwear that fits .attempt to engage .in ADLs that improve strength, balance, and posture .instruct .on safety measures to reduce the risk of falls (posture, changing positions, use of handrails) .keep areas free of obstructions to reduce the risk of falls or injury .keep nurse call light within easy reach .Instruct .to use call bell or call out for assistance .keep personal items within easy reach; bed to be in lowest position with wheels locked .bean bag provided to reduce the risk of falls .self-releasing lap buddy to reduce the risk for falls with injury . Continued review revealed none of the interventions documented on the care plan had been dated to illustrate when the interventions were initiated and implemented. Review of an Incident/Accident Report dated 4/5/18 and timed 7:30 PM revealed Resident #47 .crawled from his room into [another room]. Multiple skin tears on bilateral elbows and L [left] knee bruise . Continued review revealed .Additional comments and/or steps taken to prevent recurrence: call before you fall, bed in low position Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the resident's fall on 4/5/18 or the intervention to post call before you fall sign. Review of an Incident/Accident Report dated 4/9/18 and timed 10:30 PM revealed the resident had a fall in the resident's room without injury .called to resident room. CNA report that resident had been on floor mat by bed on knees . Further review revealed, .Additional comments and/or steps taken to prevent recurrence: call before you fall, increased rounds . Medical record review of Resident #47's care plan revealed the resident's care plan was not revised to reflect the new intervention of increased rounds. Review of an Incident/Accident Report dated 4/11/18 and timed 2:45 PM revealed, .sitting in wheelchair in day room with spouse. Leaned forward and slid out of chair. Landed on buttock . Continued review revealed, .Additional comments and/or steps to prevent recurrence: Informed spouse of need for full time sitter . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the recommendation for the family to hire a sitter. Medical record review of a nurse note dated 4/25/18 revealed, .resident was transferred to floor [to another unit] .he has been getting out of his w/c since he arrived to floor, causing his personal alarm to go off, staff has been able to prevent resident from falling or scooting on the floor up to this point, he has wandered in the area between staff bathroom and med room and scooted himself out of his chair and onto the floor .transferred back to his chair after assessment for injury . Medical record review of the resident's care plan revealed the use of a personal emergency alarm for the resident was not included on the resident's care plan. Review of an Incident/Accident Report dated 4/25/18 and timed 11:30 PM revealed, .CNA notified this nurse that resident was lying in floor beside bed . Review of a Fall Investigation Tool dated 4/25/18 revealed, .intervention .fall mats . Medical record review of Resident #47's care plan revealed no revision to the care plan to reflect the use of fall mats for the resident. Review of an Incident/Accident Report dated 6/13/18 and timed 11:50 AM revealed, .called to room by PT [physical therapy] staff. Pt [patient] was already back in bed but was asleep on mat beside bed when physical therapy found him .he says 'I did not fall or get hurt' . Continued review revealed, .Additional comments and/or steps taken to prevent recurrence: offer rest periods, know whereabouts . Medical record review of Resident #47's care plan revealed the care plan was not revised to reflect the fall on 6/13/18 and was not revised to reflect the interventions of offering rest periods and .know whereabouts . Observation and interview on 8/18/18 at 3:50 PM, in the resident's room, with CNA #17 revealed no call before you fall sign posted. Interview with CNA #17 confirmed fall mats were located on each side of the resident's bed (not on the resident's care plan). Continued interview revealed the CNA had never known the resident to have had any alarms or seatbelts since the time the resident was moved to the secure unit (approximately 2 months ago). Continued observation in the resident's room also revealed no bean bag chair was in the resident's room as documented on the resident's care plan. Interview and review of Resident #47's care plan with the DON on 8/20/18 at 3:45 PM, in the conference room, revealed the Household Nurse Mentor was responsible for ensuring revisions to the resident's care plan after a fall. Continued interview and review of Resident #47's care plan confirmed the resident's care plan was not revised to reflect the fall on 6/13/18 or the interventions of offering rest periods and .know whereabouts . Continued interview confirmed the resident's current plan of care did not accurately reflect the actual interventions which were observed to be in place at this time. Medical record review revealed Resident #80 was admitted on [DATE] with diagnoses including Dysphagia, Contracture of Left and Right Knee, Muscle Weakness and Unspecified Abnormalities of Gait and Mobility. Medical record review of the significant change MDS dated [DATE] revealed Resident #80 required extensive assistance with bed mobility and personal hygiene, and was totally dependent upon staff for dressing, eating and personal hygiene. Continued review revealed a BIMS score of 3, indicating severe cognitive impairment. Medical record review of the quarterly care plan undated revealed Resident #80 was at risk for falls. Further review revealed Resident #80's care plan was not updated with effective interventions after falls on 3/1/18, 4/20/18 and 6/19/18 nor after a fall with serious injury on 7/2/18. Medical record review of the clinical notes dated 7/2/18 revealed .returned from [hospital] .C1[cervical]-C2 Fx [Fracture] and Aspen [Rigid neck brace] collar placed around residents neck, collar is to stay in place for 3 months .laceration to forehead with stitches .will continue to monitor . Interview with MDS Coordinator #3 on 8/17/18 at 7:55 AM, in the MDS office, revealed the MDS coordinators updated the care plans quarterly with the MDS assessments. Continued interview revealed the care plans were updated all other times by the nurses on the floor. Interview with LPN #1 on 8/18/18 at 3:00 PM, on 2 South Hallway, revealed interventions were to be placed on the care plan and updated by the .care plan manager . Refer to F689

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Contracture of Left and Right Knee, and Unspecified Abnormalities of Gait and Mobility. Medical record review of the quarterly care plan, undated, revealed Resident #80 was at risk for falls .d/t: Weakness, decreased mobility, unsteady gait . Continued review revealed the following interventions were care planned 7/6/16 .Attempt to engage [Resident #80] in ADL's [Activities of Daily Living] that improve strength, balance, and posture .Instruct .on safety measures to reduce the risk of falls .Keep areas free of obstructions .call light within easy reach .Keep personal items within easy reach; bed to be in lowest position .Pressure sensor alarm on bed . Further review revealed an intervention on 12/19/16, .offer resident to go back to bed following dinner . Continued review revealed fall interventions for floor mats, 2 person assist (assistance) for all transfers, and non-skid footwear were added on 5/25/18. Continued review revealed after a fall on 7/2/18, a scoop mattress was check marked as initiated and .keep bed remote out of reach . Medical record review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) Score of 0 indicating severe cognitive impairment. Continued review revealed Resident #80 required 1 person extensive assistance with bed mobility, locomotion on unit, eating, toileting, dressing and hygiene, and 2 person assistance for transfers. Medical record review of a clinical note dated 1/27/18 revealed Resident #80 was found lying on the floor in the resident's room on his left side and had a skin tear to the left elbow. Review of the Incident/Accident Report dated 1/27/18 revealed Resident #80 was observed in the floor in front of his wheelchair in the resident's room. Continued review revealed the intervention was .Ask resident if he would like to lay down directly after meals . (An intervention already on the care plan as of 12/19/16.) Medical record review of the clinical notes dated 3/1/18 revealed the resident fell out of a chair and received a skin tear to the right forearm. Review of the Incident/Accident Report dated 3/1/18 revealed Resident #80 .tried to put himself into bed and fell . Continued review revealed the intervention was to .Lay down directly after dinner . Medical record review of a Clinical Note dated 4/20/18 revealed .observed lying on his left side in Bedroom .Patient has a Bed Alarm. Bed Alarm did not sound off . Review of the resident's Incident/Accident Reports revealed no falls investigation was initiated for the fall on 4/20/18 and no fall interventions were put in place to prevent further falls after the fall on 4/20/18. Interview with the DON on 8/17/18 at 10:10 AM, in the conference room, confirmed there was not a fall investigation completed for the fall on 4/20/18. Medical record review of Resident #80's undated care plan revealed fall interventions for floor mats, 2 person assist (assistance) for all transfers, and non-skid footwear were added to the care plan on 5/25/18, 35 days after the fall on 4/20/18. Medical record review of the clinical notes dated 7/2/18 revealed .heard the residents bed alarm .discover that the resident was on the floor with his head bleeding .done first aid .transported to [hospital] . Medical record review of the ER (emergency room) General Adult Worksheet dated 7/2/18 revealed .fall, neck pain .Acute fracture at the base of the dens [pronounced feature in the neck where it joins the main body of the vertebra] .Patient was placed in c-collar [cervical collar] .Serious .Diagnosis: Acute C1 [cervical]-C2 fracture, fall .Acute forehead laceration . Continued review revealed the resident received sutures to the forehead laceration. Medical record review of the hospital radiology report dated 7/2/18 revealed .Fractures of C1 and C2 . Review of the Incident/Accident Report dated 7/2/18 revealed a scoop mattress was check marked as initiated and .keep bed remote out of reach . was written in as a new intervention. Medical record review of the Falls Assessment Instrument dated 7/10/18 revealed it was initiated 8 days after the fall, but was not completed. Observation of Resident #80 on 8/14/18 at 4:20 PM, in the resident's room, revealed the resident was lying in bed with pool noodles on both sides of the mattress under the sheet (pool noodles were used as a substitute for scoop mattress) and the resident had the bed remote within reach (was not to be in reach as a falls intervention after the fall on 7/2/18). Medical record review of the CNA Care Guide (indicates care needs of the residents for the CNAs) updated 8/14/18, revealed the following fall interventions were in place for Resident #80: bed in low position, bilateral floor mats, and bed sensor. Continued review revealed the following interventions had not been added to the CNA Care Guide: lay resident down after dinner, the scoop mattress, pool noodles (used as substitute for scoop mattress), keep bed remote out of reach, and non-skid foot wear. Observation of Resident #80 on 8/15/18 at 9:17 AM, in the resident's room, revealed the resident was lying in bed, with the bed remote lying across his stomach and the pool noodles under the sheet on both sides of the mattress. Observation of Resident #80 on 8/16/18 at 2:20 PM, in the resident's room, revealed the resident was lying in the bed with the pool noodles on both sides of the mattress under the sheet, and he had the bed remote within reach at the head of the bed. Observation of Resident #80 on 8/17/18 at 8:45 AM, in the resident's room, revealed the resident was lying in the bed with the pool noodles on both sides of the mattress, and he had the bed remote within reach at the head of the bed. Observation of Resident #80 on 8/17/18 at 5:40 PM, in the resident's room, revealed the resident was lying in the bed with the pool noodles on both sides of the mattress, under the sheet, and the bed remote was lying across his chest. Observation of Resident #80 on 8/18/18 at 9:22 AM, in the resident's room, revealed the resident was lying in the bed, with the pool noodles on both sides of the mattress, and he had the bed remote within reach at the head of the bed. Observation of Resident #80 on 8/18/18 at 2:46 PM, in the resident's room, revealed the resident was lying in the bed, with the pool noodles on both sides of the mattress, and he had the bed remote within reach. Further observation revealed the bed was not in the lowest position. Observation of Resident #80 and interview with LPN #1 on 8/18/18 at 3:00 PM, in the resident's room, revealed the resident had the following fall interventions in place: low bed, pool noodles on both sides of the bed, under the mattress, .used as a substitute for the scoop mattress , bilateral floor mats, non-skid socks, bed alarm sensor pad, and call-light within reach. Continued interview revealed .that is all the fall interventions . Continued interview confirmed the resident's bed remote was within reach and the resident was able to use the remote. Further interview revealed the fall interventions for Resident #80 should on the CNA care guide. Observation of Resident #80 on 8/20/18 at 9:15 AM, in the resident's room, revealed the resident was lying in the bed with the pool noodles under the sheet on both sides of mattress, and he had the bed remote within reach. Observation of Resident #80 on 8/20/18 at 3:45 PM, in the resident's room, revealed the resident lying in the bed with the pool noodles on both sides of the mattress, under the sheet, and the bed remote was positioned above the resident's left shoulder. Interview with LPN #1 on 8/17/18 at 9:00 AM, on the 2 South hallway, revealed after a fall was discovered .the resident is assessed by a nurse, we get vital signs . Continued interview revealed an intervention was put in place after a fall such as .mats at floor, non-skid socks, bed alarm, call-light . Further interview revealed the information was verbalized to the staff. Interview with CNA #1 on 8/18/18 at 9:29 AM, on the 2 South Hallway, revealed after a fall was discovered or witnessed, the nurse was notified and the resident was assessed for injuries. Continued interview revealed information about a resident fall was verbalized to staff or on the .Care Guide . Medical record review revealed Resident #28 was admitted to the facility 7/9/16 with diagnoses including Dementia, Heart Disease, Previous Myocardial Infarction, Osteoporosis, Anemia, and Osteoarthritis. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #28 scored a 6 on the BIMS, indicating the resident was severely cognitively impaired. Further review revealed the resident required limited assistance of one person for transfers, was occasionally incontinent of urine, always continent of bowel, and used a wheel chair for ambulation. Medical record review of Resident #28's current care plan, not dated, revealed the resident was care planned for being at risk for falls due to decreased mobility, dementia, and previous left hip fracture. Continued review revealed the facility initiated the following interventions: non-skid footwear, engage in activities to improve activities of daily living, instruct on safety measures, call light in reach and instruct to use call light or call out for assistance, personal items in reach, and bed in lowest position. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #28 scored a 15 (high risk for falls). Medical record review of the Clinical Notes Report (nurse's note) dated 2/15/18 at 9:45 AM revealed .Called to resident [#28's] room by CNA. States resident fell and she is in the floor. Observed resident laying on her right side in front of the bathroom door. Resident states she was trying to reach her w/c when she fell. W/C was in front of the air unit close to the foot of her bed .Resident had her house slippers on. Resident voicing complaints of pain to left hip and all around her left knee. No redness or bruising noted on left leg or right leg. Assisted resident into w/c. Resident very hesitant to move and continues to complain of pain primarily left knee. Call placed to NP [Nurse Practitioner] regarding resident's condition. The nurse went back into room and observed some swelling to left knee. Resident transferred into bed and pillow placed under legs and foot of bed elevated. PRN [as needed] Tylenol given for comfort. NP came to floor and assessed resident. New order to x-ray to left hip and left knee noted. Call placed for mobile x-ray services and will send technician out today . Review of an Incident/Accident Report dated 2/15/18 and timed 9:45 AM, revealed, .Called to [Resident #28's] room by CNA. Resident laying in the floor on her R [right] side in front of the bathroom door. Voicing c/o [complaints of] left knee and left hip pain. Some swelling to left knee. States she was trying to get her w/c when she fell . Continued review revealed .Additional comments and/or steps taken to prevent recurrence: Ensure w/c is within reach while in bed . Continued review revealed the resident was sent to the hospital for evaluation and treatment of a left hip fracture. Review of the Investigation Tool for All Incidents and Falls dated 2/15/18 revealed .Injury sustained: yes .Type: Swelling to left knee .Intervention: keep w/c in reach while in bed . Continued review revealed .keep w/c within reach when in bed . Probable Cause: w/c @ [at] a/c [air conditioning] unit . Medical record review of Clinical Notes Report (nurse's note) dated 2/15/18 at 10:58 AM revealed .X-ray results received. Results called to NP. New orders received to send to Hospital ER Medical record review of an acute care hospital record dated 2/15/18 revealed Resident #28 sustained a .Displaced intertrochanteric fracture of left femur [largest bone in the upper leg] . Plan: Admit to [hospital] for surgical repair . Medical record review of a quarterly MDS assessment dated [DATE] revealed Resident #28 scored a 3 on the BIMS, indicating the resident was severely cognitively impaired. Further review revealed the resident required extensive assist of 2 staff for bed mobility, was occasionally incontinent of urine and always continent of bowel, and used a wheel chair for ambulation. Medical record review of Clinical Notes dated 6/7/18 revealed .nurse called to dining room by CNA, who witnessed resident leaning forward in her w/c and topple out of chair to the floor. Resident hit right forehead and sustained medium sized skin tear to left forearm. Area to forearm cleansed and dressed without difficulty or complaints. Resident re-educated as to dangers of leaning forward . Review of an Incident/Accident Report revealed Resident #28 had a fall on 6/7/18 at 2:00 PM in the dining room .CNA observed res. topple forward from her w/c to the floor. Res. remained alert. Skin tear noted to left forearm. Res. did hit her head on right forehead. No bruising @ [at] this time .Additional comments and/or steps taken to prevent recurrence: Res. cautioned re: [regarding] leaning forward in w/c . Review of a facility Investigation Tool for All Incidents and Falls dated 6/7/18 revealed .Injury sustained: yes .Type: skin tear left forearm . Continued review revealed .Intervention: implemented: Res. re-educated regarding leaning forward .Probable Cause: Leaning forward in w/c . Observation of Resident #28 on 8/17/18 at 9:30 AM, in the Secure Unit Dining Room, revealed the resident was sitting at the table in a wheelchair eating dinner. Observation of Resident #28 on 8/18/18 at 9:15 AM, revealed the resident sitting in wheelchair in the Sun Room eating breakfast, wearing house shoes. Continued observation revealed no staff member was present in the Sun Room. Interview and medical record review of fall reports and investigations with LPN Nurse Mentor #1 on 8/17/18 at 5:05 PM, in the secure unit nurses station, confirmed the intervention of leaving Resident #28's wheelchair within reach would not prevent the resident from having another fall, as it would likely encourage the resident to get up without assistance. Continued interview with Mentor #1 confirmed Resident #28 had no safety awareness. Further interview confirmed that re-educating a resident to not to lean forward in her wheelchair would not be effective due to the resident's impaired cognitive status. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Major Depressive Disorder, Presence of Left Artificial Hip, and Lumbago with Sciatica, Scoliosis, and Chronic Kidney Disease. Medical record review of a quarterly MDS dated [DATE] revealed Resident #34 scored a 6 on the BIMS, indicating the resident was severely cognitively impaired. Further review revealed the resident required the assist of 1 staff member for transfers, required limited assist of 2 staff for toilet use, was occasionally incontinent of urine, and always continent of bowel. Medical record review of a Falls Risk assessment dated [DATE] revealed Resident #34 scored a 13 (high risk for falls). Medical record review of Resident #34's current care plan, not dated, revealed the resident was care planned for being at risk for falls due to decreased mobility and narcotic and psychotropic medication use with the following interventions: assist with toileting as needed; attempt to engage in activities that improve strength, balance and posture; fall risk assessment as indicated; keep call light within reach and remind how to use as needed; keep room free from clutter and walkways clear; keep frequently used items within reach; monitor medications for changes that may effect [affect] falls; footwear will fit properly and have non-skid soles; instruct on safety measures to reduce the risk of falls. Medical record review of Clinical Notes Report (nurse's note) dated 2/25/18 at 4:30 AM revealed, .Heard someone calling out. Went to pt's [patient's] room and found her outside the bathroom on floor. States she was going to the bathroom and fell. Assessed and placed back in bed .c/o .pain in lt. [left] hip. Crying with pain . Review of an Incident/Accident Report dated 2/25/18 revealed, .Heard someone crying and found pt on the floor in her room. She states she was going to BR [bathroom] and fell. C/o [complaint of] .hip pain. Skin tear to Lt elbow . Continued review of a written statement RN #2 for the fall on 2/25/18 revealed . Heard a resident crying. Went to check and found [resident] .in floor against bathroom wall. Got [Resident #34] back into bed with help. Resident has a skin tear on left elbow and complaining of left hip pain . Review of a facility investigation Tool for all Incidents and Falls dated 2/25/18 revealed Resident #34's fall was unwitnessed and the resident was in the bed prior to the fall. Continued review revealed .Injury sustained: yes .skin tear LT. elbow, c/o LT. hip pain. Intervention: sent to [acute care hospital] ER . Further review revealed interventions documented at the time of the fall were non-skid socks, reevaluate toileting program, and night light. Further review revealed .Additional comments and/or steps taken to prevent recurrence: Call before you fall [sign] posted . Continued review revealed the fall was not reviewed by the Interdisciplinary Team and no new interventions other than posting a call before you fall sign (for a cognitively impaired resident) were implemented after the fall. Medical record review of Physician Order Sheet and Progress Note dated 2/25/18 at 4:45 AM revealed .send pt. out to [hospital] for left hip x-ray . Medical record review of a Clinical Notes Report dated 2/25/18 at 10:05 AM revealed .Call placed to [hospital] resident update. Informed that she will be admitted for dx [diagnosis] left femoral neck fracture [fracture of the femur near the hip joint] and will be having surgery . Medical record review of a hospital record dated 2/25/18 revealed Resident #34 sustained a fractured hip Impression: Displaced left femoral neck fracture . Plan: Admit to [hospital] . Interview with RN #2 on 8/16/18 at 6:30 AM, in the nurses' office, revealed before Resident #34 fell in February 2018, the resident got up by herself all the time, however since she fell, she did not get up anymore. Further interview revealed the resident did use the call light at times, but not very often. Continued interview revealed when the resident saw staff during rounds, the resident would ask to get up to go the bathroom. Further interview revealed the night of the fall on 2/25/18, the resident got up to go the bathroom and fell. The RN stated the only way the staff knew the resident fell was because the roommate put her call light on .then heard her crying . Further interview revealed Resident #34 was in a lot of pain and appeared different since the fall. When RN #2 was asked about the Incident/Accident report, she stated she was responsible for filling out both the Incident/Accident Report and the Investigation Tool, however she did not update the care plan .I figured there was a team somewhere that filled out that part and make new recommendations . Further interview with RN #2 revealed Resident #34 had really .failed [gotten worse] .[since the 2/25/18 fall] .before she use to be out in wheelchair and go around, doesn't do that much . Continued interview revealed .we would remind her [to not get up unassisted] prior to the fall in February, but that doesn't mean a lot . Medical record review of a Significant Change MDS dated [DATE] revealed Resident #34 had a significant decline in status following the fall on 2/25/18. Continued review revealed the resident scored a 3 on the BIMS, indicating the resident was severely cognitively impaired, and required the extensive assist of 2 staff for bed mobility and transfers. Continued review revealed the resident only walked in room [ROOM NUMBER] time during the assessment period, was occasionally incontinent of urine, and always continent of bowel. Review of an Incident/Accident Report revealed Resident #34 had a fall from her wheelchair on 6/16/18 at 9:55 PM, in the resident's room. Continued review revealed .resident was on the floor in her room, went to assess resident, she had skin tear to lt. [left] hand, bump on left side of head and was c/o lt [complaining of left] hip pain . Further review revealed .Additional comments and/or steps taken to prevent recurrence .Call before you fall [sign], posey grip [rubberized mat for resident to sit on while in wheelchair to prevent sliding from chair] .to w/c . Continued review revealed the resident was sent to the hospital for evaluation. Review of an Investigation Tool for all Incidents and Falls dated 6/16/18 revealed .Circumstances: What was the resident doing prior to incident: sitting in her room in w/c . Further review revealed interventions documented as in place prior to the fall were non-skid socks and low bed. Continued review revealed the Interdisciplinary Team (IDT) had reviewed the fall with recommendations .posey grip to w/c, call before you fall . Further review revealed .Probable cause: Res [resident] self-transferring. No safety awareness . Medical record review of Clinical Notes Report dated 6/17/18 at 3:30 AM revealed Resident #34 was evaluated at the hospital with no injuries noted. Observation and interview with CNA #11 on 8/16/18 at 9:47 AM, in Resident #34's room, revealed the resident laying in the bed and sleeping. Continued observation revealed a Call Before You Fall sign was not posted in the resident's room. Further observation revealed the posey grip for the resident's wheelchair was located on the nightstand next to the resident's bed and was covered up by a box of Kleenex, a stuffed animal, and 2 wash cloths. Observation and interview with CNA #5 on 8/16/18 at 5:45 PM, in the Secure Unit Sunroom, revealed Resident #34 was sitting at a table in her wheelchair eating dinner. Interview with CNA #5 revealed the CNA was unaware of what a posey grip was, and was not able to confirm if the posey grip was on the resident's wheelchair or not. Observation and interview with CNA #6 on 8/16/18 at 5:48 PM, in the Secure Unit Sunroom, revealed Resident #34 was sitting at a table in her wheelchair eating dinner. Continued observation confirmed no posey grip was under Resident #34 and .It should be . Interview with CNA #5 on 8/16/18 at 6:07 PM, in the secure unit hallway, revealed if the CNA did not know what fall interventions were to be put in place she would ask the nurse or she would look in the computer for the resident's plan of care. Continued interview revealed when the CNA attempted to retrieve Resident #34's care plan from a computer kiosk [computer charting system], the CNA received a message which stated .no interventions found . Observation of Resident #34 on 8/17/18 at 6:46 AM, in the resident's room, revealed the resident was lying in a low bed, the room was dark, and the resident's wheelchair was located at the foot of the bed. Continued observation revealed no Call before you fall sign was posted. Medical record review of Clinical Notes Report dated 7/14/18 revealed .[Resident #34] fell in her room by her sink, her roommate yelled for help and [staff] and I ran to her room and found her on the floor in front of the sink with blood pooling around her head .received the order to send her to the [emergency room] for eval and treatment . Review of an Incident/Accident Report dated 7/14/18 at 7:05 PM, in the resident's room revealed, .Resident's roommate was calling for help [CNA #26] and I [LPN #16] went to the room and [Resident #34] was on the floor in front of the sink and blood was pooled around her head . Further review revealed .Additional comments and/or steps taken to prevent recurrence: Call before you fall. Encourage out of room more . Review of an Investigation Tool for all Incidents and Falls dated 7/15/18 revealed .Circumstances: What was the resident doing prior to Incident? .sitting in her rm [room] in her w/c .Injury sustained: yes, Type: head laceration . Further review revealed interventions in place at the time of the fall were low bed and night light. Continued review revealed no evidence the Posey grip was in Resident #34's wheelchair at the time of the fall. Further review revealed the IDT failed to review the fall, and no further recommendations or interventions were made after this fall. Medical record review of a Physician's Order Sheet and Progress Note dated 7/14/18 revealed .Resident fell hit head .send to ER via ambulance .Staff to leave nightlight on and bed in low position . Medical record review of an Emergency Department note dated 7/14/18 revealed, .Progress: 1830 [6:30 PM]: I have repaired patient's laceration with a small stapler. Patient's laceration was cleared of debris. I used 2 staples. Patient tolerated procedure well. Patient was informed that these will have to be removed in 7 days . Interview with the Secure Unit Nurse Mentor #1 on 8/17/18 at 7:49 AM, in the Secure Unit dining room, revealed fall interventions for the residents should be documented on the CNA's assignment sheets, and also in the CNA kiosk. Continued interview revealed the House Mentor (nurse) or House Coordinator (CNA) was responsible for updates to the assignment sheets. Further interview revealed after a fall, the nurse assigned to the resident was to complete the Incident/Accident Report and the Investigation Tool. Further interview revealed the House Mentor was responsible for reviewing every incident and .there should be a new intervention . Continued interview confirmed the only intervention recommended after the fall on 2/25/18 was to .Call before you fall .that doesn't always work especially with dementia . Continued interview revealed the Posey grip was to be placed directly under the resident when the resident was up in the wheelchair, and confirmed it was unknown if the Posey grip was in use at the time of the resident's fall on 7/14/18. Further interview confirmed the IDT team section of the Investigation Tool should be completed during the morning Huddle. Review of the IDT section for the 2/25/18 and 7/14/18 falls confirmed this section had not been completed. Interview and observation with CNA #9 and Household CNA Coordinator #4 on 8/17/18 at 8:10 AM, at the CNA Kiosk in the Secure Unit hallway, revealed Resident #34 was documented as a fall risk on the summary page with a low bed documented as an intervention. Continued interview with the Household Coordinator revealed all residents should be in a low bed. Further review of the Resident #34's CNA care plan, revealed when the CNA checked the care plan in the computer, a pop-up window appeared with .no interventions found . Interview with Nurse House Mentor #1 on 8/17/18 at 8:39 AM, in the Secure Unit dining room, revealed Resident #34 rarely used the call light and the intervention of the Posey grip to the wheelchair was not updated on the resident's care plan. Further interview confirmed no other interventions had been implemented for the resident and the intervention to instruct the resident on safety measures was not appropriate because .she can't retain information . Further interview revealed . [Resident #34] still tries to get up at times and sometimes she still gets up by herself. She did it the other day, just depends on how she feels . Interview with the DON on 8/18/18 at 12:08 PM, in the Conference Room, revealed Incident/Accident Reports and Investigation Tools are reviewed in Huddle meetings Monday through Friday at 9:00 AM. Continued interview revealed there was also a meeting on Thursdays to review falls .however I have never been to that one . Review of Resident #34's Incident/Accident Reports and Investigation Tool reports with the DON confirmed .call before fall . instructions for the resident could not be retained by a cognitively impaired resident. Further review revealed the DON was not able to verbalize how a Posey grip would prevent the resident from falling and .I thought it was a pommel cushion .I don't think Posey grip would be appropriate . Further interview confirmed the interventions for Resident #34 were not appropriate and would not address the circumstances of the resident's individual falls. In summary, Resident #34 had a total of 3 falls from 2/2018 to 7/2018, 2 with a major injury. Observations of the resident and interviews with staff confirmed the facility failed to ensure appropriate interventions, based upon review of the resident's individual fall risk, were implemented. Interviews conducted on all 3 shifts during the survey confirmed there was not a system in place to ensure what fall interventions were to be in place for the resident. Observations conducted revealed the interventions the facility implemented, call before you fall sign and Posey grip to the resident's wheelchair were not appropriate, were not observed to have been in place at the time of the survey, and were not effective in preventing future falls or injury. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Dementia, Cerebral Vascular Accident, Shizoaffective Disorder, and Bipolar Disorder. Medical record review of a Falls Risk assessment dated [DATE] revealed there was no score completed. Medical record review of Resident #47's comprehensive care plan with an effective date of 4/5/18 revealed the resident was care planned for being at risk for falls due to weakness, prior hip fracture, vision impairment, encephalopathy, and dementia. Continued review revealed the facility implemented the following interventions: assist to wear non-slick footwear that fits; attempt to engage in activities that improve strength, balance, and posture; instruct on safety measures to reduce the risk of falls; keep areas free of obstructions to reduce the risk of falls or injury; keep nurse call light within easy reach; instruct to use call bell or call out for assistance; keep personal items within easy reach; bed to be in lowest position with wheels locked; bean bag provided to reduce the risk of falls; self-releasing lap buddy to reduce the risk for falls with injury . Continued review revealed none of the interventions documented on the care plan had been dated to illustrate when the interventions were initiated and implemented. Medical record review of a Clinical Notes report dated 4/5/18 revealed, .Called to [Resident #47's] room by CNAs. CNA's stated they had found resident on bedside mat on knees . Review of an Incident/Accident Report dated 4/5/18 and timed 7:30 PM, revealed Resident #47 .crawled from his room into [another room]. Multiple skin tears on bilateral elbows and L knee bruise . Continued review revealed .Additional comments and/or steps taken to prevent recurrence: call before you fall, bed in low position Review of an Investigation Tool for a[TRUNCATED]

Based on review of the facility's CMS-672 Resident Census and Conditions of Residents, review of the Matrix for Providers, review of the facility's Daily Census Report, review of facility staffing schedules, observation, medical record review, review of facility incident reports, and interview, the facility failed to maintain adequate staffing levels to ensure the supervision of residents to prevent repeated falls for 7 residents (#28, #34, #39, #40, #47, #80, #119) of 40 residents reviewed for falls in the facility, and to ensure residents were provided assistance with activities of daily living (ADLs) care for 3 residents (#53, #80, and #89) of 52 residents reviewed. The facility's failure to ensure adequate staffing levels resulted 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) for 7 residents (#28, #34, #39, #40, #47 #80, #119) with serious injuries after falls. The facility's failure to provide assistance with toileting resulted in Harm to Residents #80 and #89. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy on 8/20/18 at 8:10 PM, in the conference room. The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility's CMS-672 Resident Census and Conditions of Residents signed by the Administrator on 8/13/18 revealed the facility had a census of 137 residents. Further review revealed 90 residents were occasionally or frequently incontinent of bladder; 80 residents were occasionally or frequently incontinent of bowel; 25 residents ambulated with assistance or assistive devices; 92 residents had dementia; 86 residents had behavioral healthcare needs; and 8 residents had pressure ulcers. Review of the Matrix for Providers completed on 8/13/18 revealed the facility had 40 residents who had experienced falls while in the facility, with 10 residents having an injury with a fall and 7 residents having a major injury as a result of a fall. Residents who had major injuries after a fall were Residents #119, #47, #28, #34, #39, #40, and #80. Review of the facility's Daily Census Report dated 8/13/18 for the Secured Unit revealed the unit had 31 residents and 2 empty beds. Review of the facility's staffing schedule for the Secured Unit for August 2018 revealed the unit was to have 1 Licensed Practical Nurse (LPN) and 4-5 Certified Nursing Assistants (CNAs) working Monday through Friday day shift; 1 LPN and 3 CNAs working weekend day shift; 1 LPN and 3-4 CNAs working Monday through Friday evening shift; 1 LPN and 2 CNAs working weekend evening shift; either 1 LPN or 1 Registered Nurse (RN) and 2-3 CNAs working Monday through Friday night shift; and 1 LPN or RN and 2 CNAs working weekend night shift. Observation on Thursday 8/16/18 at 10:50 AM, in the Secured Unit dining room, revealed residents seated in chairs and wheelchairs. Continued observation revealed no CNA or nurses were in the line of sight of the residents in the dining room and sunroom. Further observations revealed all the residents' doors were open without a staff member in line of sight. Further observation revealed the Wound Care Nurse and Wound Nurse Practitioner were in one of the resident's rooms. Medical record review and review of facility incident reports revealed Resident #119 had 9 falls between 7/1/17 and 7/10/18, with 3 falls requiring transfer to the emergency room, and 2 falls resulting in fractures of the legs. Interview with CNA #16 on 8/16/18 at 2:42 PM, in the Secured Unit hallway, revealed .We don't have enough supervision for her [Resident #119] .If we do have enough staff they pull us . Interview with Household CNA Coordinator #4 on 8/16/18 at 2:47 PM, in the Secured Unit hallway, revealed .We always have staff, but [they are] pulled .When [they] get pulled, don't have enough staff .With 3 people just can't do it . Interview with CNA #5 on 8/18/18 at 8:59 AM, on the Secured Unit hallway, revealed .Right before supper we position them [residents] [in chairs] that is how we supervise .last 3 months before it was horrible . Observation on Saturday 8/18/18 at 9:10 AM, in the secured unit sunroom, revealed Resident #119 was seated in her wheelchair. Continued observation revealed no CNAs or nurses were in line of sight of the resident. Medical record review and review of facility incidents revealed Resident #47 had 10 falls between 4/9/18 and 6/13/18 with one fall requiring sutures for a laceration. Further review revealed the resident was not safe to ambulate independently. Observation on 8/18/18 at 10:30 AM, in the Secured Unit dining room, in front of the kitchen, revealed LPN #5 was at the medication cart between the dining room and the sunroom, preparing medications for a medication pass. Continued observation revealed 16 total residents were in the dining room, sitting area, and sunroom. Further observation revealed Resident #47 ambulated into the dining room, in front of the kitchen, pushing his wheelchair towards the sunroom. Further observation revealed LPN #5 began to yell out to the homemaker/cook staff member, who was located in the kitchen, to find a staff member to help assist the resident, who was observed to be unsteady on his feet. Further observation revealed the other CNAs were in resident rooms. Further observation revealed the homemaker staff member went out on the unit and tried to find a CNA to help with Resident #47. Continued observation revealed LPN #5 assisted the resident back into a wheelchair and continued to prepare medications for medication pass while the homemaker was locating a CNA to assist. Review of the facility's Daily Census Report dated 8/13/18 for 2 South revealed the unit had 31 residents and one empty bed. Review of the facility's staffing schedule for 2 South for August 2018 revealed the unit was to have 1 nurse and 3 CNAs per shift Monday through Friday and 1 nurse and 2 CNAs per shift on the weekends. Interview with Resident #61, who lived on 2 South, on 8/13/18 at 10:31 AM, in the resident's room, revealed Resident #61 did not think there was always enough staff to provide baths. Continued interview confirmed .the girls [CNAs] will come in and say there are only 2 of us [CNAs] and we can't do your bath today . Further interview revealed .sometimes there is only 1 to 2 to take care of all of us [residents] .because they have to go to the kitchen to work sometimes . Interview with Resident #96, who lived on 2 South, on 8/13/18 at 10:39 AM, in the resident's room, revealed .[the facility] short staffed .staff have quit and they haven't replaced them .a lot of times there is just 1 or 2 [CNAs] on the floor . Interview with Resident #53, who lived on 2 South, on 8/13/18 at 11:08 AM, in the resident's room, revealed .didn't get a shower last week at all .not Tuesday or Friday they told me they were short staffed .it has happened .several times .not enough of them . Interview with CNA #3 on 8/15/18 at 9:25 AM, in the 2 South dining rooms, revealed the facility did not always have enough help to take care of the residents. Continued interview revealed there had been times when residents had not received showers. Interview with Household CNA Coordinator #1 on 8/15/18 at 9:40 AM, in the 2 South dining room, revealed there had been .call offs and have lost some employees and do not always have enough staff to take care of the residents about 2 to 3 days out of the week . Continued interview revealed .pulled to the kitchen sometimes 3 to 4 times a week . Further interview confirmed there had been times the residents had not received showers because of staffing. Interview with CNA #4 on 8/15/18 at 9:56 AM, in the 2 South dining room, revealed there was not always enough staff to meet the needs of the residents .it upset me .we are understaffed. I can't do my job the way I would like . Continued interview revealed .At least once a week we try to give a shower .there have been times on the weekends that we have not been able to get some residents up out of bed because there is not enough staff . Interview with LPN #2 on 8/15/18 at 10:05 AM, in the 2 South living room area, revealed there was not always enough staff to meet the needs of the residents. Continued interview confirmed .like today the person I was working with put her notice in so there is only 1 nurse. The weekends are not enough CNAs. Last Sunday there was only 1 nurse and 2 CNAs .there have been times the residents have not received a shower due to staffing . Review of the facility's staffing schedule for 1 South for August 2018 revealed the unit was to have 1-2 nurses for each shift Monday through Friday; 3-4 CNAs on day shift, 2-3 CNAs on evening shift, and 2 CNAs on night shift Monday through Friday; 1 nurse each shift on weekends; and 2 CNAs on day and evening shift and 1 CNA on night shift on the weekends. Further review revealed there were no nurses scheduled for 7:00 AM - 3:00 PM shift on 8/18/18 and 8/19/18. Interview with Nurse Mentor #5 on 8/14/18 at 7:50 AM, in the 1 South nursing station, revealed .we need the help last night .I only have 1 nurse [LPN #13] working today . Review of the staffing schedule for 8/14/18 day shift on 1 South revealed the unit was supposed to be staffed with 2 nurses. Interview with LPN #13 on 8/14/18 at 8:25 AM, in the 1 South hallway, confirmed .I am the only nurse on the floor today .I have 30 patients today .it happens all the time being the only nurse on the floor . Interview with Resident #89, who lived on 1 South, on 8/14/18 at 9:47 AM in the resident's room, confirmed .They are real short on day shift. I have called out because I need the bed pan and they did not get to me for a while and I had an accident on myself. It made me feel shamed . Interview with RN #4 (night shift nurse on 1 South) on 8/17/18 at 6:35 AM revealed .I had 30 patients last night .I was the only nurse with 1 CNA . Review of the staffing schedule for 2 South for 8/16/17 11:00 PM - 7:00 AM shift revealed the unit was to be staffed with an RN and 2 CNAs. Interview with CNA #2 on 8/17/18 at 5:45 PM, on the 2 South hallway, revealed .just 2 of us working down here and I don't even know these patients .I work upstairs on the skilled .I was pulled from the 3rd floor and that left 1 CNA up there to take care of 17 or 18 patients . Review of the staffing schedules for 2 South and 3rd floor for the evening shift of 8/17/18 revealed 2 South was to have 2 CNAs and the 3rd Floor was to have 2 CNAs. Interview with LPN #1 on 8/18/18 at 9:12 AM, on the 2 South hallway, revealed .is never enough staff .recently had a setback with a CNA getting fired, a nurse quit, a CNA quit .they haven't been replaced .I have reported to the DON [Director of Nursing] and the Administrator . Interview with the DON on 8/20/18 at 5:30 PM, in the conference room, revealed the Nurse Mentors and Household CNA Coordinators schedule staff 6 weeks in advance and staffing is to be reviewed by each house daily. The DON stated staffing in the facility was consistent, unless a staff member needed to be pulled to another unit in the facility. Further interview revealed staffing was based upon census and acuity in each house and was determined by utilizing a computerized staffing calculator. Further interview revealed staff turnover was discussed in the leadership meetings every 2 weeks and CNA turnover was high, but nursing turnover was stable. Interview with the DON on 8/20/18 at 5:35 PM, in the conference room, revealed staff had reported to the DON there was not enough staff, but the DON stated staffing was adequate. The DON stated if someone was pulled to work on another unit or another role, then staff felt they didn't have enough adequate staff. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up [restrain residents] . Telephone interview with the Chair of the Board on 8/20/18 at 3:47 PM, confirmed .the facility had staff turnover .turnover in these positions are critical . Refer to F-550, F-657, F-677, F-689, F-726, F-835, F-841, F-867, and F-947.

Based on review of the facility's Quality Assurance and Performance Improvement Plan, review of the facility's 2018 Assessment, and interview, the facility failed to implement a program to ensure nursing staff education and competency were completed The failure to ensure nursing staff were educated and competent placed 7 residents (#28, #34, #39, #40, #47, #80, and #119) in Immediate Jeopardy (IJ), 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). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan, revised 2/27/18, revealed .The Quality Assurance (QA) Committee consists of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Preventionist .All associates including contracted staff are educated on the principles of QAPI .Associates will be trained on using QAPI process including participation on a Performance Improvement Project (PIP Team) .The QAPI program is sustained during transitions in leadership and staffing through all-associate education and involvement in the QAPI process . Facility associates and management have been trained on Root Cause Analysis .The QAPI program will be evaluated annually by the QAPI Steering Committee with input from the Leadership Team/Executive Leadership. This review will include whether goals were met, if standards of practice are being followed, any training needs will be identified and addressed . Review of the 2018 Facility Assessment revealed .Each job description identifies the required education .Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population .competencies are based on the care and services needed by the resident population .competencies are verified upon orientation, at least annually and as needed .The Staff Development Coordinator tracks and trends course completion history and performance trends, reporting those to the Administrator and Director of Nursing (DON) . Interview with the DON on 8/18/18 at 10:36 AM, in the conference room, and review of falls investigations and interventions put in place by staff to prevent further falls, revealed and intervention for Resident #119 included Velcro noodles to the bed. The DON stated .I don't know what Velcro noodles would be exactly, maybe pool noodles . Telephone interview with Registered Nurse (RN) #5 on 8/15/18 at 1:45 PM, confirmed Resident #236 had extreme pain during dressing changes. Continued interview revealed she tried to give her the pain medication 20 minutes before dressing changes and she hollered out each time. Further interview revealed the nurse had not notified the Physician or Nurse Practitioner that she had pain. My thought processes were that she was being seen by the wound care team . Telephone interview with RN #3 on 8/15/18 at 2:00 PM, confirmed she had completed dressing changes on Resident #236 and most times she had pain during the dressing changes. Further interview confirmed the nurse gave pain medication 30 minutes to an hour prior to the dressing change. Continued interview confirmed .I think it [wound] hurts because it is so deep . Further interview confirmed sometimes the resident will ask the staff to stop because of the pain and will refuse dressing changes at times. Continued interview revealed .I think the Doctor already knows about the pain. I didn't report it because it's the nurse's discretion to assess if the patient can tolerate the dressing change . Interview with the Staff Development Coordinator on 8/18/18 at 4:30 PM, in the conference room, revealed the nursing staff has an orientation period that begins with Human Resources (HR) onboarding. The nurses have HR videos they watch and Relias (computer-based training modules) they watch. Some modules are for all staff and some are specific to nursing. The Staff Development Coordinator conducts a diabetic lab with the nurses that lasts approximately ½ a day with competency checked on insulin administration. When the nurses have completed the videos, the Staff Development Coordinator sends them to their nursing unit with an orientation checkoff sheet and then the House Mentor is responsible for the nurse's training. The nurses are paired with a preceptor of the House Mentor's choosing. The Staff Development Coordinator only receives the orientation checkoff sheet from the Mentors when they are done and states she is not involved in decision making of when nurses are competent. Further interview revealed she did not recall any specific training on falls other than the computer based Relias training assigned during orientation and annually. When asked if falls was covered in that training, the Staff Development Coordinator stated that she thought she remembered something on falls, like what to do if you see water in the floor. Further interview revealed she was new to the position and stated she did not have an annual plan or monthly plan for education. The Staff Development Coordinator stated she was still trying to find where deficiencies in education were, where annual trainings were due and had not been done, and was developing education month to month if someone told her there was a need. The Staff Development Coordinator stated the monthly trainings she had developed since being in her role was on the evacuation policy in May 2018, then they conducted mock evacuation drills in June and July 2018 and she was currently conducting one on one training with everyone on Personal Protective Equipment (PPE) and handwashing. Interview with the Director of Nursing (DON) on 8/18/18 at 7:13 PM, in the conference room, confirmed the facility staff were responsible for investigating falls. Falls were reported to the nurse on duty and the accident report was turned into the Clinical Mentor. The Clinical Mentor checked for completeness of the report and the nurse and Clinical Mentor discussed the interventions to put in place to prevent further falls. The DON stated the current facility practice was for the nurse Clinical Mentor to decide on a fall intervention and to put it in place immediately after an incident. The nurse was to do a fall risk assessment after every fall and it was put with the investigation packet. Any interventions put in place depended on interventions already in place. The DON stated the nurses knew what options were available and they used .nursing clinical judgement [used when deciding which intervention to put in place] .no education on falls .just their [staff] clinic experience . The DON stated the nurses did not do any root cause analysis at the time of the fall and the leadership was also not doing a root cause to determine the cause of the fall in order to implement interventions to prevent further falls. The DON stated they were aware the care plans were not updated, I don't know when the care plans [were updated] .the mentor in the house should be updating the care plans .I think that there is work to be done .doing weekly meetings we will be able to get more in depth and with dementia they [residents] forget they can't get up . Interview with the DON on 8/18/18 at 7:15 PM, in the conference room, revealed, .I am not familiar with long-term care, and she [Administrator] had taught me regarding [fall] interventions . Further interview with the DON revealed the DON was familiar with Resident #47 and stated as far as she was aware the resident had not had any further falls once he was admitted to the secured unit following his return to the facility after a psychiatric hospital stay (resident had 2 falls since his return). Refer to F-657, F-689, F-725, and F-947.

Based on facility policy review, medical record review, review of facility falls investigations, review of facility dailycensus and staffing, observation, and interview, the Administrator failed to ensure facility policy and procedures were implemented for falls; failed to ensure revision of care plans was completed with appropriate and individualized interventions to prevent falls; failed to prevent avoidable pressure ulcers; failed to ensure an effective falls program was implemented to prevent residents from having multiple falls and multiple injuries with falls; and failed to ensure adequate staffing to supervise residents who had falls and adequate staffing to provide activities of daily living care (ADL) care to residents. The Administrator's failure to ensure an effective falls program was implemented placed 7 residents (#28, #34, #39, #40, #47, #80, and #119) in Immediate Jeopardy (IJ), 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). The Administrator's failure to ensure residents were provided assistance with toileting resulted in Harm to Residents #80 and #89. The Administrator's failure to ensure residents received pain control resuled in Harm to Resident #236. The Administrator's failure to ensure residents did not develop pressure ulcers resulted in Harm to Resident #80. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F 689, F725, F 726, F 841, F 867 and F 947. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: During the annual Recertification survey conducted 8/13/18 - 8/20/18, review of clinical notes, accident reports, and fall investigations revealed Resident #119 had 9 falls between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left hip fracture; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a fracture of the left femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left hip fracture and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma [a collection of blood outside the brain]; and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #80 developed 1 avoidable unstageable wound to the right clavicle. Interview with the Administrator on 8/20/18 at 12:20 PM, in the conference room, revealed the Administrator led the Quality Assurance and Performance Improvement (QAPI) meeting. During the meeting they discussed how many falls during a month looking for trends and patterns. Falls were reviewed during the morning meeting. The Administrator stated .some things I was concerned about .some of the interventions were not appropriate .after doing it that month [review of falls in AM meeting] our teams were educated .educate as we go .if nursing staff used same intervention or inappropriate intervention we would educate the mentor at that time . Further interview confirmed the facility had not used root cause analysis during falls and a resident's historical falls was not being discussed. The facility conducted the first root cause analysis in July. Further interview revealed, .saw increase in falls .increase multiple resident falls .we knew fall rate increased . Further interview revealed, .have not discussed pressure ulcers in huddle .not sure if they're talking about them in therapy .we have not done it in morning meeting yet . Interview with the Consultant, who was the facility's previous Administrator from 3/18 - 6/18, on 8/20/18 at 1:47 PM, in the conference room, revealed the falls program included household huddles daily to find interventions. The previous Administrator stated he did not attend the meetings and did not have clinical experience and relied on the nurses for interventions. Further interview revealed that approximately the 3rd week of April he became aware falls had increased. The previous Administrator called on the Minimum Data Set (MDS) nurse to assist in decreasing falls. The previous Administrator stated there was a falls task force with in the form of huddle meetings. The previous Administrator confirmed he had no involvement in the huddles or Interdisciplinary Team (Interdisciplinary Team) meetings. He stated MDS would facilitate those meetings and .informal monitoring to ensure meetings [huddles] being held with [MDS #1] were informal .nothing formal . Refer to Refer to F-550, F-657, F-677, F-686, F-689, F-697, F-725, F-726, F-867, F-947

Based on review of the Medical Director Contract, review of the Advanced Practice Nurse (APN) Protocol, review of the Facility Assessment, medical record review, review of facility falls investigations, observation, and interview, the Medical Director failed to ensure identification, development, and implementation of appropriate plans of action and ensure the effective use of its resources to maintain the highest practicable well-being of all residents, failed to ensure performance improvement was implemented and monitored, failed to provide an individualized pain management plan to avoid pain and mental anguish, failed to ensure interventions were implemented for residents with repeated occurrences with falls which placed residents at risk of harm, failed to ensure revision of care plans were done with appropriate and individualized interventions to prevent falls, failed to prevent avoidable pressure ulcers, failed to ensure an appropriate falls intervention program was implemented to prevent residents from having multiple falls and injuries, and failed to ensure a facility assessment was performed and implemented. The Medical Director's failure placed 7 residents (#119, #28, #34, #39, #40, #47, #80) in Immediate Jeopardy (IJ), 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). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 835, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the Medical Director Contract revealed .4. Services to be performed by provider .Responsible for the overall coordination of medical care at the Facility. Coordination of care means Provider shares responsibility for assuring Facility is providing appropriate care as required which involves monitoring and ensuring implementation of resident care policies and providing oversight and supervision of medical services and medical care of residents .Evaluate and take appropriate steps to correct any problems associated with any possible inadequate care Provider identifies .Participate, upon request, in personnel evaluations and other quality monitoring programs established by the Facility including attendance at the Facility's Quality Assurance Committee meetings .Provider will deliver high quality services that .Promote standards of timeliness .enhance continuity of service to all Health Center residents .conform to federal and state regulations . Review of the Advanced Practice Nurse (APN) Protocol, undated, revealed .Requiring Authority .the [APN] will provide health care services under the general supervision of [Medical Director] .F. Interpret and analyze patient data to determine patient status, care management and treatment and effectiveness of interventions . Review of the Facility Assessment 2018, dated 6/2/18, revealed .Community Staff .The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . During the annual Recertification survey conducted 8/13/18 - 8/20/18, review of clinical notes, accident reports, and fall investigations revealed Resident #119 had 9 falls between 7/1/17 - 7/10/18 and sustained 3 major injuries: a right tibia fracture, left femur fracture, and left hip fracture; Resident #28 had 2 falls between 2/15/18 - 6/7/18 and sustained 1 major injury: a fracture of the left femur; Resident #34 had 2 falls between 2/25/18 - 7/14/18 and sustained 2 injuries: a left hip fracture and a laceration to the back of the head requiring staples; Resident #39 had 9 falls between 4/2018 - 8/2018; Resident #47 had 8 falls between 4/5/18 - 6/13/18 and sustained 1 injury: a right eye injury requiring sutures. Resident #40 had 4 falls between 4/2018 - 8/2018 and sustained 1 injury: a subdural hematoma; and Resident #80 had 5 falls between 1/27/18 - 7/2/18 and sustained 1 major injury: a Cervical 1 - Cervical 2 fracture. During the Recertification survey, review of wound reports, Wound Nurse Practitioner documentation, and interviews, revealed Resident #39 developed 3 avoidable wounds: 1 stage II on the right buttock, 1 stage III to left buttock, and an unstageable to the coccyx; Resident #80 developed 1 avoidable unstageable wound to the right clavicle; Resident #86 developed 1 avoidable stage IV wound to the right hip; and Resident #119 developed 2 avoidable wounds: 1 unstageable to the left ischium and 1 stage II to the right foot. Review of facility Quality Assurance and Process Improvement Meeting (QAPI) meeting minutes dated 8/29/17 - 7/24/18 revealed the Medical Director attended 11 out of 13 QAPI meetings. Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed she attended the QAPI meetings and falls were reviewed monthly in the meetings. Continued interview confirmed recurrent falls were reported to the Nurse Practitioners (NP) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . Continued interview confirmed .involvement with pressure ulcers primarily supervisory. I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff that are unfamiliar. Difficult to do training with mostly on the job training, and turnovers in leadership have not been helpful .Falls .We can't tie them up . Continued interview confirmed when the Medical Director signed the Incident/Accident reports she was agreeing with the interventions put in place. The Medical Director stated .the reports are not always timely . Refer to F 550, F657, F 677, F 686, F 689, F 697, F 725, F 726, F 835, F 867, and F 947.

Based on review of the facility Quality Assurance and Performance Improvement Plan, Facility Assessment review, medical record review, observation, and interview, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to have an effective, ongoing QAPI program to ensure an effective falls program was implemented to prevent repeated falls for residents, resulting in injuries after falls. The QAPI committee's failure to ensure an appropriate falls intervention program was implemented, failure to ensure care plans were revised after falls, failure to ensure sufficient staffing to supervise residents at risk for falls, and failure to ensure competent staff, resulted in residents having multiple falls and injuries, and placed 7 residents (#119, #28, #34, #39, #40, #47, and #80) of 40 residents in the facility who had falls, in Immediate Jeopardy (IJ), 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). The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F-657, F725, F 726, F 841, F 867 and F 967. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the facility Quality Assurance and Performance Improvement Plan, revised 2/27/18, revealed .Purpose .[QAPI] Program utilizes an on-going, data driven, pro-active approach to advance the quality of life and quality of care for the residents .Quality Assurance and Performance Improvement principles drive our decision making as we endeavor to produce positive outcomes .QAPI committee consists of representatives from various departments .Performance Improvement Projects (PIPs) will be implemented when an opportunity for improvement is identified. These PIPs may apply to processes or systems throughout the community .QAPI program is ongoing, comprehensive and addresses the services provided .data will be obtained from the following reports .Clinical reports - infection, medication error, pressure injuries, falls .The QAPI team will meet monthly, or more often as needed, to review findings and identify potential PIPs .The Nursing Home Administrator (NHA) and Board of Directors are responsible and accountable for the development, implementation and monitoring of the QAPI program .The Quality Assurance (QA) Committee consists of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the Infection Preventionist .The QA Committee meets at least quarterly to coordinate and evaluate the activities under the QAPI program .The QAPI Steering Committee, which includes the Medical Director as co-chair, meets monthly and is accountable for the continuous improvement in Quality of Life and Quality of Care .The QAPI Steering Committee collects data from QA sub committees (e.g., pain, falls, and weight loss) .All associates including contracted staff are educated on the principles of QAPI .Associates will be trained on using QAPI process including participation on a Performance Improvement Project (PIP Team) .The QAPI program is sustained during transitions in leadership and staffing through all-associate education and involvement in the QAPI process .PIPS .identify areas where gaps in performance may negatively affect resident .In prioritizing activities, the team will consider: high-risk to residents .high-volume or problem prone areas .health outcomes .resident safety .resident choice .At least annually a project that focuses on high risk or problem-prone areas will be addressed through the QAPI program including PIP development .The team will utilize root cause analysis to identify the cause of the problem and any contributing factors. Plan-Do-Study-Act PDSA will also be used .Our community uses a systematic approach to determining the root cause of an issue and any contributing factors. Facility associates and management have been trained on Root Cause Analysis .The QAPI program will be evaluated annually by the QAPI Steering Committee with input from the Leadership Team/Executive Leadership. This review will include whether goals were met, if standards of practice are being followed, any training needs will be identified and addressed . Review of Facility Assessment 2018, dated 6/2/18, revealed .Community Assessment and QAPI .Information from the Community Assessment will be incorporated into the Quality Assurance Performance Improvement (QAPI) process .The identification of residents will help to drive the activities of the QAPI process. The description of care, services and resources available at our community provides both areas for monitoring of processes and outcomes as well as information for investigation of root causes of adverse events and gaps in performance .Community Staff .Our community is overseen by a Board of Directors, an Executive Director and a licensed Nursing Home Administrator. The Medical Director oversees medical practice and provides guidance in the development of clinical policies and programs at our community .Currently, there is 1 Medical Doctor and 2 Nurse Practitioners who visit the community two to three times a week to see residents . Interview with the Director of Nursing (DON) on 8/18/18 at 7:13 PM, in the conference room, confirmed the facility staff were responsible for investigating falls. Falls were reported to the nurse on duty and the accident report was turned into the Clinical Mentor. The Clinical Mentor checked for completeness of the report and the nurse and Clinical Mentor discussed the interventions to put in place to prevent further falls. The DON stated she was not familiar with Long Term Care and had a background in acute care. The DON stated the facility had plans to reinstate a weekly fall meeting that the facility used to conduct before her arrival in April of 2018. The DON was not sure when weekly fall meetings had stopped, but they had reviewed the falls and ensured care plans were updated. The DON stated the current facility practice was for the nurse Clinical Mentor to decide on a fall intervention and to put it in place immediately after an incident. The accident reports were filed and tracked by the Minimum Data Set (MDS) Coordinator in an excel spread sheet that was brought to QAPI. The nurse was to do a fall risk assessment after every fall and it was put with the investigation packet. Any interventions put in place depended on interventions already in place. The DON stated the nurses knew what options were available and they used .nursing clinical judgement [used when deciding which intervention to put in place] .no education on falls .just their [staff] clinic experience . The DON stated fall investigation reports were then brought to a leadership huddle with leadership staff, to the DON, to the Administrator, and to the Medical Director for signatures. The DON stated in the leadership huddles they just reviewed the investigation completed by the unit nurses and looked at what the nurses indicated was the probable cause, interventions nursing implemented, time of fall, and any patterns. The DON stated the nurses did not do any root cause analysis at the time of the fall and the leadership was also not doing a root cause to determine the cause of the fall in order to implement interventions to prevent further falls. The DON stated they were aware the care plans were not updated, I don't know when the care plans [were updated] .the mentor in the house should be updating the care plans .I think that there is work to be done .doing weekly meetings we will be able to get more in depth and with dementia they [residents] forget they can't get up . The facility started a PIP for falls in May after there had been 3 falls with injury and the facility needed to re-evaluate falls. The DON then stated the facility started looking at fall interventions when the new Administrator arrived in June. Interview with the Administrator on 8/20/18 at 12:20 PM, in the conference room, confirmed she led the QAPI meeting and staff discussed how many falls during a month and any trends or patterns. QAPI looked at residents with multiple falls in a month but did not look back further. The Administrator stated they didn't go back and look at every fall back in June or last year.we haven't gotten there yet . The Administrator started a PIP plan and they reviewed falls in the morning meeting. The Administrator stated .some things I was concerned about .some of the interventions were not appropriate .after doing it that month [review of falls in morning meeting], our teams were educated .educate as we go .if nursing staff used same intervention or inappropriate intervention we would educate the mentor at that time . The Administrator stated root cause analysis during falls and related to a history of falls was not being discussed and the first root cause analysis was conducted in July. The facility saw an increase in falls and increase in multiple resident falls, and they looked at one month of falls. The Administrator stated they knew the fall rate increased. The Administrator stated .as we are starting the PIP plan we would talk .about education .have not discussed pressure ulcers in huddle .not sure if they're talking about them in therapy .we have not done it in morning meeting yet . Interview with the Consultant, who was the previous Administrator from 3/18 - 6/18, on 8/20/18 at 1:47 PM, in the conference room, revealed he did not attend the falls meetings or huddles and stated he did not have clinical experience. He stated he relied on the nurses for implementation of interventions. Further interview revealed he became aware approximately the 3rd week of April falls had increased and he .Called on MDS [Minimum Data Set nurse] . to address. He stated, .MDS would facilitate those meetings .informal monitoring to ensure meetings [huddles] being held with [MDS #1] were informal .nothing formal . Interview with the Medical Director on 8/20/18 at 11:14 AM, in the conference room, confirmed recurrent falls were reported to the Nurse Practitioners (NPs) and any concerning issues went directly to the Medical Director. Further interview confirmed .I don't know how much detail is in QAPI meeting . [Medical Director's] involvement with pressure ulcers primarily supervisory, I use wound trained NP's and a wound Nurse . Further interview confirmed .greatest trend identified is the multiple changes in leadership and large turn-over in staff .and turnovers in leadership have not been helpful .Falls .We can't tie them up . Refer to F-550, F-657, F-677, F-686, F-689, F-697, F-725, F-726, F-835, F 841, and F-947.

Based on review of the facility's 2018 Assessment, review of the facility's computer based training documentation, and interview, the facility failed to implement a system to track nurse aide competency levels in order to ensure training was sufficient based on the resident population. The Administrator and the Director of Nursing (DON) were informed of the IJ in the conference room on 8/18/18 at 8:10 PM. The facility was cited Immediate Jeopardy at F657, F689, F725, F726, F841, F867 and F947. The facility was cited Substandard Quality of Care (SQC) at F-689 The IJ was effective 11/10/17 and is ongoing. The findings include: Review of the 2018 Facility Assessment revealed .Each job description identifies the required education .Additional competencies are determined according to the amount of resident interaction required by the job role, job specific knowledge, skills and abilities and those needed to care for the resident population. Certified nursing assistants may have additional required competencies .competencies are based on the care and services needed by the resident population .competencies are verified upon orientation, at least annually and as needed .The Staff Development Coordinator tracks and trends course completion history and performance trends, reporting those to the Administrator and Director of Nursing (DON) . Review of the facility's computer based training documentation revealed no tracking system in place to determine nurse aide competency after required annual training and in-service education, including understanding falls and skin checks. Interview with the Staff Development Coordinator on 8/18/18 at 4:30 PM, in the conference room, confirmed she was not involved in decision making of when nurse aides were competent and did not recall any specific training on falls other than the computer based Relias training assigned during orientation and annually. When asked if falls was covered in that training, the Staff Development Coordinator stated that she thought she remembered something on falls, like what to do if you see water in the floor. Further interview revealed she was new to the position and stated she did not have an annual plan or monthly plan for education. She was still trying to find out where deficiencies in education were and developing an education month to month if someone told her there was a need. Interview with the Staff Development Coordinator on 8/20/18 at 2:49 PM, in the conference room confirmed .[Nurse] Mentors check [computer based training] and HR [human resources] follows that .I just started .orientation begins with me .goes on to mentor .[mentors] pick a preceptor .[nurse mentors] evaluate in 1st 90 days and if not performing .mentors talk to DON [Director of Nursing] .[nurse mentors] keep in contact with HR for Relias [computer based training] .Excel [spreadsheet] is more for me to know who is with what mentor .what household they are [on] . Interview with the Staff Development Coordinator on 8/20/18 at 4:55 PM, in the conference room, confirmed the facility did not have a system in place to track and trend the competency levels of nurse aides. Refer to F-550, F-677, F-689, F-725