**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for two (Resident #1 and Resident #2) of five residents reviewed for accidents and hazards. The facility failed to: - Address or put in place new interventions when Residents #1 and #2 had a change-in-condition and began experiencing more frequent falls in a short time-frame. - Implement the new intervention of a helmet that was documented in a nursing noted for Resident #2 after a fall on 07/27/24. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 09/18/24 at 9:15 AM. While the IJ was removed on 09/19/24 at 3:55 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk of harm, injuries, or hospitalization. Findings included: Resident #1 Review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including COPD (a chronic lung disease), morbid obesity, TBI, and a risk of falling. Review of Resident #1's quarterly MDS assessment, dated 07/17/24, reflected a BIMS of 8, indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she had not experienced any falls since admission. Review of Resident #1's quarterly care plan, dated 09/03/24, reflected she was a moderate risk for falls related to gait/balance problems with an intervention of evaluation and treating as ordered or PRN. The care plan was not revised or updated to include additional interventions after she experienced falls on 08/21/24, 08/23/24, and 08/24/24. Review of Resident #1's progress notes, dated 08/21/24 at 8:28 PM and documented by LVN A , reflected the following: [Resident #1] noted lying on her right side in front her wheelchair I missed my bed while transferring myself I just sled [sic] off the chair I have no pain from the fallstated [sic] assessed for injuries none noted assisted to the bed . Review of Resident #1's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 08/21/24. Review of Resident #1's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted after the fall on 08/21/24 at 7:23 PM. Review of Resident #1's progress notes, dated 08/23/24 at 3:22 PM and documented by RN B , reflected the following: [Resident #1] had an unwitnessed fall in her room. She denied hitting her head on the floor. Head to toe examination was done and no obvious injuries were noted . Review of Resident #1's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 08/23/24. Review of Resident #1's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted after the fall on 08/23/24 at 5:52 PM. Review of Resident #1's Fall Risk Evaluation, dated 08/23/24, reflected she was a high risk for falls. Review of Resident #1's progress notes, dated 08/24/24 at 7:34 AM and documented by LVN C , reflected the following: CNA called this nurse. This nurse entered room and found [Resident #1] lying on the bathroom floor in prone position. Put [Resident #1] back to wheelchair with 3 people assistant [sic]. [Resident #1] able to explain the situation. I was self-transferred [sic] to use toilet and fell. [Resident #1] complained pain on left hip and forehead 10 out of 10. [Resident #1] has a big bump on top of left eye. It's getting bigger. Sent to (hospital) . Review of Resident #1's progress notes, dated 08/24/24 at 1:32 PM and documented by LVN C, reflected the following: [Resident #1] came back with EMS stretcher. [Resident #1] companied [sic] of pain left hip and left side of forehead. Gave pain medication. CT scan is cleared . Review of Resident #1's ER discharge documentation, dated 08/24/24, reflected she was seen for a hematoma of scalp. Review of Resident #1's Fall Risk Evaluation, dated 08/24/24, reflected she was a moderate risk for falls. Review of Resident #1's progress notes, dated 09/02/24 at 9:37 AM and documented by LVN C, reflected the following: [Resident #1] was found on the floor at 8:20 AM, face down and bleeding from the forehead. [Resident #1] was unresponsive and without a pulse . Review of Resident #1's hospice note, dated 09/02/24, reflected the following: .ME contacted at 10:37 AM spoke with the investigator (name), gave ME all information on [Resident #1] and past falls that occurred. ME stated that they will be picking up the body d/t falls . [Resident #1]'s left eye is dark purple d/t fall last weekend. On 09/03/24 at 11:27 AM, all neurological checks for Resident #1 for the past month were requested from the ADM. During an interview on 09/03/24 at 12:00 PM, the ADM stated he was being told that there was only one neurological check conducted and had a copy of the one from 08/23/24. During an interview on 09/03/24 at 5:03 PM, the DON stated the last time she saw Resident #1 was on 08/30/24. She stated she remembered she had bruising from a fall by her left eye but could not remember the color. She stated it was the nurses' responsibility to document bruising in the residents' progress notes and skin assessments. The DON was asked if it met her expectations that the bruise was not documented and she stated, Well, it was fading . Resident #2 Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including mild intellectual disabilities, age-related physical debility, unsteadiness on feet, and other lack of coordination. Review of Resident #2's significant change in status MDS assessment, dated 07/26/24, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she had experienced a fall since admission that resulted in a major injury. Review of Resident #2's quarterly care plan, dated 06/12/24, reflected she had an actual fall with an intervention of checking range of motion daily. The care plan was not revised or updated to include additional interventions after she experienced falls on 06/14/24, 07/21/24, and 07/27/24. Review of Resident #2's progress notes, dated 06/14/24 at 7:17 PM and documented by LVN B , reflected the following: [Resident #2] was transferred to the hospital post fall. The documentation did not reflect what/how the fall occurred. Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 06/14/24. Review of Resident #2's assessments in her EMR, on 09/04/24, reflected six neurological checks were conducted; 06/14/24 at 10:14 PM and 06/15/24 at 6:27 AM, 6:34 AM, 6:42 AM, 1:24 PM, and 11:37 PM. Review of Resident #2's ER documentation, dated 06/14/24, reflected the primary impression was a scalp contusion. Review of Resident #2's progress notes, dated 06/19/24 at 12:44 PM and documented by the DON, reflected the following: [Resident #2] was sent to the hospital for further evaluation . There was no documentation reflecting why further evaluation was needed. Review of Resident #2's progress notes, dated 07/21/24 at 1:25 PM and documented by LVN E , reflected the following: . [Resident #2] was found kneeling on the floor, using her hands to hold the upper body up. She was morning [sic] in pain, while bleeding from the back of her head . 911 was called . Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 07/21/24. Review of Resident #2's assessments in her EMR, on 09/04/24, reflected one neurological check was conducted on 07/21/24 12:00 PM. Review of Resident #2's progress notes, dated 07/27/24 at 12:39 AM and documented by LVN A, reflected the following: [Resident #2] returned from (hospital) . [Resident #2] has dx of L1 fracture and well as seventh left side rib fracture . Review of Resident #2's progress notes, dated 07/27/24 at 5:14 PM and documented by LVN B, reflected the following: [Resident #2] fell in the hallway while using her walker to ambulate . Review of Resident #2's progress notes, dated 07/30/24 at 9:34 AM and documented by LVN B, reflected the following: . history of falls. Intervention for frequent falls will include use of helmet as an intervention. The helmet was not listed as an intervention in her care plan, nor was there a physician order for a helmet. Review of Resident #2's assessments in her EMR, on 09/04/24, reflected neither a skin/fall assessment were conducted after the fall on 07/27/24. During an observation and interview on 09/03/24 at 12:36 PM, Resident #2 was in the dining room eating lunch. She was unable to answer questions appropriately and was fixated on missing clothes. She was not wearing a helmet. Observation on 09/03/24 at 12:42 PM revealed the helmet was not able to be located in Resident #2's room. A telephone call was made on 09/03/24 at 12:48 PM to LVN B to ask about the documentation of the helmet. A returned call was not received prior to exiting. During an interview on 09/03/24 at 12:50 PM, LVN F stated if a resident had an unwitnessed fall, a head-to-toe assessment would need to be conducted. She stated she would document the fall and conduct neuros every 15 minutes X4, every 30 minutes X4, and so on for 72 hours. She stated neuro checks were documented in the residents' EMR, not on paper. LVN F stated she did not believe Resident #2 had a helmet as she had never seen her wearing one. During an interview on 09/03/24 at 2:37 PM, the DON stated after a resident has a fall the nurse is to complete an assessment. She stated after the assessment is complete, if there was no injury, the nurse would get the resident up. She stated the nurse then had to monitor the resident for three days. She stated if it was an unwitnessed fall you had to treat it as a head injury so neuro checks would need to be documented for 72 hours, a fall assessment would need to be completed, and one more thing, but I cannot remember what it was. She stated she was responsible for ensuring neuro checks were done and to complete any missing items. She stated it would not meet her expectations if neuro checks were not documented after a fall and maybe the nurses did them on paper - I am sure it is there. When asked why fall risk assessments were not completed accurately, why new interventions were not put into place when both Residents #1 and #2 began experiencing more frequent falls in a short time period, and why Resident #2's helmet intervention was never implemented, the DON just shook her head and said it probably all happened before she started working at the facility. She stated resident falls were discussed in the morning meetings and if need be, the IDT would get together to discuss new interventions for safety, but could not answer why this was not done for Residents #1 and #2. During an interview on 09/03/24 at 2:44 PM, LVN G stated neuro checks and fall assessments were documented in the residents' EMR, not on paper. During an interview on 09/03/24 at 2:50 PM, RN H stated neuro checks and fall assessments were documented in the residents' EMR, not on paper. During an interview on 09/03/24 at 4:17 PM, the ADM stated if an aide found a resident on the ground, they should notify the nurse immediately who would conduct a fall assessment and beigin doing neuros. He stated all falls were discussed in the morning meetings and the DON was responsible for ensuring all assessments were being completed. He stated a negative outcome of not completing all proper assessments could be that an injury could go missed, or if they hit their head, they could have a brain bleed. During an interview on 09/03/24 at 4:52 PM, the DON stated she started an in-service (that day) on neurological checks being documented on an observation sheet (paper). She stated she started the in-service because she could not find the missing neuro checks in the computer for Resident #1 and #2. During a telephone interview on 09/04/24 at 9:39 AM, Resident #1 and #2's MD stated he was notified of their increase in falls. He stated if a resident had an unwitnessed fall or hit their head, he would expect neurological checks to be conducted for 72 hours to ensure there was not a change in condition. He stated he would have expected the facility to have put new interventions in place when the falls increased. Review of the in-service entitled Falls, dated 09/03/24, reflected the following: Neurological checks must be done on all falls, witnessed and unwitnessed falls. Neuro checks will be done: Q 15 minutes X 4 Q 30 minutes X 4 One hour X 4 Every 8 hours until completion of 72 hours Review of the facility's Fall Evaluation and Prevention Policy, revised 08/2020, reflected the following: Purpose: To ensure that the resident's environment remains as free of accident hazards as possible, and that each resident receives adequate supervision and assistance to prevent accidents. The facility will evaluate residents for their fall risk and develop interventions for prevention . The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. Following a fall, the following steps should be undertaken: -Evaluate the resident promptly in order to identify and treat injuries. The resident should not be moved until the licensed nurse has evaluated their condition, unless absolutely necessary. The evaluation should include vital signs and neurological status. - If there was a loss of consciousness or the fall was unwitnessed, neuro signs should be initiated and checked for at least 72 hours. - Following the resident's evaluation, transfer the resident to the appropriate surface and evaluate further if indicated. Monitor closely for indications of pain or discomfort in any area, reddened or discolored areas, or other signs of injury. The ADM and DON were notified on 09/18/24 at 9:15 AM that an IJ had been identified and an IJ template was provided. The following POR was approved on 09/19/24 at 7:40 AM: The notification of Immediate Jeopardy states as follows: F689 -The facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision. Action: DON and ADON in-serviced by CNO on Inservice on Fall Documentation and interventions, Assessments and interventions, on Fall policy and procedure, and on Abuse and Neglect. Start Date: 9/18/24 Completion Date: 9/18/24 Responsible CNO Action: In-service on Fall policy and procedure implemented to all nursing staff- Ongoing until 100% completion. All Nursing Staff will complete in-service prior to starting their next shift. Start Date: 9/18/2024 Completion Date: 9/18/2024 (any nursing staff not completed the in-service, will not be permitted to work a shift until in-service has been completed.) Responsible: DON, ADON , Administrator Action: Inservice on Abuse and Neglect implemented to all staff, ongoing until 100% completion. Staff will complete in-service prior to starting their next shift. Start Date: 9/18/2024 Completion Date: 9/18/2024 (any staff not completed the in-service, will not be permitted to work a shift until in-service has been completed.) Responsible DON, ADON, Administrator Action: Inservice on Fall Documentation, Assessments, and fall intervention, has been implemented with all Nurses, Ongoing until 100% completion. Staff will complete in-service prior to starting their next shift. Start Date: 9/18/2024 Completion Date: 9/18/2024 (any Nurse not completed the in-service, will not be permitted to work a shift until in-service has been completed.) Responsible DON, ADON, Administrator Action: Audit all resident with fall risk to ensure interventions are in place and documented Start Date: 9/18/2024 Completion Date: 9/18/2024 Responsible DON, ADON, MDS, Administrator Action: ADHOC Qapi meeting conducted by IDT Team on fall events. Attending staff Admin, DON, ADON, SW, DOR, Activities Director will attend. Start Date: 9/18/2024 Completion Date: 9/18/2024 Responsible Administrator, DON, ADON, SW, DOR, Activities Director. The Surveyor monitored the POR on 09/19/24 as followed: During interviews on 09/19/24 from 11:56 AM - 3:20 PM, staff from all shifts were interviewed (one RN, four LVNs, four CNAs, and two MAs ). The CNAs and MAs all stated they were in-serviced before their shifts on abuse and neglect and the facility's fall policy. They all stated if they witnessed a resident on the floor, they would press the call light or call for a nurse so they could be assessed. They stated they would not move the resident nor would they leave the resident alone. The nurses all stated they were in-serviced before their shifts on abuse and neglect and falls. They all stated if a resident fell, they would immediately assess them with a head-to-toe assessment and ensure they were not bleeding. They would conduct a fall assessment, fall risk assessment, and start neurological checks if they hit their head or if the fall was unwitnessed. They all stated that neurological checks needed to be documented and continued for 72 hours. They all stated neuro checks popped up in the EMR when the next one was due. They stated the importance of documentation was to ensure all assessments had been completed and all of the nursing staff were aware of the fall. They stated if a resident began having more frequent falls, it was important to put further interventions in place to attempt to lessen the number of falls. During an interview on 09/19/24 at 3:06 PM, the DON stated she, the ADON, and ADM received training by their CNO. She stated fall risk assessments should be done on admission, quarterly, and after a fall. She stated neuro checks were to be done every 15 minutes x4, every 30 minutes x4, every hour for 24 hours, and completed after 72 hours. She stated she was completing daily audits after resident falls of nursing documentation of neuro checks, fall assessments, and fall risk assessments. Review of the facility's QAPI Meeting Agenda, dated 09/18/24, reflected the ADM, DON, ADON, SW, DOR, AD, and MD were in attendance. Review of an in-service, dated 09/18/24 and conducted by the CNO, reflected the ADM, DON, and ADON were in-serviced on the Fall Management Policy and Procedure. Review of an in-service, dated from 09/18/24 - 09/19/24 and conducted by the DON, reflected all staff were in-serviced on abuse and neglect. Review of an in-service, dated from 09/18/24 - 09/19/24 and conducted by the DON, reflected all nursing staff were in-serviced on frequent rounding, documentation of falls, conducting neuros, and fall and skin assessments, and their fall policy. Review of nine residents' EMRs that experienced a fall in September 2024, on 09/19/24, reflected updated care plans, a fall assessment, a fall risk assessment, and neuro checks as needed. While the IJ was removed on 09/19/24 at 3:55 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) experiencing falls. The facility failed to include frequent falls as a focus area to provide possible preventive interventions despite the resident having serious injuries from falls in his recent history, prior to admission and multiple falls since his admission. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/01/24 at 6:03PM and the facility was notified and given an IJ template. While the IJ was removed on 06/04/24 at 4:00 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at an increased risk for falls, injury, or death, due to an interdisciplinary team not having included interventions in the care plan developed specifically to meet the needs of each resident. Findings include: Review of Resident #1's Face sheet, undated, revealed he was admitted to the facility on [DATE] from a local hospital. Resident #1's admitting diagnoses included traumatic subdural hemorrhage (brain injury resulting in a bleed from a vessel causing blood to collect between the brain and skull), epileptic seizures, fracture of skull and facial bones, unspecified fall. Review of Resident #1's Local Hospital Discharge summary dated [DATE] revealed Resident #1 had been admitted on [DATE] with a problem list of 1.Fall with Injury (Acute, Onset:3/13/24) 2. Intercranial subdural hemorrhage (Acute, Onset:03/13/24) discharge date : 4/29/24 Discharge diagnosis: Found down with TBI Pt condition on discharge: stable. Review of Resident #1's 5-day MDS assessment, dated 5/3/24 revealed a BIMs score of 10 indicating moderate cognitive impairment. In section J for the question asking has the resident had a fall in the last month prior to admission/entry or reentry the answer is yes. For any falls since Admission/entry or reentry or prior assessment the answer is no. (Resident #1 had falls on 5/1 and 5/2.). Review of Resident #1's admission MDS assessment, dated 5/3/24 revealed a BIMs score of 10 indicating moderate cognitive impairment. Section GG notes Resident #1 is dependent on staff helper does all the effort to walk ten feet. In section J for the question asking has the resident had a fall in the last month prior to admission/entry or reentry the answer is No . For any falls since Admission/entry or reentry or prior assessment the answer is no. (Resident #1 had falls on 5/1 and 5/2.) Review of Resident #1's Care Plan revealed falls are not included in the areas addressed. The only area addressed with a goal and interventions is elopement initiated on 4/29/24. Another focus area listed was the resident requires antidepressant medication. There are instructions to include the medication and the diagnosis, however, neither are included. There are no goals and no interventions. The focus area was initiated 5/1/24. The third and final focus area states the resident has impaired cognitive function/dementia or impaired thought processes. The goal is the resident will maintain his current level of cognitive functioning. No interventions are listed. Review of Resident #1's Care Plan Conference, dated 5/6/2024 revealed that other than the resident's name and date the form is blank . Review of Resident #1's Nursing Progress Notes reveals falls documented on 5/1/24, 5/2/24, 5/4/24, 5/5/24, 5/10/24, 5/15/24, and 5/30/24. The fall on 5/1/24 required a trip to the hospital for a CT scan after Resident #1 complained of hitting his head. The fall on 5/30/24 required overnight hospitalization after the facility nurse found Resident #1 on the floor in his bathroom with a knot to the back of his head. Observations and interview on 6/1/24 at 9:40 AM of Resident #1's room revealed he was sitting in the room attempting to put on his shoes. Resident #1's bed was noted to be neatly made with the call light attached to the top cover of the bed which was at a normal bed height. A fall mat was noted to be folded against the wall on the opposite side of the room near an empty bed. When asked what the call light was for Resident #1 was unsure. When asked if he could use it to call for help such as when going to the bathroom, Resident #1 denied that he needed help and began to stand from his wheelchair. Resident #1 was able to read a sign on his wall that said his family did his laundry but there were no other signs in the room including any to prompt him to call for help. Observation on 6/1/24 at 1:40 PM of Resident #1's room revealed the bed remained at a normal height and fall mat remained in the same position against the wall on the other side of the room. Interview on 6/1/24 at 10:25 AM with Resident #1's FM revealed there is a concern that he will reinjure his head with all these falls he has been experiencing at the facility. The FM stated he had a TBI in 2004 and recently a few months ago was found wandering around after a fall at his apartment and his brain bled again causing the damage to his brain to be worse. They were told that he does not need to be getting any further injuries to his head. The FM stated the facility is frequently calling family saying that he has fallen but they will lower his bed and use a mat beside his bed. It does not seem to have worked. The FM stated I wish they would understand that he is probably trying to take himself to the bathroom when he falls, does anyone ever ask him if he needs to go to the bathroom and offer to help. He frequently is urinating in clothes baskets and trash cans. He has brain damage he cannot remember to call for help, they say they are reminding him but that is not helping either. The FM stated they have not been asked to meet with a team to discuss a plan of care about him they have just been telling ideas to random people that they meet one time then the next time they go it will be somebody new in that position. The FM has tried explaining to staff Resident #1 is left-handed and gets up from the bed easier if he can use that side, but they have the bed positioned so that is not possible . The FM stated it seems as though it is just a matter of time before he has a fall that will hospitalize him again. Interview on 6/1/24 at 1:45 PM with CNA A who had worked the 6am to 2pm shift, revealed that she was unable to speak English. When the surveyor pointed to the mat folded against the wall and asked if it was for Resident #1, MA B came in from the hallway and said CNA A did not understand what the surveyor was asking but it was a mat for Resident #1 and the bed was supposed to be in a low position but Resident #1 must have moved the mat and lowered the bed. MA B was asked to ask CNA A if she was aware the bed was to be low and fall mat was to be beside his bed, and CNA A shook her head No. MA B stated CNA A knows now because she just explained it to her. Interview on 6/1/24 at 1:47 PM with MA B revealed she had been aware of fall precautions were to be in place for Resident #1 but had not noticed today that they were not in place. When asked how she and the CNAs learn who is on fall precautions she stated the nurse for the hall would tell the staff in the morning rounds. Interview on 6/1/24 at 1:58 PM with RN C revealed he is the nurse for Resident #1's hall working the 6 AM to 6 PM shift. RN C stated he was made aware this morning during report, from the previous nurse, that Resident #1 had returned from the hospital yesterday after a fall during which he had hit his head. RN C stated the nurse had written on the 24-hour report that the resident was a high fall risk, but RN C was not aware that included the use of the fall mat and bed in lowest position, therefore he was not checking for those things this shift and had not told CNA A anything other than Resident #1 was a high fall risk. Interview on 6/1/24 at 2:04 PM with the facility DON revealed the mat and bed in low position would normally be in place, but the hospital had returned Resident #1 last night without giving them a heads up that he was returning and therefore the staff had probably not been prepared for him. Interview on 6/1/24 at 2:23 PM with CNA E revealed she is working the 2-10 shift tonight on Resident #1's hall. CNA E stated she has worked with Resident #1 multiple times during the month he has been here, but he has not fallen while she was working with him. She stated until today when she came into work, she was not aware that they were to be having the bed in the lowest position and a fall mat in place. CNA E stated she has seen Resident #1's bed low and fall mat in place but she did not know they were always supposed to have those precautions in place. CNA E stated there is not a place where the CNAs can look to see interventions/ care plan or what they are to do but the nurses will tell them when they come to work. If they have a question they can ask the nurse if they are available. CNA E stated the area where the CNAs document does say Resident #1 is high fall risk. But does not say anything about the bed position or fall mat. Interview on 6/1/24 at 3:07 PM with NP Q revealed she normally would be the NP for Resident #1. She stated she did not know about any of the falls except the one recently when he hit his head of the floor, so she sent him to the hospital. Her expectation is that if a resident has more than one fall, fall precautions are put in place. Interview on 6/2/24 at 9:56 AM with LVN F revealed that she had just come to work at 6 AM and was told Resident #1 was a 1:1 now because of the number of falls he had since his admission. LVN F stated she knew about his falling before today but felt like the nursing staff was doing all they could to protect him. If he falls, they lower his bed and put the mat down next to the bed. Now they will be adding the soft helmet. When asked how long the bed is to stay on low and fall mats should be in place, she said it probably should stay that way but if not, then they do it each time he falls. Interview on 6/2/24 at 10:04 AM with CNA G revealed today is her first day to work with Resident #1. She stated she is providing the 1:1 and was told to make sure she uses the fall mat and document every 30 minutes what he is doing. She stated he mostly has been sleeping but when she asks him if he wants to go to the dining room or if he needs to go to the bathroom he does so without problems. CNA G stated she is trying to teach him to use the call light, and he seems to understand. Interview on 6/2/24 at 2:20 PM with CNA E revealed she will be providing Resident #1's 1:1 supervision tonight. She knows he needs to have the helmet, the bed in low position and the mat on the floor in front of the bed when he is in bed. When asked how she was aware of all that she said the nurse let her know and there is an in-service she read today. When asked if she is always able to remember each person's needs, she stated usually but if she does not, she can ask the nurse, and she has heard it is being added to the CNA's POC . When asked if she could show the surveyor the plan of care that CNAs use, she agreed. We went to the nurse's station, and she showed the surveyor where they document the amount of meals eaten and if the resident had been checked on every 2 hours. When asked where the mat, bed, 1:1 and helmet info was she initially was not sure and asked another staff to show her. The other staff found where there is a check off for whether the resident is incontinent and the use of the helmet, which was added today. There is no mention of the low bed or the fall mat use. Interview on 6/2/2024 at 11:49 AM with the MDS Nurse revealed he does at times add needed items to the care plans of residents, but he works as needed and part time. The MDS nurse stated that the DON and SW can also add anything needed. He does not recall developing a care plan for Resident #1, but he may have. He stated when someone was admitted it is usually the nursing staff or DON that will initiate a care plan. The MDS nurse stated when they are answering the section in the MDS assessment about falls they are only looking at the previous 7 days. If Resident #1 had as many falls as you are describing it should have been added to the care plan by the DON since he is usually only at the facility on weekends. The MDS nurse was asked if there is a purpose for the CNAs to see the interventions in the POC and he stated so that they can know those things need to be done for the residents. He stated he went over the Care Plan for Resident #1 yesterday and they added falls and the use of a fall mat and soft helmet. Interview on 6/3/24 at 3:30 PM with the facility DON revealed that when asked if he could provide any documentation regarding interventions and/or precautions put in place to prevent further falls he stated when a fall occurred, they put out a fall mat and have the bed in lowest position, that is the interventions. The nurses do so after every fall. When asked about documentation of these interventions the DON stated the nurse's progress notes will contain that information. When asked if the falls are being tracked for patterns which may provide additional interventions, the DON stated other interventions are listed on internal documents that could not be shared with the surveyor, and the falls are reviewed in the morning meetings. Investigations are performed by the nursing staff and are included in the progress notes. Additionally, the facility's written Incident Reports are internal documents that also could not be provided. He suggested the surveyor look at the progress notes of the nurses to obtain information needed. The DON stated he just became aware yesterday that he can add areas of focus to the care plan, he had not known before, and he agrees it should be added for this resident. Interview on 6/3/24 at 3:35 PM with the Administrator revealed he is aware there is a problem with the care plans. They have hired a new SW and have the MDS nurse so plan to make all corrections soon. The ADM stated they review all investigations that the nurse writes in the progress notes, during the morning meeting and are considering that as an interdisciplinary meeting for everyone who had an incident and/or accident. All department heads, administrators, nursing, wound care nurse, the DON, the activities person, and rehab medical director will sign off if there are any orders as a result of the meeting. The Administrator stated the fall precautions were put in place after each fall by the nursing staff. Each time a fall was documented it automatically populated the fall risk assessment, the bed being lowered to the lowest position and a fall mat being placed at the bedside. The Administrator stated they cannot prevent a person from falling that is an unrealistic expectation. The Administrator confirmed knowing that investigations at times provided other interventions such as the possibility of a toileting program to prevent Resident #1 from attempting to get up without assistance. He was not aware that Resident #1's family felt falls could be related to him trying to get to the toilet. Review of the facility policy titled Care Planning, undated, revealed, the Purpose of the policy is: To ensure that a comprehensive person-centered care plan is developed for each resident based on their individual assessed needs. The policy includes that each resident's plan will describe the following: Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. I. The facility Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident in accordance with OBRA and MDS Guideline II. The Care Plan serves as a course of action where resident (resident family and/or guardian or other legally authorized representative), resident's attending physician, and IDT work to help the resident move toward resident specific goals that address the resident's medical nursing, mental and psychosocial needs. III. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with OBRA/NDS guidelines and updated as indicated for change in condition, onset of new problems resolution of current problems and as deemed appropriate by clinical assessment and judgement on an as needed bases . The ADM was notified on 06/01/2024 at 06:03 PM, that an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/04/2024 at 12:35 PM, and included: Plan of Removal Immediate Jeopardy On 06/01/2024 an abbreviated survey was initiated at the facility. On 06/01/2024 the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of immediate Jeopardy states as follows: F656 -The facility failed to develop and implement a comprehensive person-centered care plan for each resident. Resident #1's care plan did not include interventions to possibly prevent falls despite a history of falls with serious injuries. Action: A Fall reassessment for Resident #1 was completed by DON on 6/1/24 and the Care Plan was updated on 6/1/24 for Resident #1 to reflect the appropriate interventions to try to help prevent injury from further falls. Resident #1 and room was reviewed to ensure that documented interventions were in place as documented in the plan of care. Intervention for safety helmet placement and fall monitoring rounds was implemented. An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on the fall management program policy and procedure along with communicating updated interventions during shift change and staff responsibilities, prior to them working the floor. All staff were re-educated on the regulatory guidelines and facility policy and procedures regarding Abuse, Neglect and Exploitation. Start Date: 06/01/2024 Completion Date: 06/01/2024 Responsible: DON Action: A full house fall risk reassessment was implemented and completed by DON for all residents to ensure no additional residents are at risk, and Care Plans will be updated to reflect appropriate fall interventions. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: DON was reeducated on the facility fall management program policy and procedure along with communicating updated interventions. Start Date: 6/1/24 Completion Date: 6/1/24 Responsible: Clinical Nurse Consultant Action: An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on the fall management program policy and procedure along with communicating updated interventions and staff responsibilities, prior to them working the floor. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: DON will monitor that clinical staff is compliant with following the Policy and Procedure for the facility's Fall Management Program and their responsibilities which include communication during shift change, review of 24-hour report and implementation of interventions for any resident that is a fall risk. 24-hour report will be reviewed by DON during morning clinical meetings. DON will report progress with monitoring to the QAPI team for review to implement any needed changes or updates to ensure compliance. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: New system implementation of tracking resident falls and interventions in a fall tracking binder for daily review by charge nurses which will help identify residents with multiple falls and appropriate interventions. DON will audit binder for updates and completeness. DON will audit the binders daily for a week, biweekly for a month, monthly for QAPI. Audit results will be reviewed and shared with QAPI team. Start Date: 06/02/2024 Completion Date: 06/03/2024 Responsible: DON Action: An Ad-[NAME] QAPI meeting was held by DON, MD, and Administrator regarding facility fall management program policy and procedure along with communicating updated interventions. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON The Surveyor monitored the POR on 06/04/24 as followed: During an interview on 6/4/24 at 9:35 AM with the Facility DON revealed. In-serviced staff on falls and ANE. Monitoring fall risk residents' daily and documenting to ensure interventions implemented and for any new incidents. No new incidents. Resident #1 family aware Resident #1 would get out of bed independently without asking for assistance and aware of Resident #1's impulsiveness, which was why Resident #1's family placed him in facility because they could not manage how often Resident #1 would fall. During an interview on 6/4/24 at 9:40 AM with the ADM, he said the facility updated Resident #1's care plan, implemented a new binder system on fall risk, put helmet on Resident #1, removed electronic control from bed, and ordered a PVC bed that would go on the floor for Resident #1 when the order arrived. Observation and interview on 6/4/24 at 10:16 AM of Resident #1 revealed he was lying in bed. Resident #1 was clean, dressed, and comfortable. Resident #1 had a fall mat next to his bed. Resident #1's bed was in low position. CNA J was sitting in a chair with 1:1 monitoring sheets across Resident #1. Resident #1 had two postings on the wall behind his bed that stated he was to wear a helmet when he got out of bed at all times and that he must have a fall mat next to his bed at all times. During an interview, Resident #1 stated he was doing fine, staff checked on him often, he had some falls in the past, staff were monitoring him, he wore a helmet whenever he got out of bed, his fall mat was always next to his bed, his bed was always in lowest position, and he had no concerns or issues. On 6/4/23 at 10:23am the facility POR for F656 was approved. During an interview on 6/4/24 at 10:21AM, CNA J revealed she was 1:1 monitoring Resident #1. CNA J stated she filled out a monitoring form that was submitted to the Charge Nurse at the end of her shift reflecting she monitored Resident #1 every 30 minutes. CNA J stated Resident #1 had no falls since her shift. CNA J also stated Resident #1's bed had been in the lowest position, had a fall mat next to his bed, and Resident #1 had been wearing a helmet for a while. CNA J did not know how long Resident #1 had the interventions that were previously mentioned or when the interventions started. She was in-serviced on falls and ANE before she started her shift. She learned how to prevent falls, listening to call lights, ensuring beds were at lowest position, ensuring fall mat on floor, ensuring belongings within reach, ensuring Resident #1 wore safety helmet, who and how to report ANE, and ADM was the abuse and neglect coordinator. During an interview on 6/4/24 at 10:30 AM, RN H revealed she had conducted 1:1 monitoring for Resident #1. RN H stated she documented the 1:1 monitoring every 30 minutes on a log. RN H also stated CNAs are 1:1 monitoring Resident #1 and logging their monitoring during their shift every 30 minutes. RN H stated she was in-serviced on falls and ANE. RN H also stated Resident #1 had a helmet on anytime he was out of bed, had a fall mat next to his bed at all times, and bed was in lowest position. RN H was in-serviced on how to respond to falls, resident rights, who and how to report ANE, and ADM was the abuse and neglect coordinator. Reviewed fall tracking binder daily. During an interview on 6/4/24 at 12:33 PM, ADM stated DON completed Resident #1's fall reassessment on 06/01/24. ADM also stated Resident #1's care plan was updated by the facility MDS Coordinator on 06/01/24. ADM stated DON reviewed Resident #1's room to ensure care plan interventions were implemented on 06/01/24. ADM also stated Resident #1's fall monitoring rounds conducted by clinical staff (nurses and CNAs) started every 30 minutes on 06/02/24 and ongoing. Resident #1's safety helmet placement was implemented. DON in-serviced clinical staff on fall management and ANE started on 06/01/24 and ongoing before staff started shifts. ADM stated he did not know CNA M was not in-serviced prior to starting his work shift on ANE and falls. DON conducted fall risk reassessment on all residents started on 06/01/24 and completed 06/02/24. He was not sure if there were any other residents identified as at risk and if there were any other residents who required updated care plans to reflect appropriate fall interventions. Clinical Nurse Consultant reeducated DON on fall management policy and procedure on 06/01/24. DON started daily monitoring clinical staff to ensure compliant with fall management by auditing the new system implementation of tracking resident falls and interventions in a fall tracking binder that was daily reviewed by charge nurses on 06/02/24. DON started reviewing all residents' 24-hour reports during morning clinical meetings started on 06/01/24 and completed 06/02/24. On 06/02/24, him, DON, and MD had QAPI meeting. DON reported progress with monitoring during the meeting. No changes or updates to ensure compliance needed to be done following QAPI meeting to discuss 24-hour reports. Charge nurses daily reviewed new system implementation of tracking falls and interventions from fall tracking binder started on 06/02/24 and ongoing. Observation on 6/4/24 at 1:17 PM of Resident #1 revealed he was sitting in his wheelchair and wore a safety helmet while watching tv in his room. During an interview on 6/4/2024 at 1:48 PM with the MDS Coordinator revealed he updated Resident #1's care plan on 06/02/24. He and the DON updated residents' care plans to reflect fall interventions on 06/01/24 and was ongoing. During an interview on 6/4/24 at 2:08 PM with the Clinical Nurse Consultant revealed she reeducated DON on 06/01/24 on fall management policy and procedure. During an interview on 6/4/24 at 2:11 PM, the ADM revealed Resident #1's safety helmet was implemented on 06/02/24. Review of the facility's in-services revealed clinical staff were trained on fall prevention protocol and interventions on 06/01/24-06/03/24. Review of Resident #1's care plan revealed his care plan was reviewed and revised on 06/01/24 to reflect new interventions. Review of Resident #1's progress notes revealed the following: On 6/1/24 at 7:57 PM RN H documentation included that Resident #1 was a high fall risk having had more than four falls the previous month. Resident #1's Care Plan was updated with fall risk prevention and management in-service was conducted regarding fall risk management and prevention. 1:1 sitter was implemented for his safety, other fall safety prevention was carried out including the bed in the lowest position, call light within reach and a fall mat next to his bed. On 6/2/24 at 10:53 AM LVN F documented Resident #1 remained with a 1:1 sitter, call light was within reach and resident was educated several times to use call light for help. During an interview on 6/4/24 at 2:18 PM, DON revealed he completed fall reassessment on Resident #1 on 06/01/24. MDS Coordinator and him sat and revised Resident #1's care plan on 06/01/24. He conducted fall risk assessment again on all residents on 06/02/24. There were some residents who were flagged as fall risks and nurses flagged some residents because nurses believed they were fall risks. He and the MDS Coordinator updated PCC profile to reflect residents were fall risks and the nurses and MDS coordinator updated care plans to reflect fall interventions started on 06/01/24 and ongoing. Clinical Nurse Consultant reeducated him over the phone on fall program policy and procedure on 06/01/24. She taught him on pulling fall reports, fall risk assessments, bed positioning, fall mat implementation, safety helmets, binder to track falls, ANE, and wander guards. He reviewed 24-hour reports during morning clinical meetings since his employment. He did not have anything to report to QAPI during meeting that needed changes or updates to ensure compliance. He started auditing the fall tracking binder daily since 06/02/24. 1:1 monitoring on the night of 06/01/24. He, ADM, and MD attended QAPI meeting on 06/02/24. Review of residents who were high risk for falls in PCC revealed care plans revised for fall risk, interventions, and PCC profile noted they were fall risks. Review of the facility's QAPI meeting, dated 06/02/24, revealed ADM, DON, and MD attended. The ADM was notified on 06/04/2024 at 03:50 PM that the Immediate Jeopardy was lowered. While the IJ was removed on 06/04/2024, the facility remained out of compliance at a scope of isolated and a severity of no actual harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not have repeated falls without attempts to decrease the severity and frequency of falls that continued to occur despite the same two interventions used each time a fall occurred. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/01/24 at 6:03PM and the facility was notified and given an IJ template. While the IJ was removed on 06/04/24 at 4:00 PM, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk for falls possibly resulting in injuries including traumatic brain injury, hospitalization and/or death. Findings included: Review of Resident #1's Face sheet, undated, revealed he was admitted to the facility on [DATE] from a local hospital. Resident #1's admitting diagnoses included traumatic subdural hemorrhage (brain injury resulting in a bleed from a vessel causing blood to collect between the brain and skull), epileptic seizures, fracture of skull and facial bones, unspecified fall. Review of Resident #1's Local Hospital Discharge summary dated [DATE] revealed Resident #1 had been admitted on [DATE] with a problem list of 1.Fall with Injury (Acute, Onset:3/13/24) 2. Intercranial subdural hemorrhage (Acute, Onset:03/13/24) discharge date : 4/29/24 Discharge diagnosis: Found down with TBI Pt condition on discharge: stable Review of Resident #1's 5-day MDS, dated [DATE] revealed a BIMs score of 10 indicating moderate cognitive impairment. In section J for the question asking has the resident had a fall in the last month prior to admission/entry or reentry the answer is yes. For any falls since Admission/entry or reentry or prior assessment the answer is no. (Resident #1 had falls on 5/1 and 5/2.). Review of Resident #1's admission MDS, dated [DATE] revealed a BIMs score of 10 indicating moderate cognitive impairment. Section GG notes Resident #1 is dependent on staff helper does all the effort to walk ten feet. In section J for the question asking has the resident had a fall in the last month prior to admission/entry or reentry the answer is No. For any falls since Admission/entry or reentry or prior assessment the answer is no. (Resident #1 had falls on 5/1 and 5/2.) Review of Resident #1's Care Plan revealed falls are not included in the areas addressed. The only area addressed with a goal and interventions is elopement initiated on 4/29/24. Another focus listed was the resident requires antidepressant medication there are instructions to include the medication and the diagnosis, however, neither are included. There are no goals and no interventions. The focus area was initiated 5/1/24. The third and final focus states the resident has impaired cognitive function/dementia or impaired thought processes. The goal is the resident will maintain his current level of cognitive functioning. No interventions are listed. Review of Resident #1's Nursing Progress Notes reveals falls on 5/1/24, 5/2/24, 5/4/24, 5/5/24, 5/10/24, 5/15/24, and 5/30/24, which detail the following: 5/1/24 at 2:14 PM [Physician name] told this nurse resident fell on the floor. This nurse went in his room. Resident lying down on the right side of the bed. Resident complained of pain on both knees, has old scabs, said hit his head. [Physician Name] also assessed resident and got order to send resident out for CT scan. Took a set of vital signs and called non-emergent transportation. DON aware of it. 11pm resident returned from hospital scan was clear, denied pain no signs or symptoms of distress. 5/2/24 at 1:16 PM Resident was found on floor of his room, no visible injuries were noted he denies pain, and said he fell on the left knee. The administrator was notified, voice message left on MD on call number and the [family member] was notified. 5/5/24 at 2:44 PM Staff reports to the nurse that the resident is lying on the floor, Nurse walks into the resident room and see the resident lying between both beds, head on floor, resident reports I fell out of my chair, Intervention: Head to toe assessment, pain medication, on call NP notified, family aware. Plan to initiate neuros , Nursing will notify NP of any change of condition. 5/6/24 at 9:40 PM Resident noted on the floor by the bathroom door in his room, wheelchair beside him assessed for injuries none noted assisted to the bed, resident able to move extremities. 5/13/24 at 3:53 AM Resident noted on the floor in his room on his stomach by the window, bed on the lowest position. Resident stated he rolled off the bed. Assessed for injuries assisted to bed, NP/DON notified. Resident continues neuros as per facility protocol denied pain. 5/16/24 at 7:02 PM Resident was found lying on floor beside his wheelchair, no injuries noted at time of assessment. Resident was safely assisted back in wheelchair. Vitals and neuro checks conducted on him. NP notified of his condition, [family member] notified, all fall safety protocol carried out on him, fall mat next to his bed, bed in lowest position and call light within reach. Encouraged him to use call light if needs assistance, he verbalized understanding. DON notified of the incident. 5/30/24 at 4:35 PM Resident was found on the floor in his room close to the bathroom door he had a bump at the back of his head, he denies pain. Resident was transferred to hospital for further assessment. The [family member] was notified, and the NP was also notified. 5/31/24 at 7:36 PM Resident returned from hospital. Hospital admission for unwitnessed fall with impact to back of head. No new findings at the hospital. Review of an Incident Report summary for the month of May 2024 revealed Resident #1 listed as having falls on 5/1, 5/2, 5/5, 5/6 and 5/13. The summary consist of the resident's name, date, time, and the words fall, no injury. A review of the actual detailed Incident Reports was attempted but the documents were not provided, due to being considered internal documents. Review of Resident #1's Fall Risk Evaluations revealed an initial admission evaluation dated 4/29/24 with a score of 20 indicating high fall risk. Resident #1 was noted to be chair bound and requires assistance with toileting, having balance problems while standing, walking, or sitting, unable to stand independently. On 5/2/24 a post fall assessment shows Resident #1's fall risk score is noted to be twelve indicating high risk. On 5/5/24 a post fall assessment shows a score of 11 indicating high risk. On 5/6/24 a post fall assessment shows a score of 9 which does not indicate a high risk. On 5/16/24 a post fall risk assessment shows a score of 20 indicating high risk. Observations on 6/1/24 at 9:40 AM of Resident #1's room revealed he was sitting in the room attempting to put on his shoes. Resident #1's bed was noted to be neatly made with the call light attached to the top cover and the bed was a normal bed height. A fall mat was noted to be folded against the wall on the opposite side of the room near an empty bed. When asked what the call light was for Resident #1 was unsure . When asked if he could use it to call for help such as when going to the bathroom, Resident #1 denied that he needed help and began to stand from his wheelchair. Resident #1 was able to read a sign on his wall that said his family did his laundry but there were no other signs including any to prompt him to call for help. Observation on 6/1/24 at 1:40 PM of Resident #1's room revealed the bed remained at a normal height and fall mat remained in the same position against the wall on the other side of the room. Observation on 6/2/24 at 9:53 AM revealed Resident #1 was in his room in bed and appeared to be asleep. Resident #1's bed was in the lowest position; a fall mat was next to his bed and there was a 1:1 staff sitting in his room. Interview on 6/1/24 at 1:45 PM with CNA A who had worked the 6am to 2pm shift, revealed that she was unable to speak English. When the surveyor pointed to the mat folded against the wall and asked if it was for Resident #1. MA B came in from the hallway and said CNA A did not understand what the surveyor was asking but it was a mat for Resident #1 and the bed was supposed to be in a low position but Resident #1 must have moved the mat and lowered the bed. MA B was asked to ask CNA A if she was aware the bed was to be low and fall mat was to be beside his bed, and CNA A shook her head No. MA B stated CNA A knows now because she just explained it to her. Interview on 6/1/24 at 1:47 PM with MA B revealed she had been aware of fall precautions were to be in place for Resident #1 but had not noticed today that they were not in place. When asked how she and the CNAs learn who is on fall precautions she stated the nurse for the hall would tell the staff in the morning rounds. Interview on 6/1/24 at 1:58 PM with RN C revealed he is the nurse for Resident #1's hall working the 6 AM to 6 PM shift. RN C stated he was made aware this morning during report, from the previous nurse, that Resident #1 had returned from the hospital yesterday after a fall during which he had hit his head. RN C stated the nurse had written on the 24-hour report that the resident was a high fall risk, but RN C was not aware that included the use of the fall mat and bed in lowest position, therefore he was not checking for those things this shift and had not told CNA A anything other than Resident #1 was a high fall risk. Interview on 9/1/24 at 2:04 PM with the facility DON revealed that the mat and bed in low position would normally be in place but the hospital had returned Resident #1 last night without giving them a heads up that he was returning and therefore the staff had probably not been prepared for him. Interview on 6/1/24 at 2:23 PM with CNA E revealed she is working the 2-10 shift tonight on Resident #1's hall. CNA E stated she has worked with Resident #1 multiple times during the month he has been here, but he has not fallen while she was working with him. She stated until today when she came into work, she was not aware that they were to be having the bed in the lowest position and a fall mat in place. CNA E stated she has seen Resident #1's bed low and fall mat in place but she did not know they were always supposed to have those precautions in place. CNA E stated there is not a place where the CNAs can look to see interventions/ care plan or what they are to do but the nurses will tell them when they come to work. If they have a question they can ask the nurse if they are available. CNA E stated the area where the CNA's document does say high fall risk. But does not say anything about the bed position or fall mat. Interview on 6/1/24 at 3:07 PM with NP Q revealed she normally would be the NP for Resident #1. She stated she did not know about any of the falls except the one recently when he hit his head of the floor, so she sent him to the hospital. Her expectation is that if a resident has more than one fall, fall precautions are put in place. Interview on 6/2/24 at 9:56 AM with LVN F revealed that she had just come to work at 6 AM and was told Resident #1 was a 1:1 now because of the number of falls he had since his admission. LVN F stated she knew about his falling before today but felt like the nursing staff was doing all they could to protect him. If he falls, they lower his bed and put the mat down next to the bed. Now they will be adding the soft helmet. When asked how long the bed is to stay on low and fall mats should be in place, she said it probably should stay that way but if not, then they do it each time he falls. Interview on 6/2/24 at 10:04 AM with CNA G revealed today is her first day to work with Resident #1. She stated she is providing the 1:1 and was told to make sure she uses the fall mat and document every 30 minutes what he is doing. She stated he mostly has been sleeping but when she asks him if he wants to go to the dining room or if he needs to go to the bathroom he does so without problems. CNA G stated she is trying to teach him to use the call light, and he seems to understand. Interview on 6/2/24 at 2:20 PM with CNA E revealed she will be providing Resident #1's 1:1 supervision tonight. She knows he needs to have the helmet, the bed in low position and the mat on the floor in front of the bed when he is in bed. When asked how she was aware of all that she said the nurse let her know and there is an in-service she read. When asked if she is always able to remember each person's needs, she stated usually but if she does not, she can ask the nurse, and she has heard it is being added to the CNAs POC . When asked if she could show the surveyor the plan of care that CNA's use, she agreed. We went to the nurse's station, and she showed the surveyor where they document the amount of meals eaten and if the resident had been checked on every 2 hours. When asked where the mat, bed, 1:1 and helmet info was she initially was not sure and asked another staff to show her. The other staff found where there is a check off for whether the resident is incontinent and the use of the helmet, which was added today. There is no mention of the low bed or the fall mat use. Interview on 6/2/2024 at 11:49 AM with the MDS Nurse revealed he does at times add needed items to the care plans of residents, but he works as needed and part time. The MDS nurse stated that the DON and SW can also add anything needed. He does not recall developing a care plan for Resident #1, but he may have. He stated when someone was admitted it is usually the nursing staff or DON that will initiate a care plan. The MDS nurse stated when they are answering the section in the MDS assessments about falls they are only looking at the previous 7 days. If Resident #1 had as many falls as you are describing it should have been added to the care plan by the DON since he is usually only at the facility on weekends. The MDS nurse was asked if there is a purpose for the CNAs to see the interventions in the POC and he stated so that they can know those things need to be done for the residents. He stated he went over the Care Plan for Resident #1 yesterday and they added falls and the use of a fall mat and soft helmet. Interview on 6/1/24 at 10:25 AM with Resident #1's FM revealed there is a concern that he will reinjure his head with all these falls he has been experiencing at the facility. The FM stated he had a TBI in 2004 and recently a few months ago was found wandering around after a fall at his apartment and his brain bled again causing the damage to his brain to be worse. They were told that he does not need to be getting any further injuries to his head. The FM stated the facility is frequently calling family saying that he has fallen but they will lower his bed and use a mat beside his bed. It does not seem to have worked. The FM stated I wish they would understand that he is probably trying to take himself to the bathroom when he falls, does anyone ever ask him if he needs to go to the bathroom and offer to help. He frequently is urinating in clothes baskets and trash cans. He has brain damage he cannot remember to call for help, they say they are reminding him but that is not helping either. The FM stated they have not been invited to meet with a team to discuss a plan of care about him they have just been telling ideas to random people that they meet one time then the next it will be somebody new in that position. The FM has tried explaining to staff Resident #1 is left-handed and gets up from the bed easier if he can use that side, but they have the bed positioned so that is not possible . The FM stated it seems as though it is just a matter of time before he has a fall that will hospitalize him again. Interview on 6/3/24 at 3:30 PM with the facility DON revealed that when asked if he could provide any documentation regarding interventions and/or precautions put in place to prevent further falls he stated when a fall occurred, they put out a fall mat and have the bed in lowest position, that is the interventions. The nurses do so after every fall. When asked about documentation of these interventions the DON stated the nurse's progress notes will contain that information. When asked if the falls are being tracked for patterns which may provide additional interventions, the DON stated other interventions are listed on internal documents that could not be shared with the surveyor, and the falls are reviewed in the morning meetings. Investigations are performed by the nursing staff and are included in the progress notes. Additionally, the facility's written Incident Reports are internal documents that also could not be provided he suggested the surveyor look at the progress notes of the nurses to obtain information needed. Interview on 6/3/24 at 3:35 PM with the Administrator revealed he stated they review all investigations that the nurse writes in the progress notes, during the morning meeting and are considering that as an interdisciplinary meeting for everyone who had an incident and/or accident. All department heads, administrators, nursing, wound care nurse, the DON, the activities person, and rehab medical director will sign off if there are any orders as a result of the meeting. The Administrator stated the fall precautions were put in place after each fall by the nursing staff. Each time a fall was documented it automatically populated the fall risk assessment, the bed being lowered to the lowest position and a fall mat being placed at the bedside. The Administrator stated they cannot prevent a person from falling that is an unrealistic expectation. The Administrator confirmed knowing that investigations at times provided other interventions such as the possibility of a toileting program to prevent Resident #1 from attempting to get up without assistance. He was not aware that Resident #1's family felt falls could be related to him trying to get to the toilet. Review of the facility policy titled Response to Falls, undated, revealed the purpose of the policy is To ensure the Facility responds quickly and appropriately to resident falls in a manner that addresses both the resident's immediate needs and longer-term fall prevention. The policy includes that after each fall the nurse will complete a post fall assessment and investigation. The investigation will help identify circumstances or factors contributing to the resident's fall. Any identified findings and the Facility's response will be documented in the resident's medical record as appropriate. The IDT will review the investigative reports on a regular basis, as they occur and make systemic changes to reasonably limit future occurrences, consider change in POC interventions, system changes, etc. Review of Facility Nursing Manual/Policy titled Fall Evaluation and Prevention, undated, revealed the purpose of the document is To ensure the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents. Policy is listed as The facility will evaluate residents for their fall risk and develop interventions for prevention. Upon Admission, the nursing staff/ interdisciplinary care team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. And in a section under procedure, titled Risk Factors Associated With A Fall, Intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications. The following are examples of intrinsic risk factors including incontinence and previous falls. Interventions include evaluate and implement toileting program if indicated, provide adequate lightening , and remove obstacles in path. Evaluate medications to determine if any can be discontinued or administration times can be changed. The ADM was notified on 06/01/2024 at 06:03 PM, that an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/04/2024 at 12:35 PM, and included: Plan of Removal Immediate Jeopardy On 06/01/2024 an abbreviated survey was initiated at [the facility]. On 06/01/2024 the surveyor provided an Immediate Jeopardy Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of immediate Jeopardy states as follows: F689 the facility failed to ensure adequate supervision and assistive devices to prevent Resident #1 from repeated falls. Action: A Fall reassessment for Resident #1 was completed by DON on 6/1/24 and the Care Plan was updated on 6/1/24 for Resident #1 to reflect the appropriate interventions to try to help prevent injury from further falls. Resident #1 and room was reviewed to ensure that documented interventions were in place as documented in the plan of care. Intervention for safety helmet placement and fall monitoring rounds was implemented. An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on the fall management program policy and procedure along with communicating updated interventions during shift change and staff responsibilities, prior to them working the floor. All staff were re-educated on the regulatory guidelines and facility policy and procedures regarding Abuse, Neglect and Exploitation. Start Date: 06/01/2024 Completion Date: 06/01/2024 Responsible: DON Action: A full house fall risk reassessment was implemented and completed by DON for all residents to ensure no additional residents are at risk, and Care Plans will be updated to reflect appropriate fall interventions. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: DON was reeducated on the facility fall management program policy and procedure along with communicating updated interventions. Start Date: 6/1/24 Completion Date: 6/1/24 Responsible: Clinical Nurse Consultant Action: An All-Clinical Staff in-service by DON to include FT/PT/PRN/New Hires (No Agency in Use) on the fall management program policy and procedure along with communicating updated interventions and staff responsibilities, prior to them working the floor. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: DON will monitor that clinical staff is compliant with following the Policy and Procedure for the facility's Fall Management Program and their responsibilities which include communication during shift change, review of 24-hour report and implementation of interventions for any resident that is a fall risk. 24-hour report will be reviewed by DON during morning clinical meetings. DON will report progress with monitoring to the QAPI team for review to implement any needed changes or updates to ensure compliance. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON Action: New system implementation of tracking resident falls and interventions in a fall tracking binder for daily review by charge nurses which will help identify residents with multiple falls and appropriate interventions. DON will audit binder for updates and completeness. DON will audit the binders daily for a week, biweekly for a month, monthly for QAPI. Audit results will be reviewed and shared with QAPI team. Start Date: 06/02/2024 Completion Date: 06/03/2024 Responsible: DON Action: An Ad-[NAME] QAPI meeting was held by DON, MD, and Administrator regarding facility fall management program policy and procedure along with communicating updated interventions. Start Date: 06/01/2024 Completion Date: 06/02/2024 Responsible: DON The Surveyor monitored the POR on 06/04/24 as followed: During an interview on 6/4/24 at 9:35 AM with the Facility DON revealed In-serviced staff on falls and ANE. Monitoring fall risk residents' daily and documenting to ensure interventions implemented and for any new incidents. No new incidents. Resident #1 family aware Resident #1 would get out of bed independently without asking for assistance and aware of Resident #1's impulsiveness, which was why Resident #1's family placed him in facility because they could not manage how often Resident #1 would fall. During an interview on 6/4/24 at 9:40 AM with the ADM, he said the facility updated Resident #1's care plan, implemented a new binder system on fall risk, put helmet on Resident #1, removed electronic control from bed, and ordered a PVC bed that would go on the floor for Resident #1 when the order arrived. Observation and interview on 6/4/24 at 10:16 AM of Resident #1 revealed he was lying in bed. Resident #1 was clean, dressed, and comfortable. Resident #1 had a fall mat next to his bed. Resident #1's bed was in low position. CNA J was sitting in a chair with 1:1 monitoring sheets across Resident #1. Resident #1 had two postings on the wall behind his bed that stated he was to wear a helmet when he got out of bed at all times and that he must have a fall mat next to his bed at all times. During an interview, Resident #1 stated he was doing fine, staff checked on him often, he had some falls in the past, staff were monitoring him, he wore a helmet whenever he got out of bed, his fall mat was always next to his bed, his bed was always in lowest position, and he had no concerns or issues. On 6/4/23 at 10:23am the facility POR for F689 was approved. During an interview on 6/4/24 at 10:21AM, CNA J revealed she was 1:1 monitoring Resident #1. CNA J stated she filled out a monitoring form that was submitted to the Charge Nurse at the end of her shift reflecting she monitored Resident #1 every 30 minutes. CNA J stated Resident #1 had no falls since her shift. CNA J also stated Resident #1's bed had been in the lowest position, had a fall mat next to his bed, and Resident #1 had been wearing a helmet for a while. CNA J did not know how long Resident #1 had the interventions that were previously mentioned or when the interventions started. She was in-serviced on falls and ANE before she started her shift. She learned how to prevent falls, listening to call lights, ensuring beds were at lowest position, ensuring fall mat on floor, ensuring belongings within reach, ensuring Resident #1 wore safety helmet, who and how to report ANE, and ADM was the abuse and neglect coordinator. During an interview on 6/4/24 at 10:28 AM, CNA K revealed he had not conducted 1:1 monitoring for Resident #1 yet. CNA K stated Resident #1 was impulsive and often tried to get out of bed independently without asking for help and would end up on his fall mat. CNA K also stated Resident #1 was reeducated by staff to use his call light for assistance, but Resident #1 still would not use it and often tried to get out of bed independently. He was in-serviced on falls and ANE before he started his shift. Learned how and who to report ANE to, ADM was the abuse and neglect coordinator, and how to respond to falls. During an interview on 6/4/24 at 10:30 AM, RN H revealed she had conducted 1:1 monitoring for Resident #1. RN H stated she documented the 1:1 monitoring every 30 minutes on a log. RN H also stated CNAs are 1:1 monitoring Resident #1 and logging their monitoring during their shift every 30 minutes. RN H stated she was in-serviced on falls and ANE. RN H also stated Resident #1 had a helmet on anytime he was out of bed, had a fall mat next to his bed at all times, and bed was in lowest position. RN H was in-serviced on how to respond to falls, resident rights, who and how to report ANE, and ADM was the abuse and neglect coordinator. Reviewed fall tracking binder daily. During an interview on 6/4/24 at 10:35 AM, CNA M stated he was not in-serviced on falls and ANE. During an interview on 6/4/24 at 10:40 AM, Nurse L revealed she was in-serviced on falls and ANE. She learned about fall preventative devices, monitoring, safety protocols, ADM was the abuse and neglect coordinator, and how and who to report. Nurse L stated Resident #1 was impulsive and often tried to get out of bed without asking staff for assistance by call light. Nurse L also stated staff had reeducated Resident #1 on multiple occasions and Resident #1 still would try to get out of bed independently. Nurse L stated Resident #1's family was aware of Resident #1 trying to independently get out of bed. She reviewed the resident fall tracking documentation daily and have reported to CNAs any updates on fall risk. Observation on 6/4/24 at 11:07 AM of 2400 hall revealed residents who were fall risks had fall preventative devices in their rooms, such as fall mats and lowered beds. During an interview on 6/4/24 at 12:33 PM, ADM stated DON completed Resident #1's fall reassessment on 06/01/24. ADM also stated Resident #1's care plan was updated by the facility MDS Coordinator on 06/01/24. ADM stated DON reviewed Resident #1's room to ensure care plan interventions were implemented on 06/01/24. ADM also stated Resident #1's fall monitoring rounds conducted by clinical staff (nurses and CNAs) started every 30 minutes on 06/02/24 and ongoing. Resident #1's safety helmet placement was implemented. DON in-serviced clinical staff on fall management and ANE started on 06/01/24 and ongoing before staff started shifts. ADM stated he did not know CNA M was not in-serviced prior to starting his work shift on ANE and falls. DON conducted fall risk reassessment on all residents started on 06/01/24 and completed 06/02/24. He was not sure if there were any other residents identified as at risk and if there were any other residents who required updated care plans to reflect appropriate fall interventions. Clinical Nurse Consultant reeducated DON on fall management policy and procedure on 06/01/24. DON started daily monitoring of clinical staff to ensure compliance with fall management by auditing the new system implementation of tracking resident falls and interventions in a fall tracking binder that was daily reviewed by charge nurses on 06/02/24. DON started reviewing all residents' 24-hour reports during morning clinical meetings on 06/01/24 and completed 06/02/24. On 06/02/24, him, DON, and MD had QAPI meeting. DON reported progress with monitoring during the meeting. No changes or updates to ensure compliance needed to be done following QAPI meeting to discuss 24-hour reports. Charge nurses daily reviewed new system implementation of tracking falls and interventions from fall tracking binder started on 06/02/24 and ongoing. Review of the facility's Behavior Rounds 06/01/24-06/04/24 revealed staff monitored Resident #1 every 30 minutes and there were no behaviors observed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for elopement. Resident #1 walked out of the facility unattended on 03/15/2024 at about 9:00PM until the police found him at about 10:00 PM from a place approximately 1.5 miles away from the facility. EMS organized by the police to take him to the hospital and at the hospital it was confirmed that resident had hairline fracture above the left eye and cheek with lacerations on left eye lid, left wrist, and lower and upper lips, and abrasions on hands. The facility staff was not aware the resident was missing until the family called the facility. This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 4:55 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy Template on 03/25/24 at 6:00 PM. While the IJ was removed on 03/27/24, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could affect residents by placing them at risk of physical harm, pain and mental anguish, or emotional distress. Findings Included: Record review of Resident #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] and discharged on 03/17/2024. His diagnoses included Parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), Prostatic Hyperplasia (enlarged prostate gland), Hypothyroidism, Hearing Loss-Left ear, and Abnormal Involuntary Movements. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS Score of 13 indicating Resident #1 was cognitively intact. Record review of Resident #1's Baseline Care Plan dated 03/10/24 reflected Resident #1 had no history of falls and no elopement risk. Record review of Resident #1's Elopement Risk Evaluation dated 03/16/24 reflected a score of 14.00 indicating Resident #1 was at imminent risk for elopement. No Elopement Risk Evaluation completed prior to the elopement. Record review of the care plan completed after the incident, dated 03/16/24 reflected , Resident #1 was at risk for elopement related to Elopement Evaluation Risk Score. No care plan was completed prior to the elopement incident. Record review of the Weekly Skin Check dated 03/16/24 reflected Resident #1 had lacerations on left eye lid, left wrist and lower and upper lips. Record review of Trauma Informed assessment dated [DATE] reflected Resident #1 felt scared, helpless, or horrified related to the sudden event of elopement with fall. Record review of facility's incident report to HHSC dated 03/18/24 reflected, on 3/15/2024 the ADM was notified by MDS C that on 03/15/24, Resident #1 was being transported to the hospital for further evaluation and treatment related to fall with injury after found him outside the facility at a place half a mile away. The facility came to know about this incident when the FM of Resident #1 notified the facility over the phone at 10:20PM, that the resident was off the property. She also informed the facility that resident was on his way to the hospital. At the hospital it was revealed that Resident #1 had a hairline fracture above the left eye and the left cheek. Resident also had abrasions on his hands. Record review of Nurses Progress Notes for Resident #1 by RN B on 03/16/24 at 6:41 AM, reflected Resident arrived from [Hospital] ER. Resident arrived with acute head injury orbital fracture, lip laceration Zygomatic arch fracture. Wander guard was placed on resident right lower leg. Notified doctor of return. Family is aware of return. Resident is comfortable at this time. During an interview over the phone on 03/25/24 at 10:30 AM, Resident #1's FM stated she was out of the state when the incident of the elopement occurred. She stated at about 10:00PM the police called and talked to her over the phone and said that they went and picked Resident #1 up from a place approx. 1.5 miles away from the facility. She said the police reported that they responded to a 911 call from a community member who found Resident #1 with injuries braced on his parked car. She said the police organized EMS and transported him to the nearby hospital for further assessment and treatment. The FM stated the facility was unaware of Resident #1's disappearance from the facility until she called and informed the FR at the facility at about 10:20 PM. FM stated, initially when she asked about Resident #1, the FR stated Resident #1 resides at the 2nd floor and she would transfer FM's call to the 2nd floor nursing station so that FM could request the staff to talk to him. During an interview over the phone on 03/25/24 at 11:00 AM, FR stated she worked as the receptionist at the facility from 6:00 PM to 10:30 PM, Monday to Friday. She said, on 03/15/24 at about 10:20 PM she received a phone call from Resident #1's FM asking if Resident #1 was there at the facility. FR said, she replied to FM that Resident #1 was living on the 2nd floor, and she would transfer the call to the nursing station at the 2nd floor so that the FM could talk to the staff there. FR said, FM then reported to FR that she was checking if staff was aware of what was going on and then reported that the police had picked up Resident #1 from a place about 1.5 miles away from the facility at about 10:00 PM and admitted to a hospital nearby due to the injuries he had. FR stated she or anyone at the facility was aware until then that Resident #1 was absconded from the facility. FR said at about 10:00 PM LVN A at the 2nd floor enquired her if she saw Resident #1 at the 1st floor as they could not find him at the 2nd floor. FR stated they were under the impression that Resident #1 was wandering around within the facility until they heard about his elopement from the facility from the FM. FR said, on 03/13/24 Resident #1 was persistently requesting to her to let him leave the facility and made unsuccessful efforts to open the coded front door at two different occasions. FR stated this behavior from him was evident since his admission on [DATE] and LVN A from 2nd floor requested her to have a [NAME] on Resident #1. She stated she also had informed LVN A about his attempts for unauthorized exit. FR stated she had a watch on him whenever he was on 1st floor and ensured that he did not exit through the front door on 03/15/24 as she was the only one who allowed the visitors to come and go from the facility. She stated the front door was secured with code numbers and only the staff members knew the code number. FR said she believed Resident #1 might have exited through the emergency fire exit door situated at the back of the facility. FR added, though the back door secured by code numbers, the lock can be override if the handle of the door holds down for some time. The door will be opened with an alarm though the alarm would not be heard at the reception area. During an interview on 03/25/24 at 10:00 AM, MDS C stated she worked at the facility in the morning shift until 5PM. She said, on 03/15/24 at about 10:30PM she received a phone call at home from FR stating Resident#1 eloped from the facility and had a fall. FR reported to her that the police found him about 1.5 miles away from the facility with lacerations on his body and admitted him to a nearby hospital for treatment. MDS C stated, as per her understanding the staff at 2nd floor did not find him there at about 9.45PM and then they informed FR to have a watch on him if he appears at the front door. She stated it appeared the staff came to know his exit out of the facility only after the FM passed on that information During a telephone interview on 03/25/24 at 10:30, LVN A stated she worked in the afternoon shift on 03/15/24 with the responsibility of the hall where Resident #1 resided. She said on 03/15/24 Resident #1 accepted his night medication at 9:00PM in his room. At about 9:45PM one of the CNAs noticed that Resident #1 was not in his room and his name tag at the door also was missing. LVN A stated she immediately informed FR to check if he was there at the reception area and by that time the information about his elopement was received from the FM of Resident #1. LVN A stated according to her Resident #1 was not an elopement risk as he mostly stayed in his room. When this investigator asked her about an incident of his two unsuccessful attempts to get out of the facility on 03/13/24 in the evening, reported by FR, LVN A stated those were the only attempts she was aware of. During a phone interview on 03/25/24 at 3:00PM, RN B stated she was the night nurse at the facility and was not aware of what was going on with Resident #1 until 10:00 PM as she was not in charge of his hall. RN B stated the staff at the facility came to know through the FM about Resident #1's disappearance and subsequent incident of finding him outside the facility. RN B stated Resident #1 arrived back at the facility on 03/16/24 at about 6:00 AM from the hospital. She said she had a nurse-to-nurse communication from the nurse at the hospital. RN B stated, the nurse from the hospital reported Resident #1 had an acute head injury, orbital fracture, lip laceration and Zygomatic Arch (the most lateral projection of the midface) fracture. She stated she had recorded this in the progress note in the electronic medical record. During an interview on 03/26/24 at 10:00 AM, LVN C stated she worked at the facility for more than a year and worked the morning shift. She said she did not work on the hall where Resident #1 resided. LVN C stated the nursing stations at the 2nd floor were equipped with alarms and any attempt to open the doors downstairs trigger the alarm. She added, staff immediately go down to ensure no elopement attempt was made by any residents. LVN C stated she did not know what really happened on that day as the incident occurred on the night shift. In an interview and observation walk through with the ADM on 03/25/24 at 3:00 PM, she stated Resident #1 must have exited through the emergency fire exit door at the back, adjacent to the kitchen. ADM stated she believed it was not an elopement since the facility was not a locked facility. She added, stopping anyone from leaving the facility, when they wanted to, was a violation of resident rights. The ADM stated Resident #1 had a BIMS score of 13, indicated intact cognition to make independent decisions. The ADM stated there was residents at the facility who regularly go Out-On-Pass to the community and return within the stipulated time (72 hours). When this investigator asked if Resident #1 left the facility as per the policies and procedures for Out-On-Pass, she stated, he was not. The ADM also stated, Resident #1 neither signed any AMA documents nor declined to sign one and exited without the knowledge of any staff members. Observation of the emergency exit door revealed there was an instruction posted on the door explaining how to override the passcode in case of any emergency however an alarm went off when opened without the passcode. The ADM said since the door was away from the reception it was difficult to hear the alarm from the reception area. Observation of the front door revealed, it was secured by number code and the entrance and exit was controlled by the receptionist. There were no other exit doors at the facility. During an interview on 03/26/24 at 12:50 PM, the DON stated he started working at the facility about a week ago, after the elopement incident of Resident #1 occurred. He stated he was well informed about the incident. The DON defined an elopement as, a resident leaving the facility without any notice or knowledge of the facility. The DON stated it appeared there was some shortfall in the security measures at the backdoor as it was believed Resident # 1 accessed the back door for his exit on 03/15/24. The DON stated it seemed the elopement risk evaluation and nursing judgement also was not accurate as there was no management plan, like usage of a wander band in place. The DON stated, when an alarm would be heard at nursing stations, the staff was supposed to go down to the 1st floor and make sure the alarm went off not because of any resident's attempt for an unauthorized exit. During an interview on 03/26/24 at 1:10 PM, MDS C stated she did not know how Resident #1 got out of the facility. She stated she was the MDS nurse and was helping the administrator within her scope of practice as an LVN, in the absence of a DON at that time. She stated the act of Resident #1 was elopement if he exited the facility without the knowledge of the staff and without completing Out-On-Pass paperwork or without signing an AMA form. Review of undated facility policy Elopement Risk Reduction Approaches reflected. Planning: As necessary, provide new residents (to the facility, wing, unit ,etc.) with additional staff assistance until they are comfortable in their new environment . Ensure that residents are able to move freely, are monitored and remain safe . .Training: Facility staff needs to know: . The resident's propensity to wander and the triggering conditions The consequences of unsafe wandering, the protocols to follow to minimize successful exiting and the procedures to follow when resident is lost . Promote identification of residents who are at risk of elopement. Ensure that photographs of residents who wander are maintained in an accessible but secure location and that receptionist, activities and clinical staff and others in appropriate positions to help are able to recognize at-risk residents and to assist in redirecting them .Environment: Ensure that staff alert and elopement alarm/warning systems are the least intrusive and burdensome possible After conferring with fire and other appropriate officials, minimize the risk of elopement. An Immediate Jeopardy was identified on 03/25/24 at 4:55 PM. The IJ Template was provided to the facility ADM on 03/25/24 at 6:00 PM. The following Plan of Removal submitted by the facility was accepted on 03/26/24 at 7:01 PM and indicated the following: Plan of Removal Immediate Jeopardy On 03/25/2024 an abbreviated survey was initiated at the facility. On 03/25/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: F689 - The facility failed to provide an environment free of accident hazards to minimize elopement risk. Action: Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. Start Date: 3/17/2024. Completion Date: 3/17/2024 Action: All residents re-evaluated for risk of elopement via assessment on 3/25/2024. No additional residents were identified based on evaluation. Elopement Binder up to date and remains at reception desk. DON ensured all residents who are imminent risk for elopement are donning a wander guard for safety. Start Date: 3/25/2024. Completion Date: 3/25/2024 Responsible: DON or Designee Action: Medical Director notified of IJ on 3/25/2024 Start Date: 3/25/2024. Completion Date: 3/25/2024 Responsible: Administrator Action: Physician orders related to residents on wander guard placement reviewed and updated for all residents Start Date: 3/25/2024. Completion Date: 3/26/2024 Responsible: Medical Director or Designee Action: In-services completed with all staff (facility does not use agency, all staff to include PRN staff) related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). As new employees are hired they will be in-serviced on all protocols in hire process. Start Date: 3/25/2024 Completion Date: 3/26/2024 Responsible Human Resources or Administrator Action: In-service completed with all staff (facility does not use agency, all staff to include PRN staff) that if resident has more than one request to leave that elopement/wandering risk assessment completed and wander guard placed if applicable as intervention for safety. Elopement risk reduction approaches policy reviewed with all staff. As new employees are hired they will be in-serviced on protocol in hire process. Start Date: 3/26/2024 Completion Date: 3/26/2024 Responsible Human Resources or Administrator Action: QAPI meeting held related to IJ. Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT, and Medical Director (via phone) present. Start Date: 3/26/2024. Completion Date: 3/26/2024 Responsible Administrator Action: HR and Administrator in-serviced by Regional Clinical Specialist on all in-services, to include Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON, and Elopement risk reduction. Start Date: 3/25/2024. Completion Date: 3/25/2024 Responsible: Regional Clinical Specialist The surveyor confirmed the facility implemented their plan of removal sufficiently from 03/25/24 through 03/27/24 to remove the IJ by: 1. Record review of Resident #1's face sheet confirmed Resident #1 discharged from facility as planned at the end of respite stay on 3/17/2024. 2. Record review of an Inservice to all nursing and CNA staff was completed on 03/27/24 by ADM and HR related to Elopement (Code Pink/Elopement Protocol, Midnight Census/Headcount/Walking Rounds, Resident Rights, Out on Pass Policy, AMA policy, Monitoring and Redirecting any wandering residents, Reporting Incidents to Admin and DON In-services Initiated and Completed). HR and Administrator were in-serviced on the above topics by Regional Clinical Specialist 3. Record review of the medical records of all the resident at the facility revealed all residents re-evaluated for risk of elopement via assessment on 3/25/2024 and ensured all residents who are an imminent or moderate risk for elopement had wander guards for safety. 4. Record review of the Elopement Binder revealed it was up to date and remains at reception desk. Copies of them were available at Nursing stations. 5. Record review on 03/27/24 of the medical records of all residents revealed physician orders related to residents on wander guard placement reviewed and no additional residents added to the existing residents with elopement risk. 6. Record review of the minutes of the QAPI meeting that was conducted for discussing elopement prevention on 03/26/24 revealed that the medical Director attended via Phone and Administrator, HR, DOR, Activities Director, DON, MDS, BOM, BD, Maintenance, DCT were physically attended the meeting. Interviews conducted with RN C on 03/27/24 at 10:15 AM; LVN A on 03/26/24 at 11:00 AM; LVN C on 03/26/24 at 10:00AM. CNA A on 03/27/24 at 11:15AM, revealed nurses was in serviced on 03/27/24. Nurses verbalized attending to call lights, rounding every 2 hours, checking any alarm doors to ensure that no resident had eloped, taking mid night census, do head count to make sure no resident missing. ADM was notified that while the IJ was removed on 03/27/24 at 00:00, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.