**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one of six residents (Resident #1) reviewed for accident hazards in that: -The facility failed to ensure Resident #1 had interventions in place after she fell on 8/10/2025, 8/11/2025, or 8/14/2025 when she sustained a hematoma to her forehead and on 8/16/2025 when she fell again and suffered a laceration over the right eye requiring 7 sutures.-The facility failed to adequately supervise Resident #1 after she experienced the first fall on 8/10/2025. -The facility failed to determine the causative factors of the falls and address those factors timely. Resident #1 was admitted on [DATE]. An Immediate Jeopardy (IJ) was identified on 8/22/2025 at 3:40pm. The IJ template was provided to the facility on 8/22/2025 at 3:40pm. While the IJ was removed on 8/24/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm as the facility continued to monitor the implementation and effectiveness of their plan of removal.This failure could place residents at risk of serious injuries requiring hospitalization or surgical intervention, and/or death.Findings Included:Record review of Resident #1's face sheet dated 8/7/2025 revealed that she was a [AGE] year-old female that was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of hypertension (high blood pressure), other muscle spasms(involuntary contractions of muscles), long-term aromatase inhibitors(used to treat hormone-receptor-positive breast cancer in women), and cervical myelopathy (a nervous system disorder that affects the spinal cord) and a history of falls.Record review Resident #1's care plan dated 8/8/2025 revealed that a 48-hour baseline had been completed. Problem: Baseline care plan will identify my care needs, risks, strengths and goals for the first 48-hoursGoal: Initial goal is to have access of services to promote adjustment to my new living environment. Approach: Safety falls: Fall risk evaluation will be completed to identify and minimize initial risk factors for falls/injury. Record review of Resident #1's initial MDS assessment dated [DATE] revealed:Section C500- Brief Interview for Mental Status was unscored.Section GG01300- Functional Abilities revealed C. toileting hygiene was coded as 04- representing supervision or touching assistance was needed by helper. E. Shower/bathe self was coded as 01- Dependent -helper does all of the work. F. Upper body dressing, lower body dressing, personal hygiene and putting on/taking off footwear were all coded as 3. Representing partial/moderate assistance needed by a helper.Section GG0170- Mobility revealed sit to stand, chair/bed-to-chair-transfer, and toilet transfer were coded as (2)- which represented substantial/maximum assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and does more than half the effort. Section J1700-Fall History A. Did the resident have a fall any time in the last month prior to entry/entry or reentry was coded 1. YesJ1800- Any falls since admission was coded as 1. Yes Record review of Resident #1's Morse Fall scale dated 8/7/2025 revealed Resident #1 had a history of falls, ambulated with a walker, had weakness, Gait: Normal. There was a score of 40 and she was deemed a low risk for falls.Record review of the morse scoring data revealed five factors for scoring:1. History of Falls (25 points)- Resident #1 has fallen prior to admission2. Secondary Diagnosis (15 points)- Resident #1 has more than one medical diagnosis3. IV Therapy- (0) - Resident #1 does not have an IV4. Gait- (20) points- Resident #1 had impaired gait, difficulty rising or poor balance5. Mental Status- (15 points) - Resident #1 overestimates her ability and is forgetful of their limitations. Low Risk if (Score of 0-24 points)Medium Risk- (Score of 25-44)High Risk (Score of 44 or higher than 50) Record review of Resident #1's admitting hospital record dated 6/25/2025 revealed the resident was admitted to the hospital and assessed due to recent falls, hemiplegia and hemiparesis following cerebral infarction. Record review of the Resident #1's clinical record from a local hospital ER visit dated 8/4/2025 revealed her chief complaint was a fall. She now presents with multiple falls due to myelopathy. CT head was negative however x-ray showed right shoulder mid shaft clavicle fracture comminuted proximal phalanx. Neurology was consulted to decompress her spinal cord as she underwent C3-C4, C4-C5, C5-C6 ACDF on 8/24/2022. She was not wearing her soft collar. Record review of Resident #1's clinical record from ER visit dated 8/14/2025 revealed she was admitted due to a fall at the facility and sustained a head injury and possible lumbar transverse process fracture. Activity instructions were for Resident #1 were to get up using only her walker, take her time standing and ask for assistance when needed. Continue wearing the cervical collar and sling. Record review of Resident #1's ER record dated 8/16/2025 revealed she was admitted to the hospital following a fall with a laceration over her right eyebrow. She received 7 sutures. Record review of Resident #1's nursing progress notes revealed: 8/10/2025 at 7:09pm- LVN D observed call light and upon arrival Resident #1 was observed on the floor. Resident #1 stated she was going to the restroom. No injuries observed, denied pain, neuro checks started every 30 minutes for 2 hours. 8/11/2025 at 2:57pm- LVN D stated she was notified by PT personnel that Resident #1 was observed on the floor. Observed to be in sitting position on the floor. Resident stated she was getting up to go to the restroom. RP, physician notified.8/14/2025 at 1:58am- LVN A wrote Resident #1 was lying on the floor, assessed and had hematoma to right forehead. She is alert with confusion, physician said send to ER via 911. No complaint of pain.8/16/2025 at 9:15am- LVN H wrote she was called to room to assess resident due to rt eye bleeding. Area cleansed with normal saline and dressing. Physician, RP, DON notified. Physician said send Resident #1 to ER. Record review of incidents of falls report dated 7/18/2025-8/18/2025 revealed:08/10/2025 06:53PM Resident #1-Fall 08/10/2025 06:51PM Resident #1- Fall08/11/2025 02:26PM Fall Resident#1's Room door was OPENED08/14/2025 02:11AM Resident#1's Room door was OPENED08/16/2025 09:14AM Resident #1's Room door was OPENED resident fell while attempting to transfer to restroomhematoma to right forehead.An observation and interview with Resident #1 on 8/18/2025 at 11:19am she had a bandage over her right eyebrow, hematoma on her forehead and a blackened right eye. She said she had been at the facility for a couple of weeks and fell twice when she was going to the restroom. She seemed confused when she was told that she had 5 falls at the facility. She said she kept falling because she lost her balance and was dizzy. She said her friend (RP) took care of her when she resided in her RV. She said she was confused sometimes and forgot to get help and that her falls were when she was going to the restroom. She said staff would not come to help her to the restroom. She admitted she would not use the call light although call light string was pinned to her fitted sheet.An interview with Resident #1's RP on 8/18/2025 at 11:21am said Resident #1 had experienced multiple falls at the facility due to staff not helping her to get to the restroom. She said Resident #1 had only been at the facility for about 2 weeks and had multiple falls. She admitted that Resident #1 had falls prior to being admitted to the facility due to her having a stroke. She said Resident #1 broke her collar bone and had surgery to remove two lipomas off her spine. She said the facility staff should be able to help her to the restroom as they were aware of her falls before coming to the facility. She said she had spoken to the DON about staff helping Resident #1 as they said they would. She said adequate supervision was needed because Resident #1 was confused. An interview with Resident #1's Psychiatrist NP on 8/18/2025 at 12:03pm she revealed she had visited with Resident #1 only once for an evaluation and said she was confused and had early signs of dementia. She said her dementia perhaps caused her to believe she was still capable of ambulating unassisted. She stated that they would be evaluating her medications to figure out if they could be causing her falls. She said this was her 2nd visit and she wanted to quickly find out if there was something she could do to help with the falls.An interview with PT Director on 8/18/2025 at 12:14pm he stated Resident #1 had received 5 days (8/11-8/15/2025) of PT to address falls, balance, and gait. He said Resident #1 participated in bilateral lower extremities (BLE) strengthening program to improve physical performance, dynamic standing balance to improve safety and prevent falls. He said Resident #1 would improve her ability to complete toilet/commode transfers with supervised or touching assistance with better balance. He said Resident #1 had been granted another 5 days of physical therapy and she started again today (8/18/2025). He said her left shoulder was also weak from a shoulder injury prior to coming to the facility. He said they would also concentrate on generalized weakness. He said the management team had discussed her falls and put therapy in place. He was not aware of any other interventions.Attempted interviews were made on 8/18, 8/19 and 8/23/2025 to contact LVN C and LVN D, which were the nurses on the night shift when Resident #1 fell on 8/10, 8/11 and 8/14/2025. These attempted phone calls were unanswered and not returned.An interview with the MDS Nurse on 8/18/2025 at 3:35pm she said she had been employed for 1 year. She said as the MDS Coordinator she completed the MDS assessment upon admission, quarterly, and upon significant change. She said she was working on Resident #1's initial MDS today (8/18/2025). She stated she had been at a work conference last week and knew coming back today (8/18/2025), that she would have to complete it. She said falls were discussed in morning meetings and there had already been discussions about Resident #1's falls. She said once there is a fall, another fall risk assessment should be completed, documentation should be done on an incident report and interventions added to the care plan. She said she looked at the care plan because she noticed there were no interventions it came up when she started the MDS. She said she discussed it with the DON today. She said they were still within their window for completing the comprehensive care plan because it was due within 7 days after completing the MDS or by day 21 of the resident' stay.An interview with the DON on 8/18/2025 at 4:25pm revealed she had been employed by the facility since April 2025. She said her duties were to oversee clinical for the residents and work closely with medical director in caring for the residents. She stated Resident #1 had about 5 falls. She said they had already provided physical therapy for her for one week. She said she was ambulatory with her walker, but she does not wait or call for assistance from staff. She said she believed that the resident was experiencing vertigo (a medical condition that causes a person to feel like they are spinning or moving). She said they did not use fall mats because they posed more of a risk for ambulatory residents. She said she had educated the resident on locking her overbed table to gain her footing first then to grab her walker. She said her bed was in its lowest position, however she had access to the remote control for the bed and would often lower and raise it as she wanted. She said Resident #1 had a C-collar when she was admitted and sling on her right arm. She said she used the affected arm which was another issue. Rehab was altering a wheelchair for her to be able to use it. She said they were in discussions with regional and had QAPI concerning the resident since it was difficult for her to determine the next steps for her. She said it was her expectation for nursing staff to make timely rounds to check on the residents. She said she felt facility staff supervised her, but Resident #1 did not wait for them to come to help. She said Resident #1 could have re-injured her shoulder or even worst she could have had a spinal injury from the falls. An interview with the VPO on 8/18/2025 at 4:27pm, he said he had been in the facility on Mondays, Thursday and Fridays since the facility did not have an Administrator. He stated that he wished he could argue their non-compliance, but he could not. He said Resident #1 had multiple falls and although PT was started to help with strengthening it was not enough especially since she continued to fall. He said there were not completed progress notes about the incidents. He said his expectation was for the nursing staff to document falls, brainstorm interventions and immediate act on those to prevent further falls.An interview with PCP-NP on 8/19/2025 at 1:13pm she stated she just started going to the facility. She said she saw Resident #1 for the first time today (8/19/2025). She said nursing staff briefed her and said she was a fall risk and had a cervical fracture prior to being admitted . She said she thought this fracture was from a few months ago, this is why she was admitted . She said Resident #1 would be having her sutures removed in the next few days. She said Resident #1 was confused and cognition seemed to be off. She said she would review any labs that were done or order labs just to check to see if there was some other underlying reason for her falls. An interview with Resident #1's PCP on 8/19/2025 at 1:28pm he said he saw her the day after she was admitted (8/8/25). He said he was not on his laptop to give specifics, but he had been notified she have had quite a few falls. He said she can slightly communicate and was very confused at times. He said what he did recall was that she wanted to do things on her own. He said Resident #1 fell this past weekend because she wanted to go to the restroom on her own. She needed help. She was not able to control her balance. He stated he was at the facility 2 times a week and his NP was there 3 times per week. He said the call light was in reach at his last visit. He said he did not think she fully understood that she could really hurt herself. He said he educated her on using the call light and the importance of her waiting for help. He said he believed the staff tried to supervise her to prevent her from falling. He said she could have injured herself badly. He agreed that a laceration requiring sutures was considered a serious injury. He said his NP was at the facility (today)and would be looking into some possible causes of her falls by looking at her labs.A subsequent interview with the VPO on 8/22/2025 at 3:34pm he stated that they discussed Resident #1's falls with the medical director because he was aware that they had no interventions in place and honesty he was upset to find there were no progress notes about the falls prior to 8/15/2025.An interview with LVN A on 8/23/2025 at 6:48pm, he said he had been employed since 2008. He worked the 6pm-6am Hall D and E (Hall 400 and 500). He stated he completed the Morse scale assessment for Resident #1 upon her admission. He input yes or no to the questions about gait, diagnosis and the system gave him a score of 40. He said he was not sure about the range for determining high or low risk. He said he entered her history of falls and answered all the questions, and the system tabulated and said she was a low risk for falls. He stated he was not the nurse on duty for none of the falls. He documented post fall observations as nurse observe 3 days after a fall. He stated that he reviewed the notes, and she fell on the day shift on 8/11 and 8/16, and he was not the night nurse on 8/10, 8/14 or 8/16/2025. He said they were oriented on the fall risk assessments being updated after a fall. He said Resident #1 could have re-injured herself and got more or worst injures from the falls. Accident and hazards policy was not received prior to exit. An IJ was identified on 8/22/2025 at 3:40 pm. The IJ template was provided to the facility on 8/22/2025 at 3:40 p.m. The Facility's plan of removal was accepted on 8/23/2025 at 11:44 a.m. and included the following: Immediate Action:Date: 08/23/2025-The facility failed to ensure Resident #1 had interventions in place after she fell on 8/10/2025, 8/11/2025, sustained a hematoma to right forehead on 8/14/2025 and a laceration over the right eye requiring 7 sutures on 8/16/2025.-The facility failed to provide an emergency plan to adequately supervise Resident #1 after she experienced the first fall on 8/10/2025. -The facility failed to determine the causative factors of the falls and address those factors timely. Resident #1 had been admitted since 8/7/2025Resident #1 was sent to the hospital for further evaluation. Resident has since returned to the facility, has sutures to right eyebrow, hematoma on her forehead, and a discoloration to right eye and is behaving per norm, no further concerns noted. Immediate action: Action: Resident #1 will have a medication review by the Medical Director. Resident #1 was care planned for the following interventions: education on safety, cont. encourage ask for assist and ask for assist to go to bathroom, monitor for orthostatic hypotension per order, frequent checks and see if needs assistance, continue with neck brace and sling per order, keep bed in low position. Notify nurse if resident removes neck brace or sling. Continue follow with Ortho.Resident #1 will be evaluated for appropriate assistive devices and will use wheelchair Resident #1 will be evaluated by PT servicesResident #1 will have medication review by Medical Director; (MD has discontinued Cycobenzapine and has initiated orthostatic blood pressure checks every shift which occurred on 8/22/2025).Resident #1 will have orthostatic b/p checks every shift-Resident will be monitored every shift, for 3 days, and daily thereafter for 7 days, on follow up charting related to the changes, including changes with medications. This will be located in the resident's progress notes and/or observations in the electronic medical record. Any concerns with medication changes and/or resident status will be communicated to the physician for further direction.Person(s) Responsible: Charge Nurse, Regional Nurse Consultant, and/or DesigneeDate: 8/22/2025Action: Review all residents fall risk assessments to ensure they are updated and accurately reflect the resident. Based on resident assessment and chart review, 25 residents were changed to from low fall risk to high fall risk. Their care plans will reflect their assessments. Person(s) Responsible: Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025 Action: A 30-day audit will be completed for all falls in the facility, 12 falls were identified, 7 total residents affected. The facility will review all care planned interventions for the fall(s) to ensure they are present and person-centered. Person(s) Responsible: Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025 Action: Initiate a review of all admissions, prior to admitting into the nursing home, to identify if a resident is at risk for falls and to create a person-centered care plan/baseline care plan with person centered interventions in an attempt to reduce the risk of falling upon admission. Administrator and/or designee will monitor for compliance. Person(s) Responsible: Nursing Administration, Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025Facility's Plan to ensure compliance quickly:Action: Educate Charge Nurses and CNAs over resident person-centered interventions for falls. Education to include implementing interventions, notifying on call nursing administration, consulting the physician, getting therapy involved, increased rounding, etc. Test will be distributed to evaluate the effectiveness of the education. All Charge Nurses and CNAs will be educated prior to working their next shift. Person(s) Responsible: Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025 Action: Educate CNAs and Nurses on resident profile that will alert staff of a resident that is a fall risk, interventions will also be located in the resident profile located in the electronic medical record. CNAs and Charge Nurses will complete a return demonstration on pulling the resident profile and where to view interventions. All CNAs and Charge Nurses will be educated prior to working their next shift. Person(s) Responsible: Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025 Action: Falls will be reviewed/monitored during clinical meetings, daily x5 days weekly, to review the event report, attempt to root cause, and update the care plan with person centered interventions. Administrator and/or designee will monitor for compliance.Person(s) Responsible: Clinical Administration, Assistant Director of Nursing, Clinical Case Manager, and/or Designee.Date of Completion: 8/23/2025 Action: Ad hoc QAPI to inform Medical Director of the IJ template for 689 and the facility's plan to remove the immediacy. Person(s) Responsible: Regional [NAME] President, Clinical Case Manager, Wound Care Nurse, and/or DesigneeDate of Completion: 8/22/2025 Monitoring: Observation of Resident #1 on 8/22/2025 and 8/23/2025 at various times revealed her to have her neck brace and sling on her right arm. Record review of Resident #1's care plan included the following interventions: Education of safety, continue to encourage ask for assist to go to the bathroom, monitor her orthostatic hypertension. Frequent checks will be provided, and staff would inform the nurse if she removed her neck brace and sling per order. Continue to follow with Orthopedic physician. Resident #1 would be evaluated for appropriate assistive devices and will use wheelchair. Resident #1 will be evaluated for PT. Resident #1's record also included a PT evaluation conducted on 8/22/2025. She was placed on services for five days.Record review of Resident #1's MAR was updated to reflect orthostatic blood pressure every shift. Further review revealed MD discontinued Cyclobenzaprine. Record review of Resident #1's progress note dated 8/23/2025 revealed she had been reporting that she was well without taking the muscle relaxer Cyclobenzaprine.Record review of the list of 25 residents listed were changed from low to high risk for falls.Record review of 5 out of 25 sampled residents from the list of 25 residents had updated care plans related to falls (Residents #1, 2, 3, 4 and 5).Record review of Resident #1's and Resident #3's resident profile revealed that it alerted staff that they are a fall risk. Record review of test given to the clinical staff asked questions concerning fall interventions, when and who should notify RP, Physician, DON, Administrator. Interviews with CNA's A, B, C, and D were conducted between 8/22-8/25/2025 on the 6am-6pm shift were able to communicate the recent in-services in which they were told where they could find resident interventions in their EMAR, notifying on-call administration after an incident event, and notifying their nurse of any incidents. Interviews with the night shift (6p-6a) staff were CNA's E, F, H, and J were conducted on 8/24/2025. They were able to communicate their in-services on interventions, resident profiles, increased rounding and notifying the Charge Nurse when there are Resident incidents. Interviews with LVN's A, B and G were conducted between 8/24 and 8/25/2025 of night shift staff revealed they had been in-serviced on completion of a fall risk assessment, adding additional or different interventions to the care plans, notifying the RP, Physician, DON and Administrator, checking Resident profile for their person-centered assessments, providing full body skin assessments.Interview with MDS Coordinator and Wound care nurse on 8/23/2025 revealed them to state they had been in-serviced on resident interventions, accurate and timely documentation, fall risk assessments, notifying Administration, RP, and Physicians. They were given a test for understanding the updated protocols. The VPO was informed the Immediate Jeopardy was removed on 8/25/2025 at 3:40pm. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.