**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 3 residents reviewed for care plans in that: The facility failed to ensure Resident #1 bed was in the lowest position per care plan while he was in the bed. The facility failed to update falls and interventions for Resident #1's care plan after his last 3 falls. This failure placed facility residents who were fall risk at risk of serious harm and injury. An Immediate Jeopardy (IJ) was identified on 9/18/2024. The IJ template was provided to the Administrator In-Training and DON on 9/18/2024 at 12:46 p.m. While the IJ was removed on 9/20/2024 at 12:30 p.m., the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at an increased risk of decline, and diminished quality of life. Findings included: Record review of Resident #1's face sheet dated 9/17/2024 revealed a [AGE] year-old male who admitted to the facility originally on 2/9/2021 and readmitted on [DATE] with the following diagnoses: Fragile X syndrome (genetic disorder and one of the most common causes of inherited intellectual disability), muscle weakness, unspecified falls, lack of coordination and cognitive communication deficit. Record review of Resident #1's Annual MDS dated [DATE] revealed he had a BIMS score of 0 which indicated severe cognitive impairment. He used a wheelchair for mobility. Resident #1 requires total assistance (helper does all the support) for sit to stand and bed transfers. Section J1900 - Number of Falls since admission/entry or reentry or prior assessment was left balnk. Record review of Resident #1's care plan revised 4/18/2024 revealed the following care areas: Problem: [Resident #1] receives anticoagulant/antiplatelet (medications that help reduce blood clotting) therapy (Plavix medication) Date initiated: 2/2021. Revision: 4/18/2024 Goal: [Resident #1] will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Date initiated: 2/10/2021. Revision on: 6/20/2024. Target date 11/3/2024. Interventions: Administer anticoagulant medications as ordered by physician .Daily skin inspection. Document any abnormalities .Observe/document/report PRN adverse reactions of anticoagulant therapy: .bruising. Revision on 8/6/2023, Resident/family /caregiver teaching to include the following: . avoid activities that could result in injury, take precautions to avoid falls . Problem: [Resident #1] is high risk for falls r/t impaired mobility. Date initiated 2/11/2021. Revision on: 4/18/2024. Goal: [Resident #1] risks and injury potential will be minimized through the next review date. Date initiated: 2/11/2021. Revision on: 6/20/2021. Target date: 11/3/2024. Interventions: Anticipate and meet the resident's needs. Dated initiated: 2/11/2021. Follow facility fall protocol. Date initiated 2/19/2021. PT evaluate and treat as ordered or PRN. 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 rails as ordered, handrails on walls, person items within reach. Date initiated 2/19/2021. Revision on 8/7/2023. Problem: [Resident #1] has had an actual fall with (Specify: no injury, On 12/28/2022) Poor Balance, Unsteady gait [the way a person walks]. 7/12/2023: actual fall, no injury. Date initiated: 1/9/2023. Revision on: 7/12/2023. Interventions: Continue interventions on the at-risk plan. Date initiated: 1/9/2023. PT consult for strength and mobility. Date initiated: 1/9/2023 .Staff will round frequently and try to anticipate his needs. Date initiated: 7/21/2024. Staff will start offering [Resident #1] to stand and relieve pressure throughout the day. Date initiated 4/1/2024. Record review of facility Incidents by Resident fall report dated 9/17/2024 revealed the following in part: o [Resident #1] - Fall on 7/21/2024 at 9:40 p.m. o [Resident #1] - Fall on 9/14/2024 at 7:34 p.m. o [Resident #1] - Fall on 9/15/2024 at 12:15 p.m. Record review of Resident #1's Fall Risk Evaluations dated 7/21/2024 - 9/14/2024 revealed the following: *Effective Date: 7/21/2024 - Score 13. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. *Effective Date: 9/14/2024 - Score 15. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. *Effective Date: 9/15/2024 - Score 16. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Record review of Resident #1's Order Summary Report dated 9/17/2024 revealed the following in part: orders: *May transfer to [Hospital] and clinical ER for CT of head r/t witness fall with head injury (order date 9/15/2024). *Transfer to .ER for CT of head and X-ray of L [left] shoulder r/t fall (order date 7/22/2024). *Clopidogrel Bisulfate oral tablet 75 mg - Give 1 tablet by mouth one time a day for blood thinner (order date 2/10/2021). Record review of facility nursing notes dated 9/14/2024 at 10:06 p.m. written by LVN B revealed Change of Condition: Signs/Symptoms Details: witnessed fal [sic], started 09/14/2024 . Record review of Resident #1's hospital Discharge summary dated [DATE] revealed Visit Summary - discharge diagnoses: tear of skin - primary, closed injury of head - primary, contusion (bruise) of right elbow - primary . Record review of facility nursing notes dated 9/15/2024 at 2:00 a.m. written by LVN B indicated Res arrived back to facility via . Ambulance transport. x2 assist by city ambulance personnel to transfer res from stretcher to bed via slide method. Res arrived back to facility a&o x1 with 0 s/s of distress or discomfort. CT scan of head negative of any new/acute findings. No new orders received with res discharge paperwork from hospital. [name of on call service] on call contact and notified of situation and res return to facility; spoke with NP. NP ordered to hold Plavix [keeps blood from coagulating (clotting)] until Monday; order implemented. POC conts [sic] as ordered. Res in bed with bed in lowest position, call light in place and all safety measures in place at this time. Interview on 9/19/2024 at 7:30 p.m. LVN B, said CNA C notified her Resident #1 was in his room, fell forward out of his wheelchair, fell on the floor and hit his head (on 9/14/2024). LVN B said she went to the Resident #1's room and he had a tear on his right elbow, skin tear to his fifth digit, an abrasion to his right thigh and top of his head. LVN B said the DON told her to fill out the incident report, fall assessment and treat his injuries. LVN B said she was not instructed to update Resident #1's care plan. LVN B said the DON instructed her to complete additional rounding (q 4 hours) and add a fall mat. She said she did not update Resident #1's interventions. LVN B said care management (MDS nurses) was responsible for updating the care plans. Interview on 9/19/2024 at 7:52 p.m. CNA C said he took Resident #1 to his room. CNA C said he turned to adjust the bed and Resident #1 fell out of his wheelchair onto the floor on 9/14/2024. CNA C said Resident #1 fell face first and did not make a sound. CNA C said Resident #1 was sent the hospital. CNA C said when the resident returned, he was told to sit with the resident while he laid in bed. He said he was not aware of new interventions for Resident #1. Record review of facility nursing note dated 9/15/2024 12:15 p.m. written by LVN A indicated Res in Bistro area in WC eating lunch and witnessed falling on floor r/t leaning forward in WC after numerous attempts of assistance from staff to reposition him in WC so that res can sit back comfortably. Upon assessment SN (LVN A) noted bleeding and swelling from previous head injury to res forehead. res states it hurts but unable to give pain scale rating . Record review of Resident #1's hospital Discharge summary dated [DATE] revealed Visit Summary - discharge diagnoses: Scalp injury, Fall. CT head without contrast. Findings: Right frontal scalp swelling is demonstrated. Interview on 9/18/2024 at 2:40 p.m. LVN A said she worked with Resident #1 while he ate lunch on 9/15/2024. She said Resident #1 leaned forward and pushed back from the table, which was his normal behaviors. She said Resident #1 pushed back from the table, while in the wheelchair, leaned forward, fell to the floor and hit his head. She said Resident #1 yelled out his head hurts. She said she was not told to update Resident #1's care plan. She said she was told by the DON keep a closer eye on him, which meant to keep him in our eyesight. She said Resident #1's leaning was not new, but it was more exaggerated. She said she was aware Resident #1 had a fall the day prior but was not told about new or updated interventions in his care plan. She said his normal interventions were to anticipate his needs and follow the fall protocol. She said the ADON said we needed to update his care plan because this behavior was not new, but it was more frequent. LVN A said the DON and ADON was responsible for updating the care plans. Interview on 9/18/2024 at 3:12 p.m. Resident #1's PCP said she was notified Resident #1 had a fall on 9/14 and he was in his wheelchair, had a hematoma to his head and the nurse [LVN B] said the hematoma was expanding. The PCP said she was at the facility when Resident #1 had the second fall on 9/15/2024 around lunch time. She said he had a raised bump on his head. She said he had tears rolled down his face. She said she observed him today (9/18/2024) in his wheelchair trying to get up using the hand railing. She said she was not sure who updated the care plans but said it was important to include behaviors that caused a risk to the resident's safety and to implement interventions to help to prevent injuries. An attempted Interview and observation on 9/17/2024 at 9:12 a.m. Resident #1 did not respond to questions asked. Resident #1 was lying in bed on a pressure reducing air mattress. Resident #1 had on a brief, no shirt and no pants, glasses and a baseball style cap. The floor on both sides of Resident #1's bed did not have a mat . The Residents bed was in a low position. Interview on 9/17/2024 at 11:46 a.m. the Activity Dir. said, Resident #1 liked to be placed against the wall next to the handrails. She said he pulls himself forward out of Resident #1's wheelchair . She said she was not updated on new interventions for Resident #1. She said she was in the morning meeting on 9/16/2024 but was not present for the full meeting and was not sure if new fall interventions were discussed for Resident #1. Interview on 9/17/2024 at 1:17 p.m. MDS A, said one of her responsibilities was to update care plans quarterly for residents with Medicare and without a payer source. She said a MDS nurse that quit the previous week. MDS A said she could not remember if it was last Wednesday or Thursday [9/11/24 or 9/12/24]. She said the former MDS nurse was responsible for updating the care plans for the long-term care residents that included Resident #1. MDS A said the DON, ADON or unit manager should update the care plans when there was an acute issue like a new fall. MDS A said she was not aware of Resident #1's last two falls. Interview on 9/17/2024 at 1:35 pm the ADON said Resident #1 had two witnessed falls on 9/14/2024 and 9/15/2024. She said after the fall on 9/14/2024 they were instructed by the DON to make more frequent rounding and make sure he was visible. She said she did not update Resident #1's care plan after the last two falls. She said care plans should be updated to ensure interventions are documented and put in place. The ADON said the MDS nurses take the workload and update the care plans and the ADMIN said a Corp. MDS nurse would update care plans since a MDS nurse quit last week (9/11/24 or 9/12/24). She said it was her understanding MDS A and MDS B would update care plans. She said she was not told it was her responsibility to update the care plan. She said Resident #1's last two falls were discussed in the morning meeting on 9/16/2024 with the IDT. The ADON said MDS A, MDS B and DON were in the morning meeting held on 9/16/2024. She said interventions were discussed related to Resident #1 with the IDT. She said she expected MDS A and MDS B to update Resident #1's care plan interventions. She said care plan interventions for Resident #1 should have been updated to address his recent falls and Resident #1's behavior of pulling up on handrails. She said the interventions are carried over to the cna's plan of care after the care plan is updated. Interview on 9/17/2024 at 2:06 p.m. with the DON, said the care plan for Resident #1 should have been updated by any nurse and care management (MDS nurses). She said the MDS nurse who was responsible for Resident #1's care plan quit last week on Thursday or Friday (9/11/24 or 9/12/24). She said she was told by the Admin. the Corp. MDS would monitor after the MDS nurse quit. She said Resident #1's fall interventions should have been update by care management (MDS A and MDS B). She said after a fall the IDT, which consisted of nurses, MDS nurses, DON and ADON, should discuss if interventions should be modified or new ones implemented. She said interventions were discussed in the morning meeting (9/16/2024) and the care management team was present. The DON said the care plan interventions should be updated so they can be seen in the cna's point of care. She said the care plan interventions should have been specific to Resident #1's needs after his two recent falls. She said Resident #1's care plan was not updated after the falls or the morning meeting (9/16/2024) where his falls were discussed. She said Resident #1 was at risk of injury because his interventions were not available to facility staff. She said the interventions she gave to LVN A and LVN B after Resident #1's falls were to monitor him closer and frequently. Interview on 9/17/2024 at 2:23 p.m. the ADMIN said the Corp. MDS was supposed to take over for the MDS nurse that quit. She said the Corp. MDS kept in contact with the care management team (MDS A and MDS B) by email. The ADMIN said she was at a conference and was not a part of the morning meeting (9/16/2024) after Resident #1's falls. Interview on 9/17/2024 at 3:08 p.m. with CNA A (via contracted Spanish interpreter) said she was Resident #1's aide. She said she was not told he had two falls during the past weekend. She said she was not informed of any updates to Resident #1's interventions. She said there was not a mat placed at the bedside earlier in the morning when the resident was in the bed. She said a mat was placed at Resident #1 bedside today at approximately 2:00 p.m. She checked the POC for any new updates related to resident interventions and she did not see new fall interventions for Resident #1. Interview on 9/18/2024 at 12:36 p.m. the ADMIN said there was not a time frame to update the care plan. She said she was not able to answer when an intervention needed to be updated and that would be a question for the DON and nursing staff. She said the issue with Resident #1 happened over the past weekend and they were not able to update the care plan. She said Resident #1's care plan was not updated after his fall, but the staff should have verbally communicated any new interventions put in place after the falls. Interview on 9/18/2024 at 1:22 p.m. with the Corp. MDS A nurse said she reviewed Resident #1's care plan. She said resident care plans should be a working document to mitigate what happened. She said Resident #1's care plan should be individualized to address his falls in his room and outside of his room. She said she was not the responsible for taking over for the MDS nurse that quit. Interview on 9/18/2024 at 1:51 p.m. with the Corp. MDS B said she was a traveling MDS nurse and helped out 1 to 2 days a week when needed at a facility. She said care plans are blueprints of what the resident needs. She said an acute issue, like a recent fall, should have been updated by the facility MDS nurses. She said her responsibility was to help update quarterly and annual care plans. Observation and Interview on 9/18/2024 at 3:45 p.m. revealed Resident #1 was lying in bed and his bed was not in the low position. CNA B said she was not sure why the bed was not in the low position. She said Resident #1 may have used the remote control for the bed. She removed the bed remote that was wedged between the mattress and bed frame. She said Resident #1 has used the remote before, but she had not notified a nurse of this behavior. She said the bed should be in the low position because Resident #1 is a high fall risk. Interview on 9/19/2024 at 12:34 p.m. the DON said Resident #1 was discussed in the morning meeting on 9/16/2024. She said a different wheelchair was discussed but was ruled it out because it would have been restrictive. She said a helmet was discussed but ruled out because they felt he would not wear it. She said they had not tried deterring him from pulling up on the handrails by not sitting him on the hall next to the handrails. She said the care management team (MDS nurses) should have updated the care plan right there in the meeting, but it was missed. She said she thought the failure happened over the weekend and she was not on her computer, so she provided verbal interventions. She said she told staff to monitor Resident #1 more frequently and that meant more rounding than the normal every 2 hours. She said the care plan was not updated timely for the interventions to care over to the CNAs POC, which would have made them aware of fall interventions for Resident #1. Interview on 9/19/2024 at 7:30 p.m. with LVN B, said CNA C notified her Resident #1 was in his room, fell forward out of his wheelchair, fell on the floor and hit his head (on 9/14/2024). LVN B said she went to the Resident #1's room and he had a tear on his right elbow, skin tear to his fifth digit, an abrasion to his right thigh and top of his head. LVN B said the DON told her to fill out the incident report, fall assessment and treat his injuries. LVN B said she was not instructed to update Resident #1's care plan. LVN B said the DON instructed her to complete additional rounding (q 4 hours) and add a fall mat. She said she did not update Resident #1's interventions. LVN B said care management (MDS nurses) was responsible for updating the care plans. Interview on 9/19/2024 at 12:47 a.m. with MDS A said Resident #1's care plan was not updated until 9/18/2024 after surveyor intervention. She said the care plan interventions are carried over to the POC for CNAs to have access as to what the interventions were. She said the intervention was to keep Resident #1 at the nurses' station while he was awake so the nurse could see him. Record review of facility policy Care Plan Revision upon Status Change dated 10/24/2022 revealed in part the following: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the resident will report resident response to new or modified interventions. f. Care plans will be modified as needed by the N (nurse), DS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. Record review of facility policy Fall Prevention Program dated 8/15/2022 revealed the following in part: High Risk Protocols: 5. a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status . 8. When any resident experiences a fall, the facility will: .E. Review the resident's care plan and update as indicated. An Immediate Jeopardy (IJ) situation was determined due to the above failures. The ADMIN and DON were notified and provided with the IJ template on 9/18/2024 at 12:46 p.m. The following Plan of Removal submitted by the facility was accepted on 09/18/2024 at 4:51 p.m. and included: September 18, 2024 [facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On September 18, 2024, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F 656 - Develop/Implement Comprehensive Care Plan The facility failed to update or modify fall interventions after falls. Falls: Fall 7/12/24 - Left elbow. Unwitnessed fall. Fall- 9/14/2024 - Hematoma to left side of head. Witnessed fall. Fall- 9/15/24 - Hematoma to right side of head. Witnessed fall. Done for those affected: On 9/17/2024, Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of the findings with no new orders received. On 9/17/2024, Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders were received. On 9/17/2024, the IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified. To Identify Other Residents: Beginning 9/17/2024, the Director of Nursing and/ or designee reassessed residents who sustained falls 9/1/2024 through 9/17/2024 head to toe for pain and injury with no new concerns. By 9/17/2024. Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns in the last 30 days for appropriate treatment, care plan interventions and resolutions. By 9/17/2024. Beginning 9/17/24, the Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated. By 9/17/2024. Beginning 9/17/2024, the IDT reviewed the falls care plans for residents identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. By 9/17/2024. There were updates completed as indicated. Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the progress notes for the last 30 days to ensure resident falls and/ or changes in condition related to falls were identified and addressed. By 9/17/2024. There were no concerns noted. Beginning 9/17/2024, the Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The Kardex and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the Kardex and task for updated interventions. Completed 9/17/2024. Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the care plans for current residents who sustained falls in the last 30 days for implementation of interventions to address the fall. Where applicable the care plans were modified for individualization. By 9/17/2024. Education/ System Change: On 9/17/2024, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. By 9/17/2024. On 9/17/2024, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. By 9/17/2024. On 9/17/2024, the Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy. By 9/17/2024. On 9/17/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: By 9/17/2024 Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status. On 9/17/2024, the Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions. By 9/17/2024. On 9/17/2024, the Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: By 9/17/2024. Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans. Effective 9/18/2024, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift. The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk. By 9/17/2024. An Ad Hoc QAPI was conducted on 9/18/2024, attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 656- Develop/Implement Comprehensive Care Plan. Monitoring: The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months, effective 9/18/2024. Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents. The surveyor confirmed the facility implemented their plan of removal and Monitoring began on 9/19/2024. Interviews on 9/19/2024 10:00 a.m. - 1:08 p.m. with 1 RN, 4 LVN, 1 Med aide and 4 CNAs the staff were not aware of the care plan updates, how interventions new and current are located and the process of which staff was responsible for updating the care plans. ADMIN and DON said they would in-service the staff again. Re-interviews after additional in-services: Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. with ADMIN, DON, MDS nurses, Therapy Director, Activity Director, SW, OT/PT staff said they were reeducated on resident care plans, timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions. They said they would ensure falls are promptly addressed by reviewing the 24-hour report and residents. They said they would ensure anticoagulant medications are care planned for new falls and new orders for anticoagulants. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. CNAs A,B,C, D, E, F, G and MA A (7a-7p,7p-7a, 3p-11p) said they were reeducated on the POC and they are aware of interventions placed in the care plans. The staff said they were aware of Resident #'s updated fall interventions. The staff said Resident #1 had a fall mat placed on the right side of his bed and the bed in the lowest position. The staff said Resident #1 should be monitored to ensure he does not try to stand without assistance and he should not be left alone in his room until he is [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for free of accidents, hazards, supervision, and devices., in that: The facility failed to ensure precautionary interventions in place Resident #1, while he was prescribed an anticoagulant, who was a known fall risk that resulted in falls with injuries to the head and hospitalization. An IJ was identified on 9/17/2024. The IJ template was provided to the AIT and DON on 9/17/2024 at 5:06 p.m. While the IJ was removed on 9/20/2021 at 12:31 p.m., with the ADMIN and DON. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility staff had not been trained on identifying residents at risk for fall, preventions, and interventions, and modification and care plan falls. This failure placed facility residents who were fall risk at risk of serious harm and injury. Findings included: Resident #1 Record review of Resident #1's face sheet dated 9/17/2024 revealed a [AGE] year-old male who admitted to the facility originally on 2/9/2021 and last admitted on [DATE] with the following diagnoses: Fragile X syndrome (genetic disorder and one of the most common causes of inherited intellectual disability), muscle weakness, unspecified falls, lack of coordination and cognitive communication deficit. Record review of Resident #1's Annual MDS revealed he had a BIMS score of 0 which indicated severe cognitive impairment. He used a wheelchair for mobility. Resident #1 requires total assistance (helper does all the support) for sit to stand and bed transfers. Section J1900 - Number of Falls since admission/entry or reentry or prior assessment was left balnk. Record review of facility Incidents by Resident fall report dated 9/17/2024 revealed the following in part: o [Resident #1] - Fall on 7/21/2024 at 9:40 p.m. o [Resident #1] - Fall on 9/14/2024 at 7:34 p.m. o [Resident #1] - Fall on 9/15/2024 at 12:15 p.m. Record review of Resident #1's care plan dated 9/17/2024 revealed the following: Problem: [Resident #1] receives anticoagulant/antiplatelet (medications that help reduce blood clotting) therapy (Plavix medication) Date initiated: 2/2021. Revision: 4/18/2024 Goal: [Resident #1] will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Date initiated: 2/10/2021. Revision on: 6/20/2024. Target date 11/3/2024. Interventions: Administer anticoagulant medications as ordered by physician .Daily skin inspection. Document any abnormalities .Observe/document/report PRN adverse reactions of anticoagulant therapy .bruising. Revision on 8/6/2023, Resident/family /caregiver teaching to include the following: . avoid activities that could result in injury, take precautions to avoid falls . Problem: [Resident #1] is high risk for falls r/t impaired mobility. Date initiated 2/11/2021. Revision on: 4/18/2024. Goal: [Resident #1] risks and injury potential will be minimized through the next review date. Date initiated: 2/11/2021. Revision on: 6/20/2021. Target date: 11/3/2024. Interventions: Anticipate and meet the resident's needs. Dated initiated: 2/11/2021. Follow facility fall protocol. Date initiated 2/19/2021. PT evaluate and treat as ordered or PRN. 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 rails as ordered, handrails on walls, person items within reach. Date initiated 2/19/2021. Revision on 8/7/2023. Problem: [Resident #1] has had an actual fall with (Specify: no injury, On 12/28/2022) Poor Balance, Unsteady gait [the way a person walks]. 7/12/2023: actual fall, no injury. Date initiated: 1/9/2023. Revision on: 7/12/2023. Goal: [Resident #1] will resume usual activities without further incident through the review date. Date initiated: 1/9/2023. Revision on 6/20/2024. Target date: 11/3/2024. Interventions: Continue interventions on the at-risk plan. Date initiated: 1/9/2023. PT consult for strength and mobility. Date initiated: 1/9/2023 .Staff will round frequently and try to anticipate his needs. Date initiated: 7/21/2024. Staff will start offering [Resident #1] to stand and relieve pressure throughout the day. Date initiated 4/1/2024. Record review of Resident #1's Fall Risk Evaluations dated 7/21/2024 - 9/14/2024 revealed the following: Effective Date: 7/21/2024 - Score 13. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Effective Date: 9/14/2024 - Score 15. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Effective Date: 9/15/2024 - Score 16. Category High Risk. Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Record review of Resident #1's Order Summary Report dated 9/17/2024 revealed the following in part: . May transfer to [Hospital] and clinical ER for CT of head r/t witness fall with head injury (order date 9/15/2024) .Transfer to .ER for CT of head and X-ray of L [left] shoulder r/t fall (order date 7/22/2024). Clopidogrel Bisulfate oral tablet 75 mg - Give 1 tablet by mouth one time a day for blood thinner (order date 2/10/2021). Record review of facility nursing notes dated 9/14/2024 at 10:06 p.m. revealed the following in part: Change of Condition: Signs/Symptoms Details: witnessed fal [sic], started 09/14/2024 . 9/15/2024 02:00 [2:00 a.m.] NURSING - Nurse Note Note Text: Res arrived back to facility via . Ambulance transport. x2 assist by city ambulance personnel to transfer res from stretcher to bed via slide method. Res arrived back to facility a&o x1 with 0 s/s of distress or discomfort. CT scan of head negative of any new/acute findings. No new orders received with res discharge paperwork from hospital. [name of on call service] oncall contact and notified of situation and res return to facility; spoke with [NAME], NP. [NAME], NP ordered to hold Plavix [keeps blood from coagulating (clotting)] until Monday; order implemented. POC conts [sic] as ordered. Res in bed with bed in lowest position, call light in place and all safety measures in place at this time. 9/15/2024 12:15 .Res in Bistro area in WC eating lunch and witnessed falling on floor r/t leaning forward in WC after numerous attempts of assistance from staff to reposition him in WC so that res can sit back comfortably. Upon assessment SN (LVN A) noted bleeding and swelling from previous head injury to res forehead. res states it hurts but unable to give pain scale rating . Record review of Resident #1's hospital Discharge summary dated [DATE] revealed the following: Visit Summary - discharge diagnoses: tear of skin - primary, closed injury of head - primary, contusion (bruise) of right elbow - primary . Record review of Resident #1's hospital Discharge summary dated [DATE] revealed the following: Visit Summary - discharge diagnoses: Scalp injury, Fall. CT head without contrast. Findings: Right frontal scalp swelling is demonstrated. Observation and attempted Interview and on 9/17/2024 at 9:12 a.m. revealed Resident #1 was lying in bed on a pressure reducing air mattress. Resident #1 had on a brief, no shirt and no pants, glasses and a baseball style cap. Resident #1's call light was not in reach. The call light was on the floor. The floor on both sides of Resident #1's bed did not have a mat. The Residents bed was in a low position. Interview on 9/17/2024 at 1:35 pm with ADON, said Resident #1 had two witnessed falls on 9/14/2024 and 9/15/2024. She said after the fall on 9/14/2024 they were instructed by the DON to make more frequent rounding and make sure he was visible. She said she did not update Resident #1's care plan after the last two falls. She said care plans should be updated to ensure interventions are documented and put in place. The ADON said the MDS nurses take the load and the ADMIN said a Corp. MDS nurse would update care plans since a MDS nurse quite last week (9/11/24 or 9/12/24). She said it was her understanding MDS A and MDS B would update care plans. She said she was not told it was her responsibility to update the care plan. She said Resident #1's last two falls were discussed in the morning meeting on 9/16/2024 with the IDT. The ADON said MDS A, MDS B and DON were in the morning meeting held on 9/16/2024. She said interventions were discussed related to Resident #1 with the IDT. She said she expected MDS A and MDS B to update Resident #1's care plan interventions. She said care plan interventions for Resident #1 should have been updated to address his recent falls and Resident #1's behavior of pulling up on handrails. She said the interventions are carried over to the cna's plan of care after the care plan is updated. Interview on 9/17/2024 at 2:06 p.m. with the DON said she was aware of Resident #1's last two falls. She said she was notified and instructed the staff to monitor him more frequently. She said Resident #1 should have had fall mat placed on the side of his bed. She said she could not explain why the mat was not there. Surveyor explained earlier observations revealed Resident #1 did not have a mat while he laid in bed. She said she was not sure why he did not have a mat and they would put one out. She said a helmet was not considered because, Resident #1 did not like to take off his caps. She said another type of wheelchair was not considered because the IDT felt it would be restrictive. She said Resident #1's care plan was not updated after the falls or the morning meeting (9/16/2024) where his falls were discussed. She said Resident #1 was at risk of injury because his interventions were not available to facility staff. Interview on 9/17/2024 at 3:08 p.m. with CNA A (via contracted Spanish interpreter) said she was Resident #1's aide. She said she was not told he had two falls during the past weekend. She said she was not informed of any updates to Resident #1's interventions. She said there was not a mat placed at the bedside earlier in the morning when the resident was in the bed. She said a mat was placed at Resident #1 bedside today at approximately 2:00 p.m. She said she would check in the POC for any new updates related to resident interventions and she did not see new fall interventions for Resident #1. Interview on 9/18/2024 at 1:22 p.m. with the Corp. MDS A nurse said she reviewed Resident #1's care plan and said it needed to be cleaned up and we should have showed each fall that occurred. She said resident care plans should be a working document to mitigate what happened. She said Resident #1's care plan should be individualized to address his falls in his room and outside of his room. She said she was not aware that Resident leaned out of his chair on both falls and that he pulls himself up when he is positioned along the handrails in the hallways. Interview on 9/18/2024 at 1:51 p.m. with the Corp. MDS B said she was a traveling MDS nurse and helped out 1 to 2 days a week when needed at a facility. She said care plans are blueprints of what the resident needs. She said an acute issue, like a recent fall, should have been updated by the facility MDS nurses. Interview on 9/18/2024 at 2:40 p.m. with LVN A, said she worked with Resident #1 while he ate lunch on 9/15/2024. She said Resident #1 leaned forward and pushed back from the table, which was his normal behaviors. She said this was his normal behavior. She said Resident #1 pushed back from the table, while in the wheelchair, leaned forward, fell to the floor and hit his head. She said Resident #1 yelled out his head hurts. She said she was not told to update Resident #1's care plan. She said she was told by the DON keep a closer eye on him, which meant to keep him in our eyesight. She said Resident #1's leaning was not new, but it was more exaggerated. She said she was aware Resident #1 had a fall the day prior but was not told about new or updated interventions in his care plan. She said his normal interventions were to anticipate his needs and follow the fall protocol. She said the ADON said we needed to update his care plan because this behavior was not new, but it was more frequent. LVN A said the DON and ADON was responsible for updating the care plans. Interview on 9/18/2024 at 3:12 p.m. with Resident #1's PCP, said she was notified Resident #1 had a fall on 9/14 and he was in his wheelchair, had a hematoma to his head and the nurse [LVN B] said the hematoma was expanding. The PCP said she was at the facility when Resident #1 had the second fall on 9/15/2024 around lunch time. She said he had a raised bump on his head. She said he had tears rolled down his face. She said she observed him today (9/18/2024) in his wheelchair trying to get up using the hand railing. She said she was not sure who updated the care plans but said it was important to include behaviors that caused a risk to the resident's safety and to implement interventions to help to prevent injuries. Observation and Interview on 9/18/2024 at 3:45 p.m. revealed Resident #1 was lying in bed and his bed was not in the low position. CNA B said she is not sure why the bed was not in the low position. She said Resident #1 may have used the remote control for the bed. She removed the bed remote that was wedged between the mattress and bed frame. She said Resident #1 has used the remote before, but she had not notified a nurse of this behavior. She said the bed should be in the low position because Resident #1 is a high fall risk. An interview was attempted on 9/18/2024 at 4:22 p.m. with LVN B by phone. Interview on 9/19/2024 at 8:35 a.m. with Therapy Director said all residents are evaluated after every fall. She said due to Resident #1's cognition, he could not learn new things and the therapy performed would maintain skills he had. She said he had poor safety awareness. She said he required queuing because he will attempt to get up, and it is not safe for him to do so. She said therapy was not effective for preventing fall for Resident #1 and it was for maintenance. Interview on 9/19/2024 at 7:30 p.m. with LVN B, said CNA C notified her Resident #1 was in his room, fell forward out of his wheelchair, fell on the floor and hit his head (on 9/14/2024). LVN B said she went to the Resident #1's room and he had a tear on his right elbow, skin tear to his fifth digit, an abrasion to his right thigh and top of his head. LVN B said the DON told her to fill out the incident report, fall assessment and treat his injuries. LVN B said she was not instructed to update Resident #1's care plan. LVN B said the DON instructed her to complete additional rounding (q 4 hours) and add a fall mat. She said she did not update Resident #1's interventions. LVN B said care management (MDS nurses) was responsible for updating the care plans. Interview on 9/19/2024 at 7:52 p.m. with CNA C said he took Resident #1 to his room. CNA C said he turned to adjust the bed and Resident #1 fell out of his wheelchair onto the floor (on 9/14/2024. CNA C said Resident #1 fell face first and did not make a sound. CNA C said Resident #1 was sent the hospital. CNA C said when the resident returned, he was told to sit with the resident while he laid in bed. He said he was not aware of new interventions for Resident #1 because he was not working with him today. * Record review of facility policy Fall Prevention Program dated 8/15/2022 revealed the following in part: High Risk Protocols: 5. a. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status . 8. When any resident experiences a fall, the facility will: .E. Review the resident's care plan and update as indicated. September 17, 2024 [facility] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Attention Sir or Madam: On September 17, 2024, the Facility was notified by the surveyor that immediate jeopardy had been called and the Facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F 689 - Accidents/Supervision The facility failed to provide Resident #1 who is on an anticoagulant medication, adequate supervision and interventions to prevent falls causing head injury. The facility failed to ensure Resident #1's care plan was updated with interventions after 3 falls that resulted in hematomas to the forehead. Done for those affected: o On 9/17/2024, Resident #1 was reassessed by Director of Nursing head to toe for injury and pain. The MD was notified of findings with no new orders received. o On 9/17/2024, Resident #1 was reassessed by the Director of Nursing and/ or designee related to use of Plavix and potential side effects, as well as falls, fall risk and fall interventions with no concerns noted. The MD was notified with no new orders received. o On 9/17/2024, the IDT reviewed Resident #1's plan of care related falls, injuries, pain and use medication Plavix. The plan of care was updated to reflect interventions regarding falls, injuries, pain and pharmacy consult medication as indicated and the RP was notified. To Identify Other Residents: o Beginning 9/17/2024, the Director of Nursing and/ or designee reassessed residents who sustained falls 9/1/2024 through 9/17/2024 head to toe for pain and injury with no new concerns. By 9/17/2024. o Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the status of resident injuries sustained from falls with no concerns in the last 30 days for appropriate treatment, care plan interventions and resolutions. By 9/17/2024. o Beginning 9/17/24, the Director of Nursing and/ or designee reviewed the fall risk assessments for current residents for timely completion where indicated fall risk was reassessed and updated. By 9/17/2024. o Beginning 9/17/2024, the IDT reviewed the falls care plans for resident identified to be at high risk for falls and/ or residents with physician orders for an anticoagulant for appropriate interventions and implementation. By 9/17/2024. There were updates completed as indicated. o Beginning 9/17/2024, the Director of Nursing and/ or designee reviewed the progress notes for the last 30 days to ensure resident falls and/ or changes in condition related to falls were identified and addressed. By 9/17/2024. There were no concerns noted. o Beginning 9/17/2024, the Director of Nursing and/or designee educated staff on updated care plans. Care Plans and/or interventions will be updated by the nursing staff at the time of occurrence. Care Plan policy was reviewed and there were no updates. The [NAME] and tasks will be updated to ensure DCS are aware of interventions placed in the care plans. Nursing staff were reeducated on reviewing the [NAME] and task for updated interventions. Completed 9/17/2024. Education/ System Change: o On 9/17/2024, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. By 9/17/2024. o On 9/17/2024, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on fall prevention and the Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. By 9/17/2024. o On 9/17/2024, the Regional Clinical Specialist reeducated the Director of Nursing on the Incident and Accident Policy. By 9/17/2024. o On 9/17/2024, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: By 9/17/2024 Abuse and Neglect and Abuse Policy to include prompt implementation and documentation of interventions to address resident falls and fall risk. Fall Prevention Policy to include prompt implementation and documentation of interventions, as well as reassessment of falls risks and adequate supervision to prevent resident falls. Resident changes in condition to include new and/ or repeat falls, changes in cognition and/ or gait and ADL status. o On 9/17/2024, the Director of Nursing and/ or designee began reeducation for the IDT (Administrator, Licensed Nurses, Social Work, Care Management Nurses, Activities Director, Director of Rehab, Dietary Manager) on resident care plans, timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions. By 9/17/2024. o On 9/17/2024, the Director of Nursing and/ or designee began reeducation with 100% of Licensed Nurses on the Incident and Accident policy to include: By 9/17/2024. Accident and Incident report completion and documentation requirements e.g. immediate actions/ interventions to prevent a fall and supervise residents. Resident fall risk and fall risk reassessment, fall interventions and timeliness, resident supervision related to falls, as well as risk for injury from falls related to use of anticoagulant medication. Resident monitoring and PN documentation post fall (minimum of 72 hours). Changes in condition, to include notifications, interventions, documentation, monitoring and follow-up. Completion of resident skin evaluations, wound assessment forms, pain assessments, treatment orders, monitoring and care plans. o Effective 9/18/2024, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, DON and/or designee prior to the start of their next scheduled shift. o The Director of Nursing/ designee will review the 24-hour report for any changes in condition related to new falls or risk for falls. Ensure the physician is notified timely and that actions are taken timely to address the change in condition, actual fall and/ or fall risk. By 9/17/2024. An Ad Hoc QAPI was conducted on 9/17/2024, attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 689-Accidents/ Supervision. Monitoring: The Director of Nursing will monitor the following daily for 30 days, then three times weekly for two months, effective 9/18/2024. o Changes in condition, to include resident falls. DON will ensure falls are promptly addressed by reviewing the 24-hour report and residents clinical records during the Morning Clinical Meeting o Accident and Incidents for completion, immediate interventions and care planning, completion of assessments and notifications. o Resident falls and anticoagulant medication are care planned for new falls and new orders for anticoagulants. o Skin evals, wounds assessments forms and orders for injuries resulting from Incidents and Accidents. Surveyor monitored the plan of removal for effectiveness as follows: Interviews on 9/19/2024 10:00 a.m. - 1:08 p.m. with 1 RN, 4 LVN, 1 Med aide and 4 CNAs the I.J. was not able to be lowered based on staff interviews revealed they were not aware of the care plan updates, how interventions new and current are located and the process of which staff was responsible for updating the care plans. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. with ADMIN, DON, MDS nurses, Therapy Director, Activity Director, SW, OT/PT staff said they were reeducated o resident care plans, timely care planning, care plan accuracy, personalized interventions, care plan documentation and implementation of care plan interventions. They said they would ensure falls are promptly addressed by reviewing the 24-hour report and residents. They said they would ensure anticoagulant medications are care planned for new falls and new orders for anticoagulants. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. CNAs A,B,C, D, E, F, G and MA A (7a-7p,7p-7a, 3p-11p) said they were reeducated on the POC and they are aware of interventions placed in the care plans. The staff said Resident #1 had a fall mat placed on the right side of his bed and the bed in the lowest position. The staff said Resident #1 should be monitored to ensure he does not try to stand without assistance and he should not be left alone in his room until he is placed in bed. Interviews on 9/19/2024 at 2:22 p.m. - 9/23/2024 12:54 p.m. with LVN A, B, C, D, E, F and G (shifts 8a-8p, 8p-8a) said they were reeducated on the policy for comprehensive care plans. Re-education included timely care planning, care plan accuracy, personalized interventions, care plan documentation and prompt implementation of care plan interventions. Nursing staff said they were reeducated on reviewing the POC and task for updated interventions. Nursing staff said they were reeducated on reviewing the [NAME] and task for updated interventions. The nursing staff said they were aware to update acute care plan interventions and they did not have to wait for the MDS nurse to update the care plans. The nursing staff said they understood it was important to update the care plan interventions so the POC for CNAs was updated. The nursing staff said the interventions should be updated and put in place immediately to ensure the residents' safety. The nursing staff said they understood care plan interventions should be individualized to meet specific resident needs. Observation on 9/19/2024 at 11:17 a.m. revealed Resident #1 was in his wheelchair and being pushed by a nurse and she offered him coffee. Observation on 9/20/2024 at 11:03 a.m. revealed Resident #1 was in bed in the lowest position and the fall mat was on the door side (left side as surveyor looked at bed). Observation on 9/20/2024 at 2:56 a.m. revealed Resident #1 was next to the nurse's station with a cup of coffee. There was a nurse standing next to him and talking with him periodically. Observation on 9/23/2024 at 9:40 a.m. revealed Resident #1 was across from station #3 with a coffee cup in his hand. A nurse was at the nurses station within a few steps of the resident. Record review of facility head to toe assessments for high fall risk residents with falls from 9/1/2024 - 9/17/2024 (12 residents). Record review of fall risk assessments for current resident for timely completion where indicated fall risk was reassessed and updated. Resident #2's fall risk assessment indicated he was low risk (7 falls between 7/18/24 and 9/7/24) and he was was not indicated on the high risk for falls reassessment intially, but was corrected after surveyor intervention and review. Record review was conducted of the facility's In-services Training Report dated 9/17/24 conducted by DON to Licensed Nurses (LVNs, RNs) revealed the topic was Incident and Accident Policy - .fall interventions and timeliness, supervision related to falls, and risk for injury from falls related to anticoagulant medications . All in attendance voiced understanding. Record review was conducted of the facility's In-services Training Report dated 9/17/24 conducted by DON to All Staff revealed the topic was Fall and Fall Management Policy - Review Fall Prevention Program and Policy and Reeducated IDT members on Fall Prevention Program and Policy as attached. All in attendance voiced understanding. The Administrator was informed that the Immediate Jeopardy was removed on 9/20/2024 at 12:31 p.m. The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents requiring respiratory care, consistent with professional standards of practice for 1 (CR#1) of 5 residents reviewed for quality of care. The facility failed to provide immediate care to CR#1 when she experienced respiratory distress on 05/08/24. After the resident was observed gurgling with emesis by LVN A, the NP was notified; monitoring nor interventions were initiated. When observed by the NP, CR #1 was unresponsive and oxygen saturation dropped to 60%. 911 was called and arrived at 12pm. During the course of hospitalization, CR #1 was declared brain dead and expired on 05/13/24 after atifical support was removed. This failure placed residents who developed a change in respiratory status at risk of physical harm, emotional distress, mental anguish, and hospitalization or death from possible neglect. On 05/18/2024 at 1:11 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 5/19/24 at 11:13am the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. Finding included: Record review of the admission sheet (undated) for CR#1 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses which included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to brain), and paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs). CR#1 was discharged on 5/8/24 to acute care hospital. Record review of CR #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 3 out of 15 indicative of severely impaired cognition. CR#1 was dependent on staff for toileting hygiene, shower, and lower body dressing. Partial/moderate assistance with upper body dressing and personal hygiene. Record review of CR#1's care plan, initiated 4/2/2019 and revised on 11/17/2023 revealed the following: Problem: [CR#1] has an ADL self-care performance deficit r/t Dementia Goal: The resident will maintain current level of function through the review date. Interventions: Eating: the resident requires (supervision) with setup. Toilet use: the resident requires (extensive assistance) by (1) staff for toileting. Dressing: the resident requires (extensive assistance) by (1) staff to dress. Record review of CR#1's Nurses note dated 5/8/24 at 12:29pm written by LVN A revealed read in part: .Note Text: Nurse entered room and observed resident gurgling and with yellow emesis on her gown Nurse called resident name; resident was not responding Nurse initiate V/S BP 120/42 P 47 BS 194 O2 Sat 90% on RA. Resident V/S Rechecked BP 112/52 P 58 O2 Sat 83% oxygen applied NP is here to assesses Resident. Resident O2 Sat 74% non-rebreather is applied. NP gave order to send Resident out 911 to [Hospital name]. Resident Guardian is contacted but there was no answer, This Nurse left a voice message to call facility at her earliest convenience . Record review of CR#1's NP's notes dated 5/8/24 revealed read in part: .Chief Complaint: acute visit. History of Present Illness: Polite 57F long term nursing home resident. Nurse called me to see the resident for sudden change in condition. Per nurse, she had breakfast and medications in am as usual. But around 1150 AM, she did vomit and kept coughing. When I saw her at the bedside, she was unresponsive and very congested breathing was noted. The gown was soaked with gastric emesis. Initial VS, bp120/42, HR 88, O2sat 88%w/ RA, RR 40 and BG 194. No IM Lasix at this facility per nurse. Stat cxr, CBC, BNP, CMP, NH3 and oral suction and breathing tx and full o2 application. Unfortunately, oral suction was malfunctioning. Breathing tx was given but her o2 sat was down to 60%. it was not successful. Apply NRB with 15L and went up to 82%. bp 112/ 52, hr 68, rr 50, o2 sat 67% with NRB 15 L. Worsening hemodynamic status and still unresponsive. at 1200 PM, called 911 for the sudden neuro change, suspected aspiration related respiratory failure and possible ET for airway protection. Notified Dr. about the change in condition and agreed with the hospital transport for the higher level of care. 911 arrived and took her to the hospital around 12 15 pm without ET, o2sat 81%w/ NRB and no status changed . Record review of CR#1's EMS records dated 5/8/24 revealed read in part: .Primary Symptom: Neuro - Unconscious/Unresponsive Began: 05/08/2024 12:00:00 Location: General/Global Activity: General - Seated or Lying Down, Not Sleeping Possible Injury: No Cardiac Arrest: No Narrative: m050 was dispatched to a possible cardiac arrest. M050 aostf a 57 yo female with a cc of unconscious/unresponsive. the pt was found laying semi-Fowler on hospital bed inside of a nursing home. Staff was not present to give a report. It is unknown the pt baseline and when the pt was last seen normal. The pt was being ventilated with a bvm and o2 by e005. The pt had vomit coming from her nose and mouth. The pt was suctioned on scene. The pt was moved to the back of the ambulance. An igel size 4 and end tidal were established. The pt was hyperventilated do to a low o2 sat. The pads were placed on the pt. IV access was obtained. The pt was administered a normal saline bolus. The pt vitals were monitored enroute to the er. The pt bp dropped below 90 systolic. Nor epi was administered while enroute to the er. The pt was suctioned throughout transport. The pt vitals were monitored. The pt bp improved and vitals remained stable. Nor epi was discontinued pmhx as listed. nkda. The pt had a gcs of 3, pupils PERRL, lungs clear and equal, skin warm and dry. 12:29:42 HR 62 O2 Sat 18% , 12:33:19 HR 80 BP 73 / 32 HR 15 O2 Sat 75% . Record review of CR#1's Emergency Department records dated 5/8/24 revealed read in part: .Procedure-Endotracheal intubation. Time: 05/08/2024 13:05. Confirmed: Patient, procedure, and site correct, Time-out taken prior to procedure. Indication: Airway protection. - The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life-threatening deterioration in the patient's condition during their evaluation in the ED . Record review of CR#1's Neurocritical Care Note dated 5/8/24 revealed read in part: .Chief Complaint 05/08/2024 12:50 Pt came from by EMS, unknown hx, unknown baseline. Found unresponsive, hypotensive at seen with BP of 50/30, started on levophed and 300ml NSS by EMS, ambu-bagged on way here. History of Present Illness 57yoF w/ PMHx prior stroke, stercoral colitis s/p colostomy, chronic paraplegia, wheelchair bound, DVT on Eliquis (unknown medication compliance), and bipolar disorder, is BIBEMS from after she was found unresponsive. Unknown last seen normal. Patient was reportedly GCS 3, and there was no staff available to provide additional history. EMS intubated the patient for airway protection and started a norepi drip when she was found to be hypoxic and hypotensive. Per EMS, patient had a copious amount of dark green mucus in the nose and mouth. CTA shows no intracranial flow. Patient is admitted to for close neuromonitoring and further evaluation with possible progression to brain death . Record review of CR#1's hospital discharge summary revealed read in part: .Date of admission: Patient was admitted on [DATE]. Date of discharge: Time of death 20:28 on 05/11/2024. All Diagnoses This Visit: Altered mental status, Anoxic brain injury, Coma Diffuse cerebral edema, other shock, Respiratory arrest. Hospital Course: 57yoF w/ PMHx prior stroke, stercoral colitis s/p colostomy, chronic paraplegia, wheelchair bound, DVT on Eliquis (unknown medication compliance), and bipolar disorder, is BIBEMS from after she was found unresponsive. Unknown last seen normal. Patient was reportedly GCS 3, and there was no staff available to provide additional history. EMS intubated the patient for airway protection and started a norepi drip when she was found to be hypoxic and hypotensive. Per EMS, patient had a copious amount of dark green mucus in the nose and mouth. CTA shows no intracranial flow. Patient is admitted to for close neuromonitoring and further evaluation with possible progression to brain death. Over the course of her hospitalization patient was declared brain dead (20:28 on 05/11/2024) by way of cerebral blood flow test. Guardian was contacted and funeral arrangements were made. Patient was taken off of artificial support on 5/13/24 and transported to the funeral home . In a telephone interview on 5/10/24 at 9:56a.m., with the Hospital Case Manager, she said CR#1 arrived from the nursing facility intubated and unresponsive. CR#1 was determined to be brain dead. She said per EMS CR#1's 02 was 18%. When the hospital nurse called the nursing home to get a report from the facility, she said there was no answer. She said the hospital had received many pts from that facility in poor condition. She said the facility's Administrator was contacted. The Administrator said it was clinical and asked ADON A to give report. ADON A said the NP was in the room at that time. Hospital Case Manager said she requested NP's number as the doctor had questions. In an interview on 5/10/24 at 1:13p.m., with LVN B, she said she had not worked with CR#1. She said she worked PRN at this facility, and this was her first day on the floor. When asked in the event of an emergency where would she get the oral suctioning machine from. LVN B said the oral suctioning machine should be at bedside if there was an order. I don't know where the machine is kept. But it's a good question I will definitely ask. In a telephone interview on 5/10/24 at 1:27p.m., with LVN A, she said when she made her morning round CR#1 was alert, oriented, and talking. CR#1 ate breakfast and took her morning meds. LVN A said she was passing meds when she heard coughing and a gurgling noise. She said she entered CR #1's room and observed CR#1 slumped over. She said when she called CR#1's name, the resident was not responding. She said she checked vitals and her O2 was in the 80s, but the resident was still not responding. She said she called the Unit Manager to assess. The NP was in the facility, and the NP assessed CR#1. Resident O2 Sat were low, non-rebreather was applied. The NP gave the order to send the resident out 911 to the hospital. In an interview on 5/10/24 at 1:40p.m., with RN Care Coordinator, she said CR#1 was fairly new to their case load. CR#1started their services in January 2024. She said CR#1was seen by the NP twice a week and once a week by the doctor. She said CR#1 was seen by the NP when CR#1 was transferred to the hospital. She said O2 sat less than 92% required oxygen via nasal cannula and non-rebreather mask was used to deliver high percentage of oxygen. Record review and interview on 5/10/24 at 1:48p.m., with the DON, ADON A, and ADON B. The DON said CR#1 was still breathing when CR#1 left the facility. ADON A said they were in a meeting when the nurse said CR#1 had a change of condition. On the way to assess the resident, the NP was met on the hallway and was asked to assess CR#1. The NP asked for Lasix IM and was told the facility did not have it. The NP ordered oral suctioning and a breathing treatment. After the treatment the O2 was in low 80s so they changed to nonrebreather mask and watched for a few minutes. ADON A said when she suctioned there were clear liquids, and nothing came out. The NP checked CR#1's eyes for neurological changes with the pen light. They called 911 and the EMS came within 10-15 minutes. She said the nurse and the NP were in the room with CR#1 while they gathered paperwork. ADON A said the oral suctioning machine was used. She said she connected the tubing to the suction machine and not the nurse so I know the suction machine was working. This State Surveyor asked to see the suction machine used on CR#1. ADON A said the machine was in the central supply to be decontaminated. The DON said the Respiratory Therapist checked the equipment once a month and as needed when visiting the facility as the facility did not have trach/vents. The DON said if the machine malfunctioned, the Respiratory Therapist would label it to be fixed. The State Surveyor reviewed the NP's note in which the NP documented oral suction was malfunctioning. ADON A said the NP was in and out of the room and on her phone most of the time don't know why she documented that. ADON A said CR#1 sats were in low 80s. She suggested to the NP to send CR#1 to the hospital. NP wanted to order stat x-rays and labs. ADON A said 911 wound not have taken CR#1 if she was not breathing. In a telephone interview on 5/10/24 at 2:16 p.m., the NP said the nurse called her to see CR#1 for sudden change in condition. Around 11:50 AM, CR#1 vomited and kept coughing. She said she saw CR#1 at the bedside. CR#1 was unresponsive and very congested breathing was noted. CR#1 gown was soaked with gastric emesis. There was no IM Lasix at this facility per nurse. She ordered oral suction, breathing treatment, and O2. Breathing tx was given but her O2 sat was down to 60%. It was not successful. Applied NRB with 15L and went up to 82%. CR#1 was still unresponsive. The NP said she documented, Unfortunately; oral suction was malfunctioning in her progress notes because she worked at the hospital and had not seen this suctioning machine before. She said there was clear liquid, no food when suctioning so she assumed the machine was malfunctioning. She said the staff brought 2nd suctioning machine and there was clear liquid. She said she called the Doctor and at 12:00 PM, the EMS was called for the sudden neuro change, suspected aspiration related respiratory failure and possible ET for airway protection. She said brain cells were very sensitive to a lack of oxygen. She said brain cells start dying less than 5 to 10 minutes after their oxygen supply disappears. In an interview on 5/10/24 at 2:50p.m., Hospital RN said CR#1's admitting diagnosis was anoxic brain injury, coma, and respiratory arrest. In an interview on 5/10/24 at 3:03p.m., Neurosurgery Doctor said CR#1 was found unresponsive and there was evidence that CR#1 had not gotten oxygen for 30 plus minutes as there was no blood flow to the brain. In an interview on 5/19/24 at 10:01a.m., with the DON, she said the facility had Lasix in the Ekit. The DON said nurses were reeducated on the contents of Ekit, to include a vial of Lasix and the procedure for updating the pharmacy for Ekit use. In an interview on 5/19/24 at 10:13a.m., with LVN A, she said one oral suctioning machine was used on CR#1. She said the machine was brought in the room by somebody there were too many people in the room she could not recall who brought the machine. She said she did not see who connected the tubing on the machine. LVN A said, I suctioned her I was the closest one to her. There was only clear liquid. She said the NP was in and out of the room at that time. She said nurses were responsible for sanitizing the used machine and to place it back in the storage room. She said she had not seen a Respiratory therapist in the facility as there were no trach/vent residents. In an interview on 5/19/24 at 10:33a.m., with CNA BB, she said CR#1 required extensive/total care with all ADLs. She said CR#1 was talking and ate her breakfast that morning. She said she went to take the food cart to the kitchen. It was matter of minutes resident had change of condition. When she returned to the hall the nurses were in the room with CR#1. In a telephone interview on 5/20/24 at 1:03p.m., with CR#1's Doctor. The Doctor said CR#1 had a change of condition and they started interventions. They checked BP, HR, and O2. Her O2 sat was low so the oxygen was given. Her O2 did not increase so the non-rebreather was applied. Pt was a full code and intended ET. Her BP was fluctuating on lower levels, unresponsive, and she did not respond well to oxygen so 911 was triggered. She said if the pt was full code, unresponsive, checked vitals, and had no pulse. CPR and 911 should be initiated. She said 911 would come in 8-10 minutes. She said if pt had BP staff should do interventions to keep pt stable until 911 arrives. Record review of facility's Abuse, Neglect, and Exploitation policy (Date Implemented: 8/15/22) revealed read in part: . Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Policy on Respiratory distress was requested along with Abuse/neglect policy. No policy on respiratory distress was provided on exit. This was determined to be an Immediate Jeopardy (IJ) on 05/18/2024 at 1:11pm. The facility's Administrator, the DON, and the Regional Clinical Specialist (on phone) were notified. The Administrator was provided with the IJ template on 5/18/24 at 10:55am. The following POR submitted by the facility was accepted on 5/18/24 at 7:41pm. The POR read in part: . LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY On May 18, 2024, the facility was notified by the state surveyor, that an immediate jeopardy had been called and the facility needed to submit a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: F- Tag 600: Free from Abuse and Neglect. Facility failed to provide prompt care to CR#l when she experienced respiratory distress in the presence of the NP. Done for those affected: Resident CR#l is no longer in the center. Identify residents who could be affected: o Beginning 5/18/24, head to toe assessments were completed by Licensed Nurses on all residents to identify any signs of change in condition. Concerns will be reported to the MD/NP. By 5/ 18/2024 o Beginning 5/18/24, the DON/ designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect and changes of condition were identified and an investigation initiated, and physicians were notified with no concerns noted. By 5/18/2024. The facility's policy and procedure related to Abuse and Neglect prohibition was reviewed with no concerns and/or updates indicated. By 5/18/2024 Systemic Process: . On 5/18/24, the Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and the Director of Nursing on Abuse and Neglect Policy to include providing prompt care to residents experiencing change in condition. By 5/ 18/2024 o On 5/18/24, the Administrator/ the DON and/ or designee began reeducation to 100% of the facility staff on the following: By 5/18/2024 o Abuse and Neglect Policy to include reporting and providing prompt care when a resident has a change in condition. o On 5/18/24, the DON and/ or designee began reeducation to 100% of Licensed Nurses on the following: By 5/18/2024 o Calling report to the ER when transferring resident to the ER o Contents of [NAME].it , to include vial of Lasix and procedure for updating pharmacy of ekit use. o Documentation in the medical record of actions taken when a resident experiences a change in condition o Use of suction machine o Staying with a resident when 911 has been activated o Effective 5/18/24, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator, the DON and/or designee prior to the start of their next scheduled shift. o The Director of Nursing/ designee will review the 24-hour report for any changes in condition. Ensure that physician is notified timely and that actions are taken timely to address the change in condition. By 5/18/2024 Monitoring: An Ad Hoc QAPI was conducted on 5/18/24, attended by the Administrator, the DON, the Medical Director, and the Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 600-Free From Abuse and Neglect. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 5/18/24 . The surveyor confirmed the facility implemented their plan of removal and Monitoring began on 5/19/2024. In an interview on 5/19/24 at 9:45a.m., with the Administrator and the DON, the Administrator said he was the abuse coordinator he was reeducated by the Regional Clinical Specialist on the Abuse policy. He said he then reeducated all staff on the Abuse and Neglect Policy to include reporting and providing prompt care when a resident has a change in condition. The DON said she reeducated nurses on calling report to the ER when transferring resident to the ER. Contents of Ekit, to include vial of Lasix. Documentation in the medical record of actions taken when a resident experiences a change in condition. Use of suction machine with return demonstration by nurses. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the [NAME] Clinical Specialist to the Administrator and the Director of Nursing. Topic: Abuse and Neglect Exploitation/ Prompt Care in the Event of Change in Condition. Contents or summary of training session: the Administrator and the DON were reeducated on the facility's abuse and neglect exploitation policy. Reeducation included examples of abuse and neglect; who was at risk and why. Reeducation also included the need for prompt intervention in the event of a change in condition. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the DON to all staff. Topic: Reporting Changes in Condition/ Communication with Charge Nurse/ MD/ NP RP/ Follow up Notification. Contents or summary of training session: Attendees were reeducated on identifying and reporting resident changes in condition and who to report changes to. Examples of changes to observe for reviewed e.g. bruises, skin tears, cough, new complaints of pain, runny nose, increased confusion, diarrhea, abnormal vital signs, odors in urine, bleeding of any kind, and any condition not normal for the resident. Immediate reporting emphasized. Staff also instructed to continue to report observations even if he/she believes it has been reported; as well as notifying the DON/ ADON and if applicable the Administrator of Changes in Condition which are identified and not addressed timely to include after-hours weekendsand holidays. Licensed Nurses reeducated on documentation, MD/NP/RP notification, and change of condition follow-up. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the Administrator to all staff. Topic: Abuse and Neglect Exploitation/ Prompt Care in the Event of Change in Condition. Contents or summary of training session: Staff were reeducated on the facility's abuse and neglect exploitation policy. Reeducation included examples of abuse and neglect; who was at risk and why. Reeducation also included the need for prompt intervention in the event of a change in condition. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the DON to Licensed Nurses (RN and LVN). Topic: Change in Condition/ Communication with MD/NP/RP and Documentation. Contents or summary of training session: Licensed Nurses were reeducated on identifying and reporting resident changes in condition. Examples of changes reviewed e.g. bruises, skin tears, cough, new complaints of pain, runny nose, increased confusion, diarrhea, abnormal vital signs, bleeding, odors in urine, and conditions reported by residents, staff, and/ or families. The Charge Nurses were reeducated on assessment of residents with reported and identified changes in condition to include head to toe assessment, completion of vital signs, and any other pertinent assessment, as well as completion of the Change in Condition Form and PROMPT communication with the MD/NP with assessment findings. Charge nurses reeducated on following any orders obtained related to change in condition, writing applicable progress notes, with time frames, and monitoring outcomes and communicating them timely with the MD/RP and as necessary with on-coming nurse. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the DON to Licensed Nurses (RN and LVN). Topic: Emergency Procedures and Communication. Contents or summary of training session: Licensed Nurses were reeducated on the procedure for monitoring and communication in the event of a medical emergency/ resident change in condition. Licensed Nurses reeducated on ensuring someone remains with the resident and resident was montiored throughout. Monitoring and interventions should be documented in the medical record and staff should remain with resident until EMS/ 911 arrival. Licensed Nurses must call report to the receiving hospital to include details of the resident condition and document communication with hospital staff in the medical record. Record review was conducted of the facility's In-services Training Report dated 5/18/24 conducted by the DON to Licensed Nurses (RN and LVN). Topic: Oral Suctioning, Checking of Suction Machine for function, Ekit Contents, and updating pharmacy on use. Contents or summary of training session: Licensed Nurses were reeducated on oral suctioning with return demonstration. Reeducation also included how to check suction machines for function, documentation on crash cart check list, and how to validate suction machine function at onset of use with return demonstration on oral suctioning). Licensed Nurses were reeducated on the facility ekits and contents (Cubex, IV, Refrigerator). Reeducation included location of ekits, use of ekits, and pharmacy refill process and notification in the event medication was needed to be refilled. Observed head to toe assessments were completed by Licensed Nurses on all residents to identify any signs of change in condition. No concerns were identified. Observed the DON reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse and neglect and changes of condition were identified and an investigation initiated, and physicians were notified with no concerns noted. During the monitoring phase, interviews were conducted by the state surveyor with various staff on different shifts (Administrator, DON, [NAME] Clinical Specialist, 9 LVNs, 3 CNAs and 4 Medication Aides). Staff interviewed indicated they had received above mentioned training. No concerns noted. The Administrator was informed that the Immediate Jeopardy was removed on 5/19/24 at 11:13am. The facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.