**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident received CPR in accordance with professional standards of practice for one (Resident #1) of six resident's reviewed for CPR. On [DATE] at 12:20 am, LVN A failed to initiate CPR on Resident #1 who was a full code status. Resident #1 expired on [DATE]. An Immediate Jeopardy was identified on [DATE] at 5:00 pm. The noncompliance began on [DATE] and ended on [DATE]. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could affect residents who are full code status and could need CPR by placing them at risk of death. Findings included: Record review of Resident #1's admission Record, dated [DATE] revealed an [AGE] year-old female, with an original admission date of [DATE] and the latest readmission date of [DATE]. The resident expired on [DATE]. The resident had a primary diagnoses of unspecified dementia (the specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss) and congestive heart failure (hearts ability to pump blood is compromised). The resident was under the care of hospice. Resident #1 was a full code. Resident #1 had a BIMS score of 14 indicating she was cognitively intact. Record review of Resident #1's Physician's Orders, dated [DATE], revealed an active order with a start date of [DATE] for full code. Record review of Resident #1's Care Plan, last revised on [DATE] revealed the following: Focus: Full Code/CPR in place. Goal: Resident has an order for CPR to be initiated will be followed. Interventions: Initiate CPR if the resident is without a heartbeat or not breathing. Notify EMS. Record review of Resident #1's progress noted, dated [DATE] at 3:40 am, by LVN A, revealed the following [in part]: [12:05 am] aide at this time has reported that patient is noted breathing abnormally. [12:07 am] This nurse went to assess pt and pt was noted semi-Fowlers (30 to 45 degree angle with the head elevated) in bed with head cocked to left side, pt appears to be taking deep breaths for air constantly at this time with eyes fixed as if she is imminent to passing. palpated for pulse and pulse is faint. skin is still warm to touch. [12:10 am to 12:15 am] Went to verify advance directive and was not found in hospice binder but did verify in PCC full code only. [12:20 am] returned to pt bedside and pt was noted unresponsive. aide prepared body immediately. A record review of Resident #1's vitals revealed there were no vitals documented in the Electronic Health Record on [DATE]. In an interview on [DATE] at 11:00 am, the DON said she did not know why LVN A did not initiate CPR on Resident #1. She said LVN A told her she was distracted by a phone call from her family member. In an interview on [DATE] at 1:40 pm, LVN A she said at the time of the incident on [DATE] at approximately 12:00 am, she had a lot going on, and said I had an emergency with my kids who were home alone and was distracted. In my head, all hospice patients have DNR's. My aide came and told me [Resident #1] took a turn, I went and saw her, and she was already basically gone. I went and looked at the hospice binder and did not see an advance directive. I looked in PCC (Electronic Health Record) and it said full code. I thought it was a mistake. I did not honor her code status. In an interview on [DATE] at 1:50 am, CNA B said on [DATE] at about 12:00 am, I went to check on and change [Resident #1] and she was having trouble breathing, I went and told [LVN A], the nurse went down with me to check her. [LVN A] said she didn't look good, and she went back to the nurses' station to look at computer. I stayed with [Resident #1], she got worse, she stopped breathing and had a blank staring off look. I went and got [LVN A] again. She came and took her vitals, told me she stopped breathing and passed, and told me to perform post-mortem care. [LVN A] did not initiate CPR. In an interview on [DATE] at 2:15 pm, the Medical Director said Resident #1 had an order for full code. He said it was his expectation for staff to follow the physician's orders. He said in this instance, failing to follow physician's orders had the potential that the resident's life could have been saved. In an interview on [DATE] at 3:19 pm, Resident #1's Family Member, he said LVN A called him sometime after midnight on [DATE] telling him that Resident #1 stopped breathing and did not have a DNR in place. He thought LVN A had told him CPR had been attempted but was too distraught to know for sure. In interview and record review on [DATE] at 10:30 am, the Administrator said he was no longer the Administrator of the facility since [DATE]. He said he was the Administrator of the facility during the time of the incident. He said he reported the incident and the LVN should have initiated CPR on Resident #1 who was a full code status. Record review of the facility policy Cardiopulmonary Resuscitation, not dated, revealed the following [in part]: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu-bag. The procedure is preformed to prevent death following cardiac or pulmonary arrest . Record review of the facility policy Self Determination End of Life Measures, not dated, revealed the following [in part]: Policy: 2. Upon admission, the facility will provide the individual with a copy of her/her rights under Texas law concerning the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.3.The facility will respect the wishes of the resident as outlined in the advanced directive . A record review of the facility policy Resident Rights, not dated, revealed the following [in part]: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her equality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Planning and Implementing Care - the Resident has the right to be informed of, participate in, his or her treatment including:b. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and d uratin of care and any other factors related to the effectiveness of the plan of care. Self-Determination: The resident has the right to and the facility must promote and facilitate resident self-determination through support of the resident choice. 2. The Resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 12. The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). The facility prior to investigator entrance on [DATE] completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. 1. Self-reporting protocol initiated on [DATE]. 2. [DATE] at 2:15 am, the Administrator was notified by the hospice nurse of Resident #1 passing that was full code and LVN A did not initiate CPR or contact emergency services. 3. Ad Hoc QAPI on [DATE] for Resident who was on hospice services but chose to have full code status, had passed away and the nurse did not initiate a code. 4. LVN A was immediately suspended on [DATE].5. The Administrator notified the DON, ADON, MD, Responsible Party, Social Services, Ombudsman, and Regional Team notified on [DATE]. Investigation started by the facility on [DATE]. Obtained witness statements. 7. The DON audited all resident code status on [DATE] - reviewed orders, care plans, DNRs. No errors were found. 8. Staff in-services were initiated on abuse/neglect, CPR, Advanced Directives, Resident Rights, Notification of Change, How to identify code status, and Following Physician Orders. Sign-in sheets observed. Quizzes were completed. The DON said all staff have been in-serviced except for a few PRN staff that hasn't worked in a while and before they return to work, they will have to complete the in-services before they will be allowed to work. Initiated [DATE]. 9. Safe surveys were conducted with residents on the LVNs hallway on [DATE], no further concerns were identified. 10. LVN A was terminated, and her nursing license was referred to the Texas Board of Nursing on [DATE]. 11. Daily monitoring by DON was ongoing. Verification of Correction 1: In an interview on [DATE] at 11:00 am, the DON said she received a call from the Administrator on [DATE] at 4:30 am in the morning about the incident. The LVN was immediately suspended and terminated after an investigation and her nursing licenses was referred to the Texas Board of Nursing all on [DATE]. The DON audited all residents' code status', making sure they were completed, care plans were correct, and physician's orders were reviewed. There were no errors found. A memo was put out for staff to not assume if a resident was on hospice care that did not mean they were not full code and how to find the code status in PCC (Electronic Health Record). In-servicing staff with a competency quiz was initiated. All staff had been in-serviced except for a few PRN staff who hadn't worked in a while. When they returned to work, they would be required to complete the in-services before being able to work. Hospice services had been contacted regarding the incident and reviewed with them the 2 residents that were currently under hospice care who were also full codes in the facility. Daily monitoring was ongoing at this time by the DON, including during the stand-up meetings to identify any evidence of any potential neglect, and during facility rounds were there any signs of staff performing or not performing their duties in a neglect manner. At the facility, per policy, CNAs were not CPR certified, only the nurses were. The facility policy states only 1 person must be in the facility per shift that is CPR certified. LVNs could not pronounce death, only RNs could do that. In this instance the LVN contacted hospice who came and pronounced death. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated and signed by staff. Verification of Correction 2:In an interview on [DATE] at 2:20 pm, the Hospice DON said the incident was reviewed in their morning stand up meeting on [DATE]. She said the hospice nurse arrived at the facility an hour after the incident at approximately 1:00 am and noted that Resident #1 was full code status, and that CPR had not been initiated. The hospice nurse did contact Resident #1's family member and he did not want anything else done at that time. She contacted the Administrator of the facility on [DATE] at 2:15 am and reported the incident to him. Verification of Correction 3:Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on [DATE] with the following members attended: Medical Director, Administrator, DON, ADON #1, ADON #2 , MDS Nurse #1, MDS Nurse #2, Area Director of Operations, and the Regional Compliance Nurse. Verification of Correction 4:Record review of the Employee Disciplinary Report dated [DATE] revealed the LVN A was suspended for investigation of failing to do CPR. Verification of Correction 5:Record review of the Provider Investigation Report, dated [DATE] revealed the Administrator, DON, ADON, Medical Director, the Resident Representative, Social Services, Ombudsman and the facility Regional Team were notified that LVN A failed to initiate CPR or notify EMS for Resident #1 that was full code status. Verification of Correction 6:Record review of documentation including the Provider Investigation Report dated [DATE] and the Self-Reporting protocol dated [DATE] revealed the facility investigation of the incident was started on [DATE] at 2:15 am by the Administrator. Verification of Correction 7:Record review of the 13 sampled Resident Code Status' were reviewed that included the advanced directives, physician's orders, and care plans. No errors were found. Verification of Correction 8:Record review in-service training records sign-in sheets and quizzes revealed completion by all active staff. Interviews with the following 12 sampled staff revealed all stated they had received in-service training including abuse/neglect, advance directives, CPR, resident rights, code status' and following physician's orders that included completing a competency quiz. They were not allowed to work until the in-services had been completed. [DATE] at 1:50 pm, CNA BXXX[DATE] at 11:29 am, CMA CXXX[DATE] at 11:55 am, Social WorkerXXX[DATE] at 11:12 am, CMA DXXX[DATE] at 11:24 am, CNA E.9/11.25 at 11:27 am, CNA FXXX[DATE] at 11:34 am, LVN GXXX[DATE] at 11:38 am, LVN HXXX[DATE] at 11:44 am, Rehabilitation ManagerXXX[DATE] at 11:48 am, CNA IXXX[DATE] at 11:52 am, CMA JXXX[DATE] at 11:57 am, CNA K. Verification of Correction 9:Record review revealed the residents on LVN A's hallway were interviewed with no additional concerns identified regarding the LVN. The resident's all said staff were respectful and appropriate, denied staff were rude or spoken abusively to, felt safe, knew how to report abuse, who the abuse coordinator was and did not express any concerns with their treatment and care. In interviews with the following sampled residents revealed none of them expressed concerns with staff. [DATE] at 11:27 am, Resident #2XXX[DATE] at 11:31 am, Resident #4XXX[DATE] at 11:35 am, Resident #3XXX[DATE] at 11:41 am, Resident # 5XXX[DATE] at 11:45 am, Resident #6. Verification of Correction 10:Record review of LVN A's employee file revealed a termination date of [DATE]. Record review of referral to Texas Board of Nursing was completed on [DATE] at 2:54 pm. Record review revealed LVN A's CPR certification was current, expiring on 03/2027. Verification of Correction 11:Record review of documentation monitoring revealed it was on-going daily since [DATE]. No further concerns have been identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #2) of 10 residents reviewed for multiple falls. The facility failed to implement a system for identifying fall patterns and implementing interventions to prevent falls that lead to emergency room visits with serious injury on 12/17/2023 and 02/07/2024 for Resident #1 and 12/10/2023 and 01/04/2024 for Resident #2. An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 10:25 am. While the IJ was removed on 02/16/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. These failures could place the residents at risk for falls, serious injuries, hospitalizations, and death. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed: Focus: The resident is at risk for falls. Goal: The resident will be free from falls through the review date. The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, keep furniture in locked position, Keep needed items, water in reach. Staff to make frequent visual checks to promote safety and reduce risk of fall, Physical therapy evaluate and treat as ordered or as needed, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side fails as ordered, handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 08/24/2021. Review of Resident #1's Fall Event Nurses' Note, dated 02/07/2024 at 4:48 PM, signed by LVN D, revealed: Resident #1 had an unwitnessed fall where he hit his head. Resident #1 was ambulating in hallway, and he fell in hallway face first. He bloodied his nose and received a bruise to the right side of his forehead. Doctor was notified and Resident #1 was sent to the emergency room for evaluation and treatment. Review of Resident #1's hospital clinical record, dated 02/07/2024, revealed: Injuries: Subdural hematoma (blood around the brain), Hemorrhagic contusion right inferior temporal region (bleeding brain bruise), left periorbital hematoma (bruise around the eye), and left 7th, 9th, and 10th rib fractures. Resident #1 was discharged back to facility on 02/08/2024. Review of Resident #1's Fall Event Nurses' Note, dated 12/17/2023 at 6:48 PM, signed by RN E, revealed: Resident #1 had an unwitnessed fall. Resident #1 fell and hit head on floor with laceration. Resident #1 was transferred to the emergency room. Review of Resident #1's hospital clinical record, dated 12/17/2023, revealed: Injury: Laceration sustained to left parietal area (top rear of head) is clean, jagged, superficial, 2.6 by 7.5 centimeters. Wound care applied 5 stiches. Resident #1 was discharged back to facility on 12/17/2023. Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #1 had falls on 12/17/2023 at 3:09 pm no injury, 12/17/2023 at 6:15 pm with injury, 01/25/2024 at 2:30 pm no injury, 01/29/2024 at 4:40 pm no injury, 01/30/2024 at 4:21 pm no injury, 02/01/2024 at 4:07 pm no injury, 02/06/2024 at 3:22 pm no injury, and 02/07/2024 at 4:46 pm with injury. Review of Resident #1's Fall Risk Assessments dated 12/17/2023 revealed a score of 13 High Risk, 01/25/2024 score 18 High Risk, 01/29/2024 score 21 High Risk, 01/30/2024 score 21 High Risk, 02/01/2024 score 18 High Risk, 02/06/2024 score 20 High Risk, and 02/07/2024 score 23 High Risk. Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. Went over care plan, with no changes at this time. Continue current plan of care. Observation on 02/14/2024 at 12:40 pm, revealed Resident #1 on the secure unit lying in bed no distress noted. Resident was alert but not oriented and not really communicating. Nurse and CNA were currently sitting at bedside. Observation on 02/15/2024 at 9:30 am, revealed Resident #1 was lying in bed. The bed was in a low position. There was no siderail or handrails on the bed. Resident #1 had his eyes open and looked at the surveyor but did not speak. There were 3 CNAs in the resident's room. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. Review of Resident #2's Significant Change MDS assessment, dated 12/15/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. Review of Resident #2's Comprehensive Care Plan, initiated 09/29/2022, revealed: Focus: The resident is at risk for falls related to She has had actual falls since entering the facility due to poor gait and balance, dementia with poor safety awareness and judgment. Actual fall 12/10/23 Fall between bed and wall causing Right Rib Fracture and mild pneumothorax resulting in emergency room visit. Goal: The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating, Staff x 1 to assist with transfers, and the resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 09/29/2022. Review of Resident #2's Fall Event Nurses' Note, dated 12/10/2023 at 6:05 AM, signed by LVN G, revealed: Resident #2 had an unwitnessed fall. CNA reported that resident had fallen on the floor. This nurse went into residents' room and found her lying on the floor on her right side and screaming in pain and holding her right side at her rib cage. Having difficulty breathing at this time. Bedside toilet and table and walker all turned over on floor by her. Resident #2 was transferred to the emergency room. Review of Resident #2's hospital discharge record, dated 12/10/2023, revealed: Diagnosis Fractured rib and head injury. Resident #2 was discharged back to the facility on [DATE]. Review of Resident #2's Fall Event Nurses' Note, dated 01/04/2024 at 9:50 PM, signed by LVN H, revealed: Resident #2 had an unwitnessed fall. CNA noticed blood on resident's shirt and observed blood in residents' hair and notified nurse. I assessed resident and observed laceration to right side of resident's head. Resident was guarding right shoulder as well. Resident #2 was transferred to the emergency room. Review of Resident #2's hospital clinical record, dated 01/04/2024, revealed: Abrasion on the right scalp and shoulder pain. Resident #2 was discharged back to the facility on [DATE]. Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #2 had falls on 11/19/2023 at 11:00 pm with no injury, 12/10/2023 at 5:44 am with injury, 12/23/2023 at 10:00 am with no injury, and 01/04/2024 at 8:15 pm with injury. Review of Resident #2's Fall Risk Assessments dated 11/19/2023 revealed score 16 High Risk, 12/10/2023 score 19 High Risk, 12/23/2023 score 15 High Risk, 01/04/2024 score 15 High Risk. Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's [family member] did attend. Went over care plan, with no changes at this time. Continue current plan of care. Observation on 02/15/2024 at 4:00 pm, revealed Resident #2 ambulating up and down the hall. Resident seemed unsteady on her feet. Resident was wandering in and out of other residents' rooms. During an interview on 02/14/2024 at 12:45 pm, LVN A stated Resident #1 had a history of falling. She stated she had been sitting in his room since his return from the hospital as much as she could because she did not want him to fall again. She stated Resident had a history of wandering and was only oriented to his name. She stated she was trying to increase supervision. She stated she had not been instructed to sit or monitor Resident #1 by the facility. She stated she just was because she was concerned. She stated she had spoken to the DON and informed her that Resident #1 needed 1:1 supervision but she was told the facility did not have the staff for that. She stated there was always 2 CNAs on the secure unit. LVN A stated Resident #2 had a history of wandering and falls also. She stated Resident #2 walks the unit continuously and it was almost impossible to keep an eye on her all the time. She stated Resident #2 had no new fall interventions that she was aware of. During an interview on 02/14/2024 at 12:50 pm, CNA B stated he was working with another resident the day Resident #1 fell and was injured. He stated his coworker was in a room and he was assisting the nurse with another resident when he heard a loud noise. He stated he turned around and Resident #1 was lying face down in his doorway covered in blood. He stated he had seen Resident #1 in his bed 15 minutes prior to the fall. He stated he always tried to watch Resident #1 closely and made sure to check on him every 15 minutes when possible. He stated he had asked for help and spoke to the DON and Administrator about not having adequate staff to meet Resident #1's needs. He stated Resident #2 was also a high fall risk. He stated Resident #2 continuously wandered and was very unsteady. CNA B stated he felt 2 CNAs was not enough to monitor the residents and to prevent falls. He stated he was not aware of any new fall prevention interventions put in place for Resident #1 or Resident #2. During an interview on 02/14/2024 at 2:00 pm, the DON stated she did not know much about Resident #1. She stated she had 130 residents and could not keep up with all of them. She stated she was not aware of any clinical issues with Resident #1 prior to the fall. She stated she was not aware of how many falls he had had but she knew he had a history of falls. She stated when a fall occurred the staff assessed the resident, notified the physician and family member, then completed an incident report. She stated she was not always notified of all falls, only falls with major injury. She stated falls were reviewed every morning during morning meeting. During an interview on 02/15/2024 at 9:35 am, CNA B stated he was told this morning by the DON to keep resident #1 in his line of site at all times. He stated they did not increase the staffing and he still had to do his normal work and watch resident. #1. He stated he had not received any in-service regarding increased supervision for Resident #1 or Resident #2. During an interview on 02/15/2024 at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated if a resident fell it would be discussed in the clinical meeting and new interventions should be put into place. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated she did not have any documentation of what was discussed in the clinical meeting she just made herself a to-do list. She stated she had missed multiple clinical meetings lately due to having to work the floor. She stated she did not have a system where she tracked falls. She stated falls were discussed in QAPI meetings monthly. She stated the facility just stated how may falls they had each month. The DON stated she was unaware of any QAPI plan specifically for falls or any fall prevention programs in place. She stated the possibility of getting Resident #1 a helmet was brought up by the family on 02/07 prior to the fall. The DON stated since Residents #1's return from the hospital on [DATE], she placed the resident on increased supervision. She stated she verbally in-serviced the staff on the secure unit and instructed them to always keep Resident #1 in line of site. She stated she did not increase staffing and did not document, or care plan the new intervention. She stated she obtained an order to refer Resident #1 to a neurologist, but she was unsure where the facility was in the process of getting that done. The DON stated she was unable to perform her clinical duties because she was working the floor or constantly putting out fires and she had not had the time do her responsibilities. She stated she did not feel that any further interventions could have been put in place to prevent the falls but agreed that the facility did not attempt any new interventions. Interview attempted on 02/15/2024 at 11:00 am with both Medical Directors via phone. Called office and left message with no returned phone call. During an interview on 02/15/2024 at 11:45 pm, the Administrator stated he monitored the number of falls in QAPI meetings and looked for trends, but he just looked at overall fall numbers not resident specific. He stated more interventions should have been put into place for Resident #1 and Resident #2 and it was ultimately his responsibility to ensure this was done. The Administrator stated he was notified of all falls and ensured all documentation was done. He stated he only investigated falls with injury or unwitnessed or suspicious falls. During an interview on 02/15/2024 at 1:00 pm, CNA C stated Resident #1 had always had multiple falls. She stated she was working the day he fell and the day he returned. CNA C stated she was not aware of any new interventions being put into place. She stated Resident #2 got up quickly and fell before staff even knew that he was out of bed. She stated she tried to watch him closely but most of the time there was only 2 CNAs on the unit, and it was hard to provide 1:1 supervision. CNA denied being in-serviced or told to increase monitoring or supervision when Resident #1 returned to the facility. During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. She stated the failure occurred because the DON had not added new interventions when the falls occurred. Review of facility policy titled, Preventive Strategies to Reduce Fall Risk, revised October 5, 2016, revealed in part: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: 1. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects .5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). This was determined to be an Immediate Jeopardy (IJ) on 02/16/2024. The Administrator, and Director of Nurses were notified on 02/16/2024 at 10:25 am that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. The Administrator was provided with the IJ template on 02/16/2024 at 10:25 am. The following Plan of Removal was accepted on 02/16/2024 at 2:35 pm and included: Problem: F689 Accidents/Hazards Interventions: Resident #1's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. o Helmet ordered for safety. o Refusal to use assistive devices. o PT/OT/ST o Offer diversions, activities, food, conversation, etc to reduce wandering. o Non-skid socks o Increased staff rounding Resident #2's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. o Increase rounding to promote safety. o Ensure a safe environment free of clutter and obstructions. All residents with falls in the last 30 days were reviewed by DON/Regional Compliance Nurse on 2/16/24 to ensure that appropriate fall interventions are listed on the care plan. There were 50 falls with 26 residents noted in the review. A task on the POC Kiosk was added for all resident at high risk for easy identification by the DON, ADON, and Regional Compliance Nurse on 2/16/24. The medical director was notified of the immediate jeopardy situation on 2/16/24 at 11:30pm by the Administrator. Ad Hoc QAPI meeting will be held on 2/16/24 to discuss the IJ and review plan of removal. In-services: The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following in-services. o Fall Prevention Policy o Care Plan Policy: Updating the care plan with fall prevention/safety interventions. o Abuse and Neglect. The following in-services were initiated by the Regional Compliance nurse, DON, and ADON on 2/16/24. Any staff member not present or in-service on 2/16/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-service at orientation. All agency staff will in serviced before assuming their assignment. All Staff: Abuse and Neglect Policy Notifying the charge nurse for any change in condition to include falls, pain or a change in mobility or transfer status. All Direct Care Staff: Abuse and Neglect Policy Fall Prevention Policy Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status. How to identify a resident who is high risk for falls on the Kiosk or Care plan Monitoring: DON, Administrator, Designee will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. DON, Administrator, Designee will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. Administrator or Designee will review the Event entry and ensure that care planned interventions are change with each fall during the weekly Standards of Care Meeting. Meeting will occur weekly, and monitoring will be in place for 6 weeks. Regional Compliance Nurse and/or ADO will monitor, on a weekly basis, that monitoring tools are in place and up to date. Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from 02/16/2023 at 2:40 pm through 02/16/2024 at 5:30 pm revealed: Review of Resident #1's comprehensive care plan revealed new interventions added on 02/16/2024 to include: Continues PT/OT. Started OT in October for safety and strength. ST picked up for weight and cognition. PT started for strengthening endurance related to weakness to lower extremity. Date Initiated: 02/16/2024 PT o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 02/14/2024 Revision on: 02/15/2024 o Ensure that the resident is wearing appropriate nonskid footwear or nonskid socks when ambulating Date Initiated: 08/24/2021 Revision on: 02/15/2024 o Helmet ordered by Therapy for prevention of head trauma Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Keep needed items, water, etc, in reach. 2/16/24 Staff to increase visual checks to promote safety and reduce risk of fall Date Initiated: 08/24/2021 Revision on: 02/16/2024 o Resident offered and refuses to use assistive device for safety. Date Initiated: 02/16/2024 o Staff x 1 to assist with transfers, staff to monitor while in room and when resident ambulating in hallway. Date Initiated: 02/14/2024 Revision on: 02/16/2024 o The resident needs a safe environment Date Initiated: 08/24/2021 Revision on: 02/16/2024. Observation on 02/16/2024 at 2:40 pm, Resident #1 was lying in bed with family members in his room. Observed staff in line of sight of Resident #1. Review of Resident #2's comprehensive care plan revealed new interventions added on 02/16/2024 to include: o Ensure a safe environment free of clutter and obstructions. Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Staff to increase rounding on resident to promote safety Date Initiated: 02/16/2024. Observation on 02/16/2024 at 2:43, Resident #2 was sitting on couch in the lobby with staff beside her. Random record reviews revealed at least 6 of the 26 residents with falls in the last 30 days had their comprehensive care plans reviewed with new interventions added on 02/16/2024. Observation on 02/16/2024 at 2:45 pm revealed CNA B accessing the POC Kiosk (computer system used by staff) and signing off on the high fall risk alert for Resident #1. Observed high fall risk alerts on 6 random residents. Review of an email dated 02/16/2024, sent from the Medical Director to this surveyor, stated he was aware of the IJ, and he attended the QAPI meeting via phone. Review of a QAPI document dated 02/16/2024 revealed d the IJ with signature page of all in attendance. In-services: Reviewed in-service information and signature sheets for in-service given by RCN to Administrator, DON, and ADON on Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect During an interview on 02/16/2024 at 3:00 pm, the Administrator and DON confirmed understanding of in-services titled: Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect. During observation on 02/16/2024 at 3:10 pm, revealed the DON educating 3 nurses, 9 CNAs, and 1 human resources staff that work the 6:30 am-6:30 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with 2 CNAs and 1 nurse verified understanding of in-service. During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 CNA and 1 medication aide that work the 2:00 pm- 10:100 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 nurse who works 6:30 pm- 6:30 am shift via phone, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with nurse verified understanding of in-service. The Administer, RCN, ADO, and DON were informed the Immediate Jeopardy was removed on 02/16/2024 at 5:30 pm. The facility remained out of compliance at a severity level of harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.