**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 (Resident's #17, #22) of 6 residents reviewed for baseline care plans. The facility failed to ensure Resident #17's and Resident #22's baseline care plans addressed their mobility abilities.The facility failed to complete Resident #27 and Resident #44's baseline care plans.This failure could place residents at risk of getting insufficient care, not having personal needs not met resulting in hospitalizations and injuries related to falls. An IJ was identified on 09/04/25. The IJ template was provided to the facility on [DATE] at 4:53 pm. While the IJ was removed on 09/06/25, 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. Resident #17 Record review of facility admission Record dated 08/19/25 reflected Resident #17 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, Hypoxemia (a condition characterized by a below normal level of oxygen), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and heart failure Record review of facility Progress Notes dated 08/04/25 at 4:44PM reflected Resident #17's family member states resident had a fall on 8/3/2025, resident had a bruise near right eye and a large contusion on top of his head near his forehead on the right side, bruising behind both arms, notified Dr and DON, neuro checks initiated, waiting for Dr order. Record review of admission MDS dated [DATE] for Resident #17 reflected section GG: Functional abilities chair/bed-to-chair transfer was marked 04 Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Record Review of Radiology report from The Hospital dated 08/04/25 reflected the fall resulted in minimally displaced acute fractures of the eighth and ninth ribs laterally. Nondisplaced acute intra-articular fracture medial left clavicle extending to the sternoclavicular joint (clavicle fracture). Record review of Resident #17s Medical Records for Baseline Care Plan reflected it was not completed. Resident #22 Record review of facility admission Record dated 08/21/25 reflected Resident #22 was admitted to the facility on [DATE]. Diagnoses included Malignant Neoplasm of Pancreas (cancer of the pancreas), Neoplasm related pain (pain due to cancer), protein calorie malnutrition, and elevated blood pressure. Resident #22 was admitted on Hospice Respite. Record review of Resident #22's progress notes dated 08/04/25 at 7:55PM reflected patient observed laying on the floor of her bathroom. CNA stated patient had requested to go to the restroom with assistance of 1 (one) staff. CNA gave patient some privacy and gave patient instructions to pull emergency call light when done, patient has successfully used emergency light before. Patient had a small but deep laceration above the right eyebrow. Patient was drowsy but responding to questions, could tell us her name and date of birth . 911 called or transport to emergency room. X3 assisted back into bed using (mechanical) lift. Vital signs: 83/56,100,94%. Dressing applied to head laceration. Emergency medical services in building and provided transport, patient hypotensive and believed to have had a syncopal episode (fainting). She is alert at this time, oriented x2-3. POA called and notified of fall and send out to emergency room. Primary Care Physician and hospice called and notified of fall with emergency room visit. Instructions left with this nurse to call hospice when patient is in facility so follow up visit can be completed. Signed by LVN F. Record review of Resident #22's admission MDS dated [DATE] reflected section GG: Functional abilities toilet transfer was marked 03 Partial/Moderate Assistance-Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Resident #22 was coded as using a walker and a wheelchair for mobility devices. Record review of Resident #22s Medical Records for Baseline Care Plan reflected it was not completed. Findings included: Resident #27 Record review of Resident #27's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: high blood pressure, diabetes mellitus (a disease in which the body's ability to produce or respond to insulin is impaired), high cholesterol, aphasia (a communication disorder that affects a person ability to speak, write, and understand both spoken and written language), stroke, hemiplegia (paralysis on one side of the body), muscle weakness, and dysarthria (a motor speech disorder that occurs when the muscles used for speech are weak or difficult to control). His BIMS score was a 12, indicating he had moderately impaired cognition. Record review of Resident #27's “Care Plan Conference” dated 11/19/2024 reflected Resident #27 was admitted on [DATE], the reason for conference was “initial”, and it included nursing, social worker, dietary, activity notes, and the members present were documented. Resident #44 Record review of Resident #44's face sheet reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included: congestive heart failure (a chronic condition where the heart cannot pump blood effectively), respiratory failure (inadequate gas exchange by the respiratory system), high blood pressure, severe kidney disease (gradual loss of kidney function), type 2 diabetes mellitus (chronic condition that affects the body's way of metabolizing sugar), iron deficiency, elevated white blood cell count, atrial fibrillation, edema (swelling caused by excess fluid in the body's tissues), tachycardia (when the heart rate exceeds 100 beats per minute), and tachypnea (rapid, shallow breathing). Record review of Resident #44's undated baseline care plan reflected she was admitted on [DATE] and under part “C. Social Services” all needs/goals were left blank. In an interview on 08/21/2025 at 1:16 PM LVN D stated the Nursing assistants never told her that the care plan was never populated for Resident #17 or Resident #22. LVN D stated staff were aware the baseline care plan information was important to prevent falls and assist with rehabilitation to ensure residents needs were met. In an interview on 08/21/2025 at 2:36 PM the DON stated that she and ADON were responsible for filling out the base line care plans. The DON stated the baseline care plans should have been completed within the first 48 hours of admission. The DON stated the baseline care plan for Resident #17 and Resident #22 were overlooked and could not say why those or the others were not fully completed. The DON stated the negative effects for having an incomplete baseline care plan could be increased falls. In an interview on 09/04/25 at 1:30pm LVN E stated that she was not present when Resident #17 admitted (7/31) to the facility. When she took his blood pressure on 08/03/25 at 9:16am she saw a bruise on his head, but she thought the bruise was from when he admitted . She did not see the knot on his head until the family told her about it. She stated that she initiated a neuro check and post fall assessment at 6:13pm on him. She stated it was an agency nurse working the night shift of 08/03/25, and when she got report from that agency nurse, she was not told that Resident #17 had a fall. She stated that he had a wheelchair and very unsteady gait (ability to walk). LVN E stated Resident #22 could not get up and walk to the bathroom on her own. Resident #22 had a lot of edema (swelling) in her legs and could not toilet transfer on her own. She stated Resident #22 needed active assistance during toileting. She stated that moderate assistance means I person assisting, and I person could have assisted Resident #22 because she was so thin. She stated that Resident #22 was not to be left alone on the toilet, she could have privacy (meaning standing in the doorway with your back toward the resident). In an interview on 09/04/25 at 2:28pm The DON stated that an agency nurse was working the night of 08/03/2025 when Resident #17 fell. The DON stated the nurse failed to conduct a neuro check, post fall evaluation, and report to the ongoing nurse that Resident #17 had a fall during her shift. The DON stated that agency nurse was the one who helped Resident #17 up from the fall, even though originally the resident told the DON he did not tell anyone about the fall. The DON stated Resident #22 used a wheelchair and typically was able to be left alone on the toilet due to being cognitively intact and her ability to sit on the toilet without assistance and had previously demonstrated successful ability to use her call light and sit on the toilet without assistance. She stated that at the time of the fall The DON was told the resident was seated on the toilet, the CNA felt the resident was safe, the call light was in reach, and the CNA was no longer present in the bathroom. She stated that she or the ADON are checking fall risk assessments, check charts every 24 hours to ensure assessments are completed fully. The DON stated she opens baseline care plans upon a resident's admission, the BOM contacts families and will set up baseline care plan meeting with RP within 48 hours of admission. Review of the facility policy titled, “Care Plans- Baseline” dated December 2016 reflected, “A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. “The Interdisciplinary Team will review the healthcare practitioners' orders and implement a baseline care plan to meet the resident's immediate care needs. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders;b. Physician orders;c. Dietary orders;d. Therapy services;e. Social services; andf. PASARR recommendation, if applicable.” An Immediate Jeopardy was identified on 09/04/25 at 4:53 PM. and an IJ template was provided to the ADM and DON. A plan of removal was requested at that time. The following Plan of Removal, submitted by the facility, was accepted on 09/05/25. Plan of Removal Immediate Threat: On 09/04/2025 an abbreviated survey was initiated at the facility. On 09/04/2025 the surveyor provided an Immediate Jeopardy (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification Immediate Jeopardy (IJ) states as follows: F655 –The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The facility failed to ensure Resident #17's and Resident #22's baseline care plans addressed their mobility abilities. Action: Director of Nursing reviewed all care plans including baseline care plans to ensure resident mobility, transfers, and supervision needs are included. Findings are recorded in an audit log and no negative findings at this time. Start Date: 09/04/2025 Completion Date: 09/05/2025 Responsible: Director of Nursing Action: Revised admission process and policy to require baseline care plan initiation within 48 hours, verified by Director of Nursing/Assistant Director of Nursing. Education will be provided to nurses, direct care staff and agencies on the revised admission process and policy to require baseline care plan initiation within 48 hours. Nurses, direct care staff and agencies staff will be required to read, acknowledge understanding and sign the in-services before the start of their shift. In addition, competency check (test) has been implemented to ensure understanding. The competency check (test) will be verified by DON for comprehension. Start Date: 09/04/2025 Completion Date: 09/05/2025 Responsible: Director of Nursing/Assistant Director of Nursing Action: Implemented admission checklist and new 'admission Quality Check' form to verify care plan and fall risk completion. Changes will be updated on the report sheet located at the nurses' desk. Education will be provided to nurses, direct care staff and agencies staff to look at the report sheet located at the nurses' desk before start of the shift and a signature is required on the report sheet acknowledging that the changes has been reviewed by the staff. Nurses, direct care staff and agencies staff will be required to read, acknowledge understanding and sign the in-services before the start of their shift. In addition, competency check (test) has been implemented to ensure understanding. The competency check (test) will be verified by DON for comprehension. Start Date: 09/05/2025 Completion Date: 09/05/2025 Responsible: Director of Nursing/Assistant Director of Nursing Action: Monitoring tools will be put in place to capture ongoing audits of all new admits' baseline care plans (daily for 30 days, weekly for 60 days, then monthly ongoing), and findings will be reported in Quality Assurance and Performance Improvement (QAPI). Start Date: 09/05/2025 Completion Date: Ongoing Responsible: Director of Nursing/Assistant Director of Nursing On 09/6/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of an audit completed on 09/05/25 by The DON reflected that all care plans and baseline care plans were reviewed ensuring residents mobility, transfers and supervision needs were included. The Audit was verified by a checkoff for each resident completed signed and dated for 09/05/25 by the DON. The Surveyor audited 7 Resident medical records including new admission and readmissions within the last 30 days for verification of baseline care plan included residents' mobility and supervision needs. Record review completed on 09/05/25 of Revised reflected the admission process and policy was updated to require baseline care plan initiation within 48 hours. The policy reflected to include assistive devices needed. Record review of education provided to nurses, direct care staff and agencies on the revised admission process and policy to require baseline care plan initiation within 48 hours. Nurses, direct care staff and agencies staff were required to read, acknowledge understanding and sign the in-services before the start of their shift. A competency check (test) had been implemented to ensure understanding. The competency check (test) was completed and signed by 5 LVNs and 2 RNs from both day and night shifts. Record review completed on 09/05/25 of an Implemented admission checklist and new 'admission Quality Check' form was verified to include care plan and fall risk completion. An Inservice given to Nursing staff was completed to include an updated report sheet located at the nurses' desk directing care staff and agencies staff to look at the report sheet located at the nurses' desk before start of the shift requiring a signature acknowledging that the changes had been reviewed by the staff. Education verification and acknowledgement of understanding per the competency check was signed by 5 LVNs and 2 RNs from both day and night shifts. Record review completed on 09/05/25 of new Monitoring tools was conducted to capture ongoing audits of all new admits' baseline care plans (daily for 30 days, weekly for 60 days, then monthly ongoing). The tool included Baseline care plan initiated within 48 hours of admission. Interviews conducted on 09/06/25 between 6:00am and 8:00am with DON, ADON, LVN C, LCN D, LVN I, LVN E, RN F, from both day and night shifts reflected They had been instructed on baseline care plans ensuring residents' mobility, transfers and supervision needs were included. They stated Nurses, direct care staff and agencies staff were required to read, acknowledge understanding and sign the in-services before the start of their shift. The staff stated agencies they were to look at the report sheet located at the nurses' desk before start of the shift and sign it acknowledging that the resident changes had been reviewed by the staff. The staff verified they were given competency test on their education. On 09/06/2025 at 8:18am, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #17 and Resident #22) of 8 residents reviewed for accidents and hazards. The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents in that The facility failed on 08/04/2025 to ensure appropriate supervision and assistive devices were in place for Resident #17 and Resident #22 to prevent falls. This failure could place residents at risk for injury and hospitalizations related to accidents. An IJ was identified on 09/04/25. The IJ template was provided to the facility on [DATE] at 4:53 pm. While the IJ was removed on 09/06/25, 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. Resident #17Record review of facility admission Record dated 08/19/25 reflected Resident #17 was admitted to the facility on [DATE]. Diagnoses included urinary tract infection, Hypoxemia (a condition characterized by a below normal level of oxygen), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and heart failure Record review of Fall Risk Assessment for Resident #17 dated 08/01/25 reflected that it was incomplete. Gait / Balance assessment was not observed and left unmarked. Medications and vision were not reviewed on the fall risk assessment. Record review of facility Progress Notes dated 08/04/25 at 4:44PM reflected Resident #17's family member states resident had a fall on 8/3/2025, resident had a bruise near right eye and a large contusion on top of his head near his forehead on the right side, bruising behind both arms, notified Dr and DON, neuro checks initiated, waiting for Dr order. Record review of admission MDS dated [DATE] for Resident #17 reflected section GG: Functional abilities chair/bed-to-chair transfer was marked 04 Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Record Review of Radiology report from The Hospital dated 08/04/25 reflected the fall resulted in minimally displaced acute fractures of the eighth and ninth ribs laterally. Nondisplaced acute intra-articular fracture medial left clavicle extending to the sternoclavicular joint (clavicle fracture). Record review of Resident #17s Medical Records for Baseline Care Plan reflected it was not completed. Resident #22 Record review of facility admission Record dated 08/21/25 reflected Resident #22 was admitted to the facility on [DATE]. Diagnoses included Malignant Neoplasm of Pancreas (cancer of the pancreas), Neoplasm related pain (pain due to cancer), protein calorie malnutrition, and elevated blood pressure. Resident #22 was admitted on Hospice Respite. Review of facility Fall Risk Assessment for Resident #22 dated 07/29/25 reflected that it was incomplete. Medications and vision were not reviewed on the fall risk assessment. Gait / Balance assessment was not observed and left unmarked. Record review of Resident #22's progress notes dated 08/04/25 at 7:55PM reflected patient observed laying on the floor of her bathroom. CNA stated patient had requested to go to the restroom with assistance of 1 (one) staff. CNA gave patient some privacy and gave patient instructions to pull emergency call light when done, patient has successfully used emergency light before. Patient had a small but deep laceration above the right eyebrow. Patient was drowsy but responding to questions, could tell us her name and date of birth . 911 called or transport to emergency room. X3 assisted back into bed using (mechanical) lift. Vital signs: 83/56,100,94%. Dressing applied to head laceration. Emergency medical services in building and provided transport, patient hypotensive and believed to have had a syncopal episode (fainting). She is alert at this time, oriented x2-3. POA called and notified of fall and send out to emergency room. Primary Care Physician and hospice called and notified of fall with emergency room visit. Instructions left with this nurse to call hospice when patient is in facility so follow up visit can be completed. Signed by LVN F. Record review of Resident #22's admission MDS dated [DATE] reflected section GG: Functional abilities toilet transfer was marked 03 Partial/Moderate Assistance-Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Resident #22 was coded as using a walker and a wheelchair for mobility devices. Record review of Resident #22s Medical Records for Baseline Care Plan reflected it was not completed. In an interview on 08/21/2025 at 1:16 PM LVN D stated Resident #17 did not use a walker or wheelchair. The family had brought in a cane from home, but he got around holding onto furniture. She stated he was very mobile. LVN D stated the CNAs always checked with the nurse to verify assistance needed for residents. LVN D stated the nursing assistants never told her that the Kardex (a section of the medical record showing how much and why type of assistance a resident needs) and care plan were never populated for Resident #17 or Resident #22. LVN D stated staff were aware the baseline care plan and Kardex information were important to prevent falls and assist with rehabilitation to ensure residents needs were met. In an interview on 08/21/2025 at 2:36 PM the DON stated the DON stated she was unsure if Resident #17 used any assistive devices other than a cane from home. She stated he was using the furniture for balance. She stated the facility did provide a walker and encouraged him to use that. The DON stated she was not sure therapy did an evaluation on Resident #17. She stated he was admitted late on a Friday and discharged quickly. In an interview on 08/21/2025 at 2:46pm the ADON stated that resident #22 entered the facility on respite care. She stated that the family decided to leave her at the facility under the care of hospice until she passed. The ADON stated that she did not feel that Resident #22 was a fall risk because there were lot of family members around and the resident was not active. The ADON stated that she did not feel that there was a need to have fall precautions in place. In an interview on 09/04/25 at 1:30pm LVN E stated that she was not present when Resident #17 admitted (7/31) to the facility. When she took his blood pressure on 08/03/25 at 9:16am she saw a bruise on his head, but she thought the bruise was from when he admitted . She did not see the knot on his head until the family told her about it. She stated that she initiated a neuro check and post fall assessment at 6:13pm on him. She stated it was an agency nurse working the night shift of 08/03/25, and when she got report from that agency nurse, she was not told that Resident #17 had a fall. She stated that he had a wheelchair and very unsteady gait (ability to walk). LVN E stated Resident #22 could not get up and walk to the bathroom on her own. Resident #22 had a lot of edema (swelling) in her legs and could not toilet transfer on her own. She stated Resident #22 needed active assistance during toileting. She stated that moderate assistance means I person assisting, and I person could have assisted Resident #22 because she was so thin. She stated that Resident #22 was not to be left alone on the toilet, she could have privacy (meaning standing in the doorway with your back toward the resident). In an interview on 09/04/25 at 2:28pm The DON stated that an agency nurse was working the night of 08/03/2025 when Resident #17 fell. The DON stated the nurse failed to conduct a neuro check, post fall evaluation, and report to the ongoing nurse that Resident #17 had a fall during her shift. The DON stated that agency nurse was the one who helped Resident #17 up from the fall, even though originally the resident told the DON he did not tell anyone about the fall. The DON stated Resident #22 used a wheelchair and typically was able to be left alone on the toilet due to being cognitively intact and her ability to sit on the toilet without assistance and had previously demonstrated successful ability to use her call light and sit on the toilet without assistance. She stated that at the time of the fall The DON was told the resident was seated on the toilet, the CNA felt the resident was safe, the call light was in reach, and the CNA was no longer present in the bathroom. She stated that she or the ADON are checking fall risk assessments, check charts every 24 hours to ensure assessments are completed fully. The DON stated she opens baseline care plans upon a resident's admission, the BOM contacts families and will set up baseline care plan meeting with RP within 48 hours of admission. Record review of the facility policy dated September 2012 titled Falls - Clinical Protocol reflected: As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. Staff will ask the resident and the caregiver or family about a history of falling. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk. Risk factors for subsequent falling include lightheadedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, An Immediate Jeopardy was identified on 09/04/25 at 4:53 PM. and an IJ template was provided to the ADM and DON. A plan of removal was requested at that time. The following Plan of Removal, submitted by the facility, was accepted on 09/05/25. Plan of Removal Immediate Threat: On 09/04/2025 an abbreviated survey was initiated at the facility. On 09 /04/2025 the surveyor provided an Immediate Jeopardy (IJ) notification that the Regulatory Services has determined that the condition at the facility constitutes an Immediate Jeopardy (IJ) to resident health and safety. The notification of Immediate Jeopardy (IJ) states as follows: F689 - The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents in that: The facility failed to ensure new admissions received timely and completed fall risk assessments to prevent accidents. Action: All residents assessed for safety and injury. Neurological checks and follow-up assessments initiated on residents with new falls . Two residents were identified with falls requiring neurological checks. Neuro checks were initiated immediately. Licensed nursing staff will perform and document all neurological checks per policy. Nursing staff educated on performing neurological check on resident post fall. All nurses, including PRN and agency nurses will be required to read, acknowledge understanding and sign the in-services before the start of their shift. Start Date: 09/04/2025Completion Date: 09/05/2025Responsible: Director of Nursing/ Assistant Director of Nursing Action:100% audit of all residents' fall risk assessments completed to ensure they are fully documented.Start Date: 09/04/2025Completion Date: 09/05/2025Responsible: Director of Nursing/ Assistant Director of Nursing Action:Registered nurses and license nurses including PRN and agency nurses re-educated on completing fall risk assessments within 24 hours of admission and ensuring proper supervision by the Director of Nursing or designee. PRN and agency nurses will be required to read, acknowledge understanding and sign the in-services before the start of their shift. Nurse consultant or designee will re-educate the Director of Nursing and the Assistant director of Nursing on monitoring that the fall risk assessments are being completed by the charge nurses within 24 hours of admission and ensuring proper supervision by the Nurse Consultant.Start Date: 09/04/2025Completion Date: 09/05/2025Responsible: Director of Nursing/Nurse Consultant Action:Monitoring tool will be put in place to capture daily audits of new admissions for 30 days, then weekly for 60 days, then monthly ongoing, findings will be reported in Quality Assurance and Performance Improvement (QAPI).Start Date: 09/05/2025Completion Date: OngoingResponsible: Director of Nursing/ Assistant Director of Nursing On 09/6/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of an audit completed on 09/05/25 by The DON reflected that an all-resident review was completed by The DON ensuring Neurological checks and follow-up assessments were initiated on residents with new falls. Neuro checks were initiated immediately for two residents identified with recent falls verified with record review. Nursing staff were educated on performing neurological check on resident post fall as evidenced by an in-service signed and dated for 09/05/25. Record review of an audit completed on 09/05/25 for all residents for admission fall risk assessment and quarterly fall risk assessments was signed completed by the ADON. Residents had current completed fall risk assessments as evidenced by a review of medical records for 7 residents within the facility. Record review completed on 09/05/25 of an Inservice verified that license nurses including PRN and agency nurses were re-educated on completing fall risk assessments within 24 hours of admission and ensuring proper supervision. The Director of Nursing and the Assistant director of Nursing on monitoring that the fall risk assessments are being completed by the charge nurses within 24 hours of admission and ensuring proper supervision by the Nurse Consultant on 09/05/25. Education was verified for 6 of 8 nursing staff Record review completed on 09/05/25 of new admission Monitoring tools was conducted. The tool included resident name, date of admission, verifying the fall risk assessment was completed along with a baseline care plan. The facility did not have any new admission as of time of exit. The [NAME] stated the tool will be reviewed daily in their morning meeting for verification of completion. Interviews conducted on 09/06/25 between 6:00am and 8:00am with DON, ADON, LVN C, LCN D, LVN I, LVN E, RN F, from both day and night shifts reflected They had been instructed on Fall Policy, Fall Risk Assessments, including assessment of neurological status. The staff stated they had been educated on need for assistive devices and fall prevention measures including keeping beds in low positions, more frequent rounding, and call light placement. The staff were able to identify the report sheet located at the nurses' station to be signed each shift verifying resident changes in condition had been reviewed from one shift to the next. On 09/06/2025 at 8:18am, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to Identify and eliminate all known and foreseeable accident hazards in the resident's environment, to the extent possible for 1of 4 residents (Resident #1) reviewed for safety. The facility failed to ensure 1 of 4 residents (Resident #1) was free from risk of accidents and injuries when he was allowed to elope from the facility. The facility failed to properly repair a door for years. An IJ was identified on 04/16/2025. The IJ Template was provided to the facility on [DATE] at 05:09 PM. While the IJ was removed on 04/18/2025, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to complete repairs and evaluate the effectiveness of the corrective systems. These failures could place cognitively impaired residents at risk for accidents, injuries, and possible death. Findings included: Record review of Resident #1's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with Alzheimer's, stroke, dysphasia (difficulty speaking), heart failure, pacemaker, and lack of coordination. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated the resident's cognitive and communication abilities were too impaired for him to complete the assessment. Record review of Resident #1's Care Plan, reflected Focus areas were initiated for the following areas: Communication problems-Resident can make basic needs known was initiated on 7/5/23 with an intervention stating, Monitor any changes in ability to communicate. Risk for elopement was initiated on 7/22/24 with an intervention stating, Make sure that wander guard is working . ADL self-care deficit related to stroke was initiated on 7/5/23 with an intervention stating, The resident requires EXTENSIVE assistance by 1 person with personal hygiene. Incontinence focus related to Dementia was initiated on 7/5/23 with an intervention stating, Ensure the resident has unobstructed path to the bathroom. Impaired cognitive function/dementia related to Alzheimer's was initiated on 7/5/23 with an intervention stating, Administer medications as ordered. Monitor/document for side effects and effectiveness. Risk for falls related to gait/balance problems was initiated on 1/18/24 with an intervention stating, Anticipate and meet the resident's needs. Record review of Resident #1's Orders, reflected an order on 7/20/24 to monitor the wander guard to the right ankle, every shift, every day, and night shift. Observation on 4/16/25 at 11:20 AM of the facility's video surveillance revealed Resident #1 was observed on 4/9/25 going out of the door on basement egress side (Door OHD) with no alarm sounding. The video did not show any staff in the area. The Resident crossed the facility back parking lot and walked along the south side of the neighboring Urgent Care Building. The front of the Urgent Care Building was located along the feeder road of a major interstate. Observation of video surveillance revealed Resident #1 went to the front of the urgent care building corner facing the interstate feeder road; then, he turned back to the facility and crossed the back and the front parking lot. He continued going south and crossed a busy residential street then turned left on another residential street. A white car (later identified as C.N.A.-A) driving by stopped and picked him up. He was brought back to the facility at that point. The video revealed the resident was gone for 10 minutes. Observation on 4/16/25 at 12:24 PM revealed Resident #1 wearing a wander guard on his ankle (device that triggers a special alarm and locked the doors if the resident got near the door). Observation on 4/16/25 at 01:10 PM revealed multiple staff going in and out of the OHD for breaks with the alarm sounding shortly each time. Observed the alarm was loud but very short as the staff shut the door quickly to stop the noise. In an interview on 4/16/25 at 10:15 AM the DM stated a lightning strike knocked 3 doors out a couple of years ago. He stated the repair company came out on 4/11/25 to assess the doors and they were waiting on a quote from them. He stated at this point, 3 doors were not working with the wander guard alarms system, and they all had access to the outside of the building. He identified the non-working doors as WHD, WLD, and the OHD. He stated the resident went out the OHD and no alarm sounded, and the wander guard system did not lock the door. He stated the facility was aware the wander guard system was not working on those doors for years, but he was unsure why they had not been repaired. He had installed a contact alarm system on all 3 doors that would alarm only when anyone held the door open and would stop upon the door closing and making contact. The noise/contact alarm was also broken on OHD door, and it failed to work when the resident eloped. DM was the facility person responsible for checking the doors weekly. In an interview on 4/16/25 at 10:26 AM the DON stated there were 3 doors that did not work on the wander guard system and this was not a new problem. She stated 2 of the 3 doors have contact (noise) alarms but the OHD did not have a contact alarm either. She stated the OHD door was the door the resident exited from, and the facility was unaware he had left. She stated the resident was seen by CNA-A as she returned from lunch, and she stopped and brought him back. She stated he was about 1.5 blocks away and going towards a local store. She stated he crossed a residential street but was not injured. She stated he was very confused and was looking for his family. She stated his antipsychotic medication had been reduced from 50mg to 12.5 mg over a couple of months per the Gradual Dose Reduction policy. She said he had gotten near other doors a few times and his wander guard had set of the alarms, but he wasn't exit seeking until 4/9/25. She stated he could get to the freeway and get hurt. In an interview on 4/16/25 at 10:41 AM the DM stated he had replaced the contact alarm on OHD today and moved it higher to avoid it getting broken off. He stated the contact alarm would activate when the door was open now until closed but the wander guard alarm was still disabled pending repairs by the electronic company. In an interview on 4/16/25 at 11:25 AM the DM stated packages were delivered through the OHD, so they likely damaged the previous contact alarm during delivery. He stated the quote for repairs 2 years ago on the wander guard alarm system went to the previous administrator and there was no record of that quote. The wander guard alarm did sound a different alarm and it locked the doors. In an interview on 4/16/25 at 11:40 AM the ADM stated she thought all the doors were repaired and she was unaware 1 was not working. She said the OHD door did not have the contact noise alarm on it that sounds when the connection was broken (when opened). She did not know why that door was not working. She stated they were working with family to try to discharge that resident, but they were waiting on the family and they would just have to monitor him until he could be discharged . She stated the facility was unaware the resident had eloped until their staff saw him outside. She was unsure if you could walk to the interstate but stated they would be putting something up as a barrier if that was a possibility. She said they did have a couple of other doors with noise alarms that did not have wander guard alarms. The DM was checking the doors. In an interview on 4/16/25 at 03:49 PM the DON stated there was not a policy for the facility cameras to be monitored continuously. She stated the wander guard on Resident #1 was definitely working because when he returned through the other door, it set of the wander guard alarm system. In an interview on 4/16/25 at 03:50 PM the DAJ stated there is not a policy to monitor the cameras continuously. There is no paperwork from the 4/11/25 visit from the electronic company assessing the door problems. She stated she would try to get email confirmation from them to provide to me. She stated that some of the cameras are off from real time, but she provided a log to show real time and which camera (multiple cameras around the facility) the resident was showing on as he traveled around the facility on 4/9/25. In a telephone interview on 4/17/25 at 01:29 PM LVN-A stated during her lunch time she saw the resident was with the activity director on the basement level watching activities. Shortly after that, the DON told LVN-A the resident had eloped. LVN-A stated she saw CNA-A holding the resident by his hand and leading him back to the building. She assessed him and there were no injuries, gave him water, and took his vitals which were stable. The doctor had just reduced his antipsychotic medication. She stated most of the time elopement risks need to have alarms on doors like the wander guard. She stated the wander guard makes a different noise and the other type alarms do become like background noise when people open and close the doors. She stated the negative outcome to a resident wandering could be death. She stated people do not pay attention driving and they hit other cars, and they could hit people. She stated we were very close to the interstate. In a telephone interview on 4/17/25 at 01:34 PM the ENG stated he did not look at the alarm system 2 years prior, but he thinks a lightning strike caused the damage. He thinks a repair proposal was sent in December, but that staff was no longer working for his company, so he was not sure if his company followed-up on that. He stated 3 doors need new product/keypads and those doors did not work with the wander guard system now. In a telephone interview on 4/17/25 at 01:45 PM CNA-A stated as she was returning from lunch, she saw Resident #1 walking and she stopped and asked him where he was going. Resident #1 stated he was leaving but he agreed to get in her car, and he let her take him back to the facility. She stated he could have made it to the freeway. She said there was a lot of traffic and people don't pay attention and he could have been hit. She admitted that alarms were sometimes tuned-out and they may assume a staff opened the door. She stated the main door has a wander guard alarm. She stated if dementia residents elope, they could get away and harm themselves. A record review of email correspondence dated 4/16/25 (copy received) between the facility and the engineering company that maintains the alarm systems revealed: Repair person had been out 4/11/25 and confirmed the keypads for the system were not working on 3 exit doors and the damage was most likely got fried because of the lightning storm. A record review of the facility policy titled, Wandering, Unsafe Resident dated 2001 with a last revision date of August 2014 reflected the following: The facility will strive to prevent unsafe wandering . for residents who are at risk for elopement. A missing resident is considered a facility wide emergency. A record review of the facility policy titled, Hazardous Areas, Devices, and Equipment dated 2001 with a last revision date July 2017 reflected the following: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Resident vulnerability is based on risk factors including the individual resident's functional status, medical condition, cognitive abilities, mood, and health treatments (e.g., medications). The Safety Committee will recommend measures to ensure that vulnerable residents cannot access hazardous areas in the facility (locks, alarms, supervision, etc.) A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include but are not limited to: Equipment or devices that are malfunctioning. Devices and equipment that are improperly maintained. Disabled locks, latches, or alarms. The POR were accepted: 4/18/2025 at 8:30 AM and included: PLAN OF REMOVAL IMMEDIATE- Jeopardy On 4/16/25 an abbreviated survey was initiated at this Facility. On 4/16/25 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety The notification of Immediate Threat states as follows: F689 The facility failed to ensure Resident #1 was free from risk of accidents and injuries. l. Immediate Action Taken A. Resident # 1 is currently in the facility. B. On 4/9/25 Resident #1 was returned to the facility via private vehicle by staff and placed on q15 minute monitoring which entails the following: staff visually confirming the resident's location, a log sheet for documenting the resident's location, including space for staff signatures, and timestamp for each observation. C. On 4/16/2025 The DON/ Designee completed a head-to-toe physical assessment on Resident #1 with no negative findings noted D. On 4/16/25 The DON/ Designee updated Resident #1 care plan for wandering/exit seeking E. On 4/16/25 The DON/ Designee completed elopement assessments on all facility residents with no changes noted. F. On 4/16/25 The maintenance director/ Designee completed environmental assessments to include checks on all door alarms. These checks identified 3 nonfunctioning door alarms (100 hall door, west hall door that faces the facility parking lot, and downstairs hallway office door). G. On 4/16/25 The administrator/Designee assigned facility staff to monitor identified nonfunctioning doors and the elevator will be locked during non-business overnight hours to allow no access without facility code to ensure that no resident exits the facility. Upstairs assigned staff will be physically present at the area that accesses the two doors waiting for repair. Department Head staff downstairs will be rotated to ensure visual observation of that door between 8a-5p. After 5p, elevators will be locked and only accessible via key access. Elevators will only be accessible via key access on the weekends. H. On 4/11/25 The Social Worker/Designee checked the wander guard appliances utilized by residents to ensure they were functioning properly with the doors that are currently functioning. No issues were identified with the appliances, and they were identified to be currently functioning properly. I. On 4/16/25 The DON/ Designee completed in-service education with facility direct care staff on the elopement policy. No employee will be allowed to work until they receive this education with drill and posttest. J. On 4/16/25 The DON/ Designee completed a Missing Resident Drill with facility direct care staff to ensure staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert via overhead paging to notify all other staff members of the missing resident and to not turn the alarm sound off until all staff are notified of the missing resident and headcount guidelines which requires visual confirmation and documentation regarding the location of each resident in the center. The designated head count coordinator will be the Administrator or DON during business hours (8a-5p) and the designated charge nurse and/or the Manager on Duty during non-business hours. (5p-8a).On 4/16/25 The facility administrator spoke with alarm company in regard to the nonfunctioning door alarm who stated they would have a tech support person to the facility on 4/17/25 to repair the nonfunctioning door alarms. K. 2. Identification of Residents Affected or Likely to be Affected: A. No other residents identified, on 4/16/25, the DON/Designee completed elopement assessments on all facility residents with no new changes noted. 3. Actions to Prevent Occurrence/Recurrence: A. On 4/16/25, the DON/Designee provided education to facility direct care staff on facility's elopement Policy including missing resident drill. B. On 4/17/25, the DON/Designee provided missing resident posttest to facility direct care staff. These in-services will be accessible via our communications platform (online information system for staff with a required 85% passing score). This will be completed at 6:00 pm on 4/17/2025 and no employee will be allowed to work until they receive this education with drill. Agency staff will be provided these trainings through access from our online communications platform as well. C. Results of facility missing resident drills will be discussed with Facility Administrator/ Designee during the facility recurring daily morning start up meetings. On 4/16/2025 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance with no new orders received. Likelihood for Serious Harm No Longer Exists: 4/17/2025. Signature of ADM on 4/17/2025 On 4/17/25 and 4/18/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: 4/17/25 Monitoring: Observation on 4/17/25 at 11:30 the ENG company at the facility working on the 3 broken doors. Office staff were turning staff away from the OHD door to prevent alarms from sounding when there was not a problem and therefore making a problem very noticeable if it occurred. Observation on 4/17/25 at 04:45 PM revealed the OHD hall staff coordinating if they leave the Office Hall to ensure staff were present to hear the alarm on OHD and to monitor the hall for residents. Observed 1 staff member assigned to the unused nurses station located between WHD and LHD with constant visual monitoring of the doors that weren't working. In an interview on 4/17/25 at 12:48 PM, the DON stated the following steps had been completed: QAPI Meeting held on 4/16/25 at 08:30 PM with the ADM, the DON, and the MD. In-services were done on 4/16/25 and 2 in-services were done on 4/17/25. Another in-service and Elopement Drill were planned for 4/17/25 on the night shift. The ENG company just left, and they confirmed doors not working and ordered the parts. They were supposed to return Monday. She further stated it was important to monitor Dementia residents because they were unaware of their own safety needs and the facility had to keep them safe. She stated the negative outcome to residents if they wander could be injury and death. She stated if alarms sound too often it becomes background noise and that was why they were now coordinating staff to not use the OHD at all so the alarm will not sound if there was not a problem. She stated they were also coordinating the office staff to make sure someone was on the hall. During the business hours the hall was accessible. Record review reflected 3 completed in-services on elopements and alarms with staff signatures attached and dated 4/1625 and 4/17/25. Record review reflected an invoice from the ENG showing doors were worked on and parts were ordered and dated 4/17/25. Record review on 4/17/25 reflected the typed minutes of the QAPI meeting held on 4/16/25 listed topics as facility elopement and the follow-up plan to sustain compliance. Attendees shown as the ADM, the DON, and the MD. 4/18/25 Monitoring: Observation on 4/18/25 at 10:50 AM revealed no residents in rooms or halls on WHD and WLD. Staff were posted specifically at these entrance points and intersections to disallow residents from accessing these doorways. Observed a staff member also posted near the nurse's station (unused station) to ensure residents did not enter that area without staff accompanying them. Observation on 4/18/25 at 11:00 AM revealed the Office Hall where the OHD was located, contained offices in which staff members were observed working with the doors open, monitoring traffic in and out. In an interview on 4/18/25 at 10:48 AM the DON stated the Elopement Drill had been completed and she would provide the documentation for that exercise. The DON stated the 3 doors that were out of service were being monitored and they were disallowing resident traffic on those halls. In an interview on 4/18/25 at 10:53 AM AL stated her role to prevent further elopements until doors were fixed was to sit at the intersection of the 2 [NAME] Halls and not allow anyone to access the malfunctioning doors. She stated this was being done for the safety and protection of the residents. In an interview on 4/18/25 at 11:00 AM the DON stated part of the plan was for staff on this hallway to monitor. She stated the staff were to communicate if they were leaving the hallway with each other to ensure someone was always downstairs. She stated the OHD would sound if opened but not for long, so staff were not to use those doors either to avoid monitoring staff from becoming accustomed to the alarm and unknowingly ignoring the alarm. Record review on 4/18/25 reflected 16 staff signatures on an Elopement Drill Sign-in form. The administrator was notified the IJ was removed on 04/18/2025 at 08:30 AM, however the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to complete repairs and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #1, Resident #2, and Resident #4) of five residents reviewed for quality of care. The facility failed to conduct a fall assessment or skin assessment after Resident #1 had a fall on 05/06/24. The facility failed to utilize a two person assist for Resident #1 while providing care, Resident #1 slipped out of bed causing an abrasion to her back and bruising on her face on 05/06/24. The facility failed to document a fall, conduct a fall assessment or a skin assessment after Resident #2 had an unwitnessed fall on 06/23/24 resulting in fractured ribs. The facility failed to document a fall and complete fall and skin assessments after Resident #4 had a fall and was sent to the hospital on [DATE] and was diagnosed with a scapula fracture. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/26/24 at 7:03 PM. While the IJ was removed on 08/29/24at 4:45 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 failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Review of Resident #1's quarterly MDS assessment, dated 04/16/24, Section A (Identification Information) reflected a[AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including unspecified dementia, lack of coordination, muscle wasting and atrophy (thinning of muscle tissue due to disuse or nerve problems), and a history of falling. Section C (Cognitive Patterns) reflected no BIMS score as resident was rarely or never understood. She had both long- and short-term memory impairment. Section GG (Functional Abilities) reflected she was dependent for bed mobility and bed to chair transfers. Review of Resident #1's comprehensive care plan, revised 12/17/23, reflected in part, Resident #1 has an ADL self-care performance deficit related to aggressive behavior, confusion, dementia, and impaired balance. The resident will maintain current level of function in ADLs through the review date. Interventions included, Bed mobility: The resident requires EXTENSIVE assistance by 2 staff to turn and reposition . The resident requires EXTENSIVE assistance by 2 staff with personal hygiene . The resident requires EXTENSIVE assistance by 2 staff for toileting . The resident requires SKIN inspection every day. Observe for redness, open areas, scratches, cuts, bruises, and report to the nurse. A second entry reflected, Resident #1 is high risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, unaware of safety needs. The resident will be free of minor injury through the review date. Interventions included, Anticipate and meet needs, be sure the call light is within reach, follow facility fall protocol. Review of a progress note dated 05/06/24 reflected, Resident noted on floor when writer entered room from hearing scream. Per CNA, during incontinence care resident was turned on side while aide on opposite side providing peri-care when resident sat up and began to slide off of bed onto floor. Red abrasion to mid back noted. No further injuries note at this time. Vitals WNL. Mechanical lift 2-person assist back to bed. MD notified and POA notified. Review of Resident #1's progress notes from 05/07/24 through 05/09/24 reflected no post-fall follow up notes. Review of Resident #1's progress note dated 05/10/24 reflected, Green to yellow bruising noted to left jaw line. Will monitor until resolved. Review of Resident #1's assessment log from 05/06/24 through 05/15/24 reflected no fall assessments. Review of Resident #1's skin observation tool dated 05/10/24, reflected bruising to left jaw line and previous witnessed fall 4 days past. Review of Resident #1's progress note dated 05/12/24 at 1:14 PM, reflected, Family here to visit at lunch. Daughter questioning bruising and swelling to left jaw. Daughter requesting resident go to ER for eval and treatment. Provider notified, okay to send to ER. ADM, DON, ADON notified. Review of Resident #1's radiology reports from the acute hospital, dated 05/12/24 reflected in part, Clinical indication: Injury or trauma, blunt trauma, injury date 05/06/24, injury details: Fall six days ago. The reports reflect a CT of the head, a CT of the cervical spine, and a CT of the face, all without contrast. There were no acute findings on the CT exams. The general instructions reflected the resident was treated for Multiple contusions (bruises) to the nose and left hip. Review of the facility's self-report signed by the ADM, dated 05/14/24, reflected in part, The resident had a recent fall with the result of hitting the nightstand. The Investigation Summary reflected, Resident had a fall previously and resulted in hitting head on nightstand. Review of an undated statement in the self-report folder, written by CNA D, reflected in part, LVN E checked resident and she was a little red on face and scratch on back . Review of a statement dated 05/12/24, written by CNA B, reflected in part, While assisting Resident #1 with her morning meal on 05/06/24, I noticed a slight redness to the left side of her face at the jaw line . On my next shift the following day, I noticed the redness to her jawline was more prominent . During an interview on 08/26/24 at 11:20 AM, LVN A stated she did not work the day Resident #1 fell so she was unaware of injuries. When reminded that she had given Resident #1 medication and written a progress note that day, she stated she did not recall the events of that day. LVN A stated if a resident fell, the nurse was notified and the nurse completed a head-to-toe assessment. She stated the nurse would complete an incident report and a nursing note then document every shift for 72 hours. She stated if it was an unwitnessed fall, they completed neuro checks. She stated she had not had any recent training on falls or the fall policy. During an observation and interview on 08/26/24 at 11:27 AM, CNA B stated Resident #1 fell on the night shift and she worked the day shift. She stated there was a very light bruise on the left side of Resident #1's face from the temple to the chin. She stated it got darker over the next few days. She stated she reported the bruising to LVN A. She stated the furniture in Resident #1's room was in the same position it was in on the day of the fall. Resident #1 was observed lying in bed. The bed was up against the wall on one side and the nightstand was against the wall next to the head of the bed. If resident sat on the edge of the bed, the nightstand would be on her left side. During an interview on 08/26/24 at 12:40 PM, CNA C stated she got report from CNA D the morning after Resident #1 fell. She did not know if anyone was in the room at the time other than CNA D. She stated the resident had a red mark on her back and an area on her face that was blue a couple of days after the fall. She stated she reported the injuries to LVN A. During an interview on 08/26/24 at 1:37 PM, the MDS Nurse stated she updated the care plan after a resident had a fall. She stated she got information from the nursing staff and updated the interventions. She stated she did not keep a fall log or complete a fall assessment. She stated she was not familiar with the facility policy about keeping a fall log. After reviewing Resident #1's comprehensive care plan, the MDS nurse stated no new interventions were implemented after the fall on 05/06/24. During an interview on 08/26/24 at 2:18 PM, the ADON stated it was her expectation that after a fall, the nurse would have assessed the resident, complete a head-to-toe assessment, a post fall assessment, and if the fall was unwitnessed or the resident hit their head, initiated neuro checks. She expected the nurse to write a progress note. The nurse would report to the family and the doctor and initiate an incident report. She stated there was a post-fall assessment form in the electronic medical records but she was not sure if all the staff used that form after a fall. She stated there is a change of condition assessment and some staff may complete that form instead. The ADON stated the electronic medical record system was updated 07/31/24 and since that time, some forms and documents have been renamed. She stated they did not use paper charts for documentation. The ADON stated there was not a fall log instead they used the incident reports to track falls. She stated the MDS Nurse and medical records person were responsible for auditing the incident documentation. Regarding Resident #1's fall on 05/06/24, she stated it was CNA D and LVN E in the room providing care when the resident fell. During an interview on 08/26/24 at 3:03 PM, the ADM stated she did not recall the details from 05/06/24 when Resident #1 fell. She stated she did not initially report the fall because it was witnessed. She stated she reported a few days later after the bruising appeared. She stated she believed it was CNA C who was in the room when the resident fell but she could not recall what other staff member was in the room. She stated the nurse was supposed to assess the resident and notify the doctor after a fall. She stated what they did next varied depending on if the fall was witnessed or not. During a telephone interview on 08/26/24 at 3:17 PM, LVN E stated she worked on 05/06/24 when Resident #1 fell. She stated CNA D was in the room by herself when the resident fell. She stated CNA D was the only CNA assigned to the hall that night and maybe that is why there was not a second person in the room. She stated Resident #1 required 2-person assist for care. She stated she was nearby and heard a thump. When she entered the room, the resident was on the floor. She stated she did a body assessment and saw an abrasion on the resident's back but did not see any other injuries. She stated she documented her findings in the medical record and notified the appropriate parties. She stated she reported the fall to the oncoming nurse in shift report. She stated after a fall the nurse was responsible for documenting in the electronic medical record. She stated the nurse would complete a body assessment, notify the doctor and chart in the electronic medical record. She stated neuro checks should be done if the fall was unwitnessed or if the resident hit their head. She stated not monitoring a resident after a fall could result in missing a change in the resident. During a telephone interview on 08/26/24 at 4:45 PM, the primary MD stated he usually got a text from the nurse if there is a fall with no injury or immediate concerns. She stated if there is something requiring more attention, he usually got a phone call. He stated he did not recall the details of Resident #1's fall on 05/06/24. He stated he expected the nurse to complete a thorough assessment after a fall. He stated he expected the nurse would initiate neuro checks if a resident hit their head during a fall. He stated it was very concerning that neuro checks were not completed for this fall as that was part of the standard routine when a resident hit their head. He stated depending on the level or severity of a head injury, there could be multiple negative outcomes. During an interview on 08/27/24 at 11:20 AM, the DON stated he had worked at the facility for a very short time. He stated he had started to build a timeline regarding Resident #1's fall because he believed the facility did everything they should have done for the resident. He stated the documentation was lacking, we missed the mark but that should not rise to the level of an IJ. He stated he had not looked at the documentation on the other residents. He stated they did not know if Resident #1 hit her face during the fall or if the bruise happened sometime later. He stated, But, bruises don't just show up yellow, that is some time into the healing process. He stated the policies provided yesterday were not the right policies as he talked with the corporate and each facility can revise their policies as needed. He stated he had received new policies from a sister facility that were dated. He stated he was still looking for policies in two large binders. During a telephone interview on 08/27/24 at 12:15 PM with CNA C, she stated she was alone in the room with Resident #1, getting her ready for incontinent care, when suddenly, the resident started to sit up in bed then the resident and the bedding started to slide off the bed. She stated the nurse was right there, she just stepped out to get medication when it happened. She stated she tried to hold the bedding but the resident ended up on the floor. She stated LVN E came in and assessed the resident then they used the lift to get the resident back in bed. She remembered there was a red mark on Resident #1's back but does not remember the resident hitting her head or having a red mark on her face. She stated she was aware the resident required two staff for incontinent care. She stated the next time she worked, the resident had started to bruise but she did not remember what color the bruise was. 2. Review of Resident #2's quarterly MDS assessment, dated 06/10/24, Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including unspecified injury of head, unsteadiness on feet, muscle wasting and atrophy (thinning of muscle tissue due to disuse or nerve problems), history of falling, rheumatoid arthritis (a chronic disorder that damages joints and other body systems), and cancer. Section C (Cognitive Patterns) reflected a BIMS score of 2, indicating severely impaired cognition. Section GG (Functional Abilities) reflected the resident required partial/moderate assistance with bed mobility and transfers. Review of Resident #2's comprehensive care plan revised 03/28/24, reflected in part, Focus: The resident is at risk for falls r/t confusion, deconditioning, incontinence. Goal: The resident will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach . Follow facility fall protocol . A second entry revised 06/26/24, reflected I part, Focus: 06/23/24 The resident had an actual fall without injury due to poor balance: fell coming from bathroom without walker. Remind to use walker and get assistance before ambulating. Goal: The resident will resume usual activities without further incident through the review date. Interventions: Continue interventions on the at-risk plan. For no apparent acute injury, determine and address causative factors of the fall. Monitor/document/report PRN for 72 hours to MD for s/sx pain, bruises, change in mental status new onset confusion, sleepiness, inability to maintain posture, agitation. Review of Resident #2's progress notes from 06/21/24 through 06/26/24, reflected in part, a note written 06/24/25 at 2:21 PM, Day 1 post fall: patient is experiencing muscle soreness and is requiring 2 person assist with transfers/ambulating, patient is usually a 1 person assist. A note written 06/25/24 at 8:52 AM Patient this AM was requesting this nurse to send to the ER at this time, reporting, I think I have broken ribs from when I fell . A note written 06/25/24 reflected resident agreed to mobile x-ray coming to the facility. A note written on 06/25/24 at 2:00 PM reflected x-rays were ordered. There was no note describing a fall, a head-to-toe assessment, or any injuries sustained. Review of Resident #2's radiology report dated 06/25/24 at 6:40 PM, reflected in part, Age-indeterminate mildly displaced fracture at anterior ninth rib is noted. Age-indeterminate nondisplaced fracture at anterior sixth to eight ribs are noted. Remaining ribs are without acute findings . Lumbar spine fusion hardware is noted. Review of Resident #2's fall assessment log reflected no fall assessment was completed after the fall on 06/24/24. 3.Review of Resident #4's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including muscle wasting and atrophy (a chronic disorder that damages joints and other body systems), abnormalities of gait and mobility, other lack of coordination, and osteoarthritis (a joint disease that causes breakdown of cartilage and bone). Section C (Cognitive Patterns) reflected a BIMS score of 6 indicating severely impaired cognition. Section GG (Functional Abilities) reflected the resident required substantial/maximal assistance with bed mobility and transfers. Review of Resident #4's comprehensive care plan, revised 12/02/24, reflected in part, Focus: Resident is at risk for falls related to gait/balance problems . Goal: The resident will be free of falls through the review date. Interventions: Remind resident to ask for assistance when transferring. Reminders for safety precautions given not to lean, bend, stoop from wheelchair. Anticipate and meet needs. Ensure call light is in reach and remind resident to use it. Follow facility fall protocol. The resident needs a safe environment. A second entry revised 06/25/24, reflected in part, Resident had an actual fall with skin tear to right wrist and back of hand and a red hematoma to right side of head. Goal: The resident's injured area will resolve without complications by review date. Interventions: Continue interventions on the at-risk plan. Monitor injuries for healing and/or complications. Monitor/document/report PRN for 72 hours to MD for s/sx pain, bruises, change in mental status . Review of Resident #4's progress notes from 05/27/24 through 06/18/24, reflected a note dated 06/02/24 at 11:00 PM, Late Entry: F/U to fall on previous shift. This writer with aide assistance transferred resident back to facility. Family waiting in room upon arrival. Patient seen in emergency room due to fall causing injury to head and right shoulder . Shoulder immobilizer in place. Subsequent notes on 6/3/14 and 6/4/24 reflected the immobilizer in place. None of the notes addressed the head injury. Review of Resident #4's Clinical Report from the acute hospital dated 06/02/24, reflected in part, Chief complaint, fall off a chair. Lost balance. Location of injuries - head and right shoulder. CTs of the head and right shoulder were completed. Clinical impression, Closed nondisplaced acromion fracture of the right scapula. Review of Resident #4's assessment log from 08/31/20 through 08/19/24, reflected no fall assessment or skin assessment after the resident fell on [DATE]. During an observation and interview on 08/26/24 at 11:10 AM, Resident #4 was sitting up in her motorized wheelchair in her room. She held a baby doll in her lap. She denied remembering any falls or injuries recently. She stated she came to this hospital after having the baby. She pointed to the doll on her lap. During an interview on 08/27/24 at 10:45 AM, CNA B stated they learned of the resident's physical abilities from the report from the hospital when they come to the facility. From that report, they would have known if the resident required one or two people for assistance. If she did not have that report, she would have asked the aid from the previous shift how the resident transferred or moved in bed. She stated if the resident required two staff for incontinent care, it was not okay to do it alone. She stated she would grab her partner or the nurse to help. She stated if the resident required two and you did it by yourself, the resident could fall or you could hurt your back. During an interview on 08/27/24 at 11:15 AM, the ADON stated it did not meet her expectations that documentation in the records is not accurate. She stated she expected the nurses to follow the policies. She stated she still believed some of the problems were related to the electronic medical record system being changed. During an interview on 08/27/24 at 12:05 PM with CNA F, she stated there were signs in the resident rooms indicating if they required assistance of one or two staff for care and transfers. She stated it was not okay to perform care alone if the resident required 2-person assist. She stated she had to get another aid or even the nurse to help if the resident required two people. She stated doing that by herself could result in skin tears, a fall out of bed, or something else depending on the situation. She stated when a resident fell, she had to notify the nurse and not move the resident until after the nurse had completed an assessment. She stated if she saw a new wound, bruise, or skin issue, she had to notify the nurse immediately. Review of the undated facility policy Falls - Prevention and Risk Reduction reflected in part, The MDS Coordinator will: d. Update interventions on the falls care plan with any new occurrence of falls. Review of the undated facility policy Falls - Risk Assessment and Identification reflected in part, 4. Fall risk assessment must be completed: d. After any fall. Review of the undated facility policy Falls - Post-Fall Protocol reflected in part, 3. The Unit Nurse will: a. Assess the resident from head to toe, and make sure it is safe to assist the resident to a chair before moving him. c. Take a full set of vital signs. e. Interview the resident and any witnesses of the fall to determine the exact circumstances and cause of the fall. f. After the assessment and treatment is done, notify the resident's responsible family member and physician. g. Document the fall in the resident's chart and the 24-hour report. h. [NAME] the spine of the resident's chart for acute charting. i. Fill out and follow through with an Incident Report. 8. The MDS Coordinator will: a. Enter the fall in the Falls Log with its time, date, and location. b. Complete a fall risk assessment which includes a full medication review. c. Add new interventions to the resident's fall risk care plan. Review of the undated facility policy Nursing Documentation reflected in part, 5. Acute Conditions and Incidents: b. A nursing note must be completed every shift each day until the acute condition is resolved. Incidents should be charted every shift for 3 days, and if the incident was a fall, vital signs should be included. The ADM and DON were notified on 08/26/24 at 7:03 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 08/28/24 at 2:01 PM and indicated the following: The Immediate Jeopardy involves the following concerns: Assessment and documentation to follow up with any incident reports. Root cause of immediate jeopardy: Based on the evidence, documentation has not been completed during after incidents and assessments completed per policy. On 8/26/2024 an abbreviated survey was initiated. On 08/26/2024 the surveyor provided immediate jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes immediate threat to resident health and safety. The notification of immediate jeopardy states as follows: F684 The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Actions taken to remove Immediate Jeopardy: 1. update appropriate policies per facility protocol (DON/ADON) 2. in-service nursing staff on the policy for incident assessment. Anyone not available will be notified via texting system here. Agency and new hires in-servicing before shift. (DON/ADON) 3. Auditing incident reporting x 3 prior months (DON) 4. ensure care plans are accurate (audit) (MDS) These actions will take place on 08/27/2024 and complete by 8/29/2024. Training: DON/designee will update policies as needed immediately to include but not limited to incident reports, documentation and care plans. MDS coordinator will audit all care plans for accuracy. In-service direct nursing staff (full time, prn and agency) on incident reporting, documentation, following the care plan. (ADON complete) ADON will be in-serviced by DON from our sister facility. Notification of in-servicing will be notified via the group texting software at the facility. DON/designee will audit all incident reports weekly for accuracy. This is a process that will be indefinite monitoring process. Monitoring: DON/designee will ensure all incident reports are complete with all assessments completed. These will be audited weekly and discrepancies will be addressed immediately and discussed during QAPI monthly for 3 months. MDS will audit care plans weekly for a month and quarterly afterwards. Any discrepancies will be noted during QAPI. DON/designee will ensure that policies are up to date and changed as needed. In-services will be conducted until all direct care staff has been in-serviced and then upon new hire. The facility will keep a check off schedule to ensure accuracy. The Surveyor monitored the POR on 08/29/24 as followed: Review of an in-service conducted on 8/28/24 - 08/29/24 and conducted by the ADON reflected six policies and presentation titled, Untie the Knot Strategies for Unraveling the Complexity of Care Planning in Long Term Care was sent out by text to all staff. 100% of the nursing staff replied via the software program, indicating the material was received and read. Review of the policies updated and reviewed by the DON from 08/27/24 through 08/29/24 and included in the training were as follows: Resident Examination and Assessment Revised April 2007 Neurological Assessment Revised August 2002 Care Plans - Comprehensive Revised October 2009 Accidents and Incidents - Investigating and Reporting Revised July 2017 Charting and Documentation - July 2017 Charting Errors and /or Omissions - December 2006 During interviews and telephone interviews conducted on 08/29/24 from 10:53 AM - 3:50 PM, one RN, four LVNs, and six CNAs from both shifts stated they were in-serviced on falls, assessments, care plans, and 2-person assistance. All staff reported they received the training material via text on 08/28/24 and the staff in the facility reported training at the beginning of their shift. They stated if there was a fall, the nurse would be notified and the resident would be assessed for injuries prior to being moved. The nurse would conduct a head-to toe assessment and note any injuries or skin concerns. All licensed staff stated if the fall was unwitnessed, or the resident hit their head, they would initiate neuro checks. The licensed staff stated they would complete an incident report and document thoroughly in the resident's chart. They stated they would report the fall to the DON, family, and provider immediately after assessing the resident. The licensed staff all stated documentation was imperative because if you did not document, it did not happen. The staff all stated all stated it was important to follow the care plan and have two staff available to provide care when the resident required two staff. Review of an Audit of Incident Reports from 05/02/24 through 07/29/24 and conducted by the DON, reflected all incident reports were reviewed to ensure the provider and responsible party was notified, documentation was initiated, neuro checks were initiated as needed, if injuries were present, and if the resident was sent out for further evaluation. Review of an Audit of care plans completed by the MDS Nurse on 08/29/24, reflected all care plans were reviewed for accuracy and updated as needed. The ADM was notified on 08/29/24 at 4:45 PM that the IJ had been removed. While the IJ was removed on 08/29/24 at 4:45 PM, the facility remained out of compliance 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.