**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision for 3 of 4 residents (CR #1, Resident#2, and Resident #3) reviewed for accidents and supervision. -CR #1 walked out of the facility unattended with a wander guard (device designed to prevent wandering in elderly) and was missing for approximately 1 hour and 9 minutes on 07/20/2024 and was located nearby an apartment complex. -The facility failed to ensure that Resident#2 had orders in place to monitor placement and functioning of a wanderguard from 07/23/2023-06/10/2025. -The facility failed to ensure that Resident#3 had orders in place to monitor placement and functioning of a wanderguard from 03/24/2025-06/10/2025. An Immediate Jeopardy (IJ) was identified on 06/11/2025. The IJ template was provided to the facility on [DATE] 5:43 PM. While the IJ was removed on 06/13/2025, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place all residents at risk of harm due to elopement. Findings Include: Resident CR#1 Record review of CR #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnoses of anemia (condition where there are not enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) Alzheimer's (a brain disorder that slowly destroys memory and thinking skills), and dementia (memory loss and difficulties with thinking, problem-solving, or language), and discharged from the facility, 06/09/2025. Record review of CR#1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 to indicate she had severe cognitive impairment with a wander/elopement alarm for daily use. Record review of CR#1's undated care plan revealed: Focus: an elopement risk/wanderer AEB impaired safety awareness exit seeking. 07/20/2024 elopement resident was placed on Q 15 min checks until seen by psych(psychiatric) Date Initiated: 03/07/2024 Revision on: 07/26/2024. Goal: Safety will be maintained through the review date. Interventions: Check for wander guard proper functioning daily. Check for wanderguard placement every shift. Focus: CR#1 is at risk for falls. Goal: CR#1 to be free from falls through the next review date, which is targeted for 07/24/2025. Interventions: CR#1 last fall was on, 03/22/2025 with no injury. The facility staff is to be sure CR#1's call light is within reach for the resident to use for assistance as needed. Record review of CR#1's Progress Notes dated 07/20/2024 at 9:59 PM signed by the LVN D read in part, .At about 8:30pm, resident was found wheeling herself back to her room. Resident's wanderguard was assessed and it was in good condition and functioning properly .At about 8:45pm, CNA came to writer, who was on 100 hall and notified writer that resident was neither in her bed in in her bathroom .Writer, CNA, CNA Coordinator and CMA (300/400 hall) immediately went into the room on all four halls before continuing the search around the premises and as far as the gas stations to the left and right of the facility. Writer returned and notified on-call staff, DON, Administrator and Resident's family. Resident was escorted into the building at about 9:59pm in her wheelchair by two emergency response staff, the Administrator and resident's daughter .Resident was fitted with a new wanderguard, which is functioning appropriately . Resident #2 Record review of Resident #2's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's (a brain disorder that slowly destroys memory and thinking skills. Record review of Resident #2's admission MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE] revealed she had a wander/elopement alarm for daily use and the resident does not require any assistive devices or staff assistance and has the ability to walk on their own, according to the MDS assessment. Record review of Resident #2's undated care plan revealed: Focus: an elopement risk/wanderer r/t (related to) wanders in facility exit seeking. Date Initiated: 03/22/2023 Revision on: 07/23/2024. Goal: Safety will be maintained through the review date. Interventions: Check for wander guard proper functioning daily. Check for wanderguard placement every shift. Focus: Resident #2 is at risk for fall with impaired mobility and fluctuation in cognition. Goal: Resident #2 will be free of falls the review date of, 07/16/2025. Interventions: Resident #2 has been free of falls since, 04/17/2023.wanderi Record review of Resident #2's Progress Notes dated 03/26/2025 at 9:28 a.m. signed by the Social Worker read in part, .Resident exit seeks at times, has a wander guard . Record review of Resident #2's Progress Notes dated 11/19/2024 at 12:49 p.m. signed by the Social Worker read in part, .Resident exit seeks at times, has a wander guard . Record review of Resident #2's electronic medical records physician orders reflected that orders to check the residents wanderguard functioning and placement daily each shift started 3/21/2023 and ended 07/27/2023. Record review of Resident #2's electronic medical records physician orders reflected that orders to check the residents wanderguard functioning and placement daily each shift started 06/10/2025. Resident #3 Record review of Resident #3's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of Cerebral Infraction (stroke) with secondary diagnosis of schizophrenia(a mental disorder that involves a range of problems with thinking, behavior and emotion) and cognitive communication deficit (results from impaired functioning of cognitive processes, including attention, memory, perception, insight, judgment, organization, orientation, and language). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed he was severely impaired for cognitive skills for daily decision making, and he had a wander/elopement alarm for daily use and and the resident does require assistive device with a manual wheelchair as they are unable to walk on their own, according to the MDS assessment. Record review of Resident #3's undated care plan revealed: Focus: an elopement risk/wanderer r/t exit seeking. Date Initiated: 03/24/2025 target date: 09/06/2025. Goal: Safety will be maintained through the review date. Interventions: Check for wander guard proper functioning daily. Check for wanderguard placement every shift. Record review of Resident #3's electronic medical records physician orders reflected orders to have a wanderguard on at all times started 03/24/2025. Record review of Resident #3's electronic medical records physician orders reflected that orders to check the residents wanderguard functioning and placement daily each shift started 06/10/2025. In an interview on 06/10/2025 at 12:10 p.m., the Administrator who stated he started at the facility in September of 2022 and the DON who stated she started at the facility in 2020. Both said that any resident that was high risk of elopement or exit seeking upon admission or anytime during the stay at the facility have interventions of a wanderguard to prevent elopement. Both said that residents with a wanderguard orders to monitor the function and placement of the guard every shift and it is documented on the MAR. Both said that CR #1 was able to elope from the facility while wearing a wanderguard. Both said that CR #1 was last seen at 8:30 p.m. inside the facility, then at 8:45 p.m. a visitor (name unknown) saw CR#1 outside of the facility and returned to the facility at 9:59 p.m. by a mobile response team. Both said that there was a concern identified that CR#1's wander guard did not alert staff that she eloped from the facility, and there was a facility investigation, report filed with State Survey Agency (SSA), a Quality Assurance and Performance Improvement (QAPI) was held in August of 2024, and Performance Improvement Plan (PIP) initiated July of 2024 to address concerns by ensuring all residents with an active wanderguard had daily monitoring for placement and functioning. The following policies were requested, Incident and accidents, Elopement/Wandering, and Wanderguard. In an interview on 06/10/2025 at 1:22 p.m., the DON a request was made for a policy wander guard placement and function testing. Interview on 06/10/2025 at 1:45 p.m. with MA A, who said that she started at the facility in December of 2024. She said while working on 07/20/2024 a visitor (name unknown) reported to her at 8:45pm that she saw an unknown resident that fit the description of CR#1 walking down the street. She said that she told CNA B to initiate the facility elopement code, and she proceeded to search for resident outside on facility grounds and in the community by car but was unsuccessful in locating CR#1. She said that she was notified that the resident was located by law enforcement sometime after 9pm and returned to the facility. She said that she did not hear the door alarm sound to indicate that CR#1's wander guard functioned to alert staff of the elopement. Interview on 06/10/2025 at 1:57 p.m., with CNA B, who said she started at the facility in October of 2022, and she is also the staffing coordinator. She said that on 07/20/2025 she worked the floor, and right before 9 p.m. a visitor (name unknown) saw unknown resident that fit the description of CR #1 walking down the street and reported to MA A. She said that facility elopement code was initiated when she reported it to LVN D the unit manager and LVN E the assigned nurse, and MA A started search for CR #1 outside of the facility immediately. She said that when CR #1 was not located inside of the facility the search was expanded by car to the community by MA A, CNA B, LVN D, MA F, CNA G, and herself. She said that CR #1 was located by a mobile response team sometime after 9 pm and returned to the facility before 10pm. She said that she did not hear a door alarm to sound to indicate that CR #1's wander guard functioned to alert staff of the elopement. Record review on 06/10/2025 of a facility provided list of current residents with a wanderguard that included Resident#2 and Resident #3. Observation on 06/10/2025 at 2:30 p.m., the DON tested the wanderguard of Resident #3 for placement and functioning using a facility device while Resident #3 was seated in his wheel chair in the main dining room, and by physically taking Resident #3 to the door located at the main entrance of facility, and it was observed to be in place and functioning. Resident #3 was not interviewable. Observation on 06/10/2025 at 2:45 p.m., Unit Manager/RN to test the wanderguard of Resident #2 for placement and functioning using a facility device at the bedside, and it was observed to be in place and functioning. Resident #2 asked the Unit Manager/RN when the wanderguard would be removed because she had for a long time. Unit Manager/RN said the wanderguard was still needed for safety. In an interview on 06/10/2025 at 3:37 p.m., CNA G said that she started at the facility in 2018. She said that she was working the on 07/20/2024 when CR#1 eloped from the facility. She said that she last saw CR#1 in the lobby at 8:30pm. She said that facility elopement code was initiated, and she assisted in the search of the resident off the facility grounds. She said that the CR#1 was located by law enforcement, but she was unsure of the time she was found or when she returned to the facility. She said that she did not hear a door alarm to sound to indicate that CR#1's wander guard functioned to alert staff of the elopement. In an interview on 06/11/2025 at 8:05 a.m., Resident #2 at the besides, said that she had a bracelet on her ankle to tell staff if she leaves the building. She said that she did not need the bracelet, and she had it for a long time. She said that staff checks every day with the box to make sure it works, and she did not take it off. In an effort to complete a phone interview on 06/11/2025 at 9:24 a.m., with former employee, LVN E, a message was left. In an effort to complete a phone interview on 06/11/2025 at 9:25 a.m. with former employee, MA F, the number was disconnected. In a phone interview on 06/11/2025 at 9:26 a.m. with the Medical Director, who said he participated in a QAPI to address concerns of an elopement in August of 2024, but he could not recall the residents name involved. He said that the resident was able to elope from the facility while wearing a wanderguard. He said that a plan was developed to train staff on the elopement process, monitor resident at high risk for elopement with a wanderguard with monitoring for placement and testing the function of the wanderguard each shift. He said that staff should follow their elopement process and monitor residents to prevent elopements, if not there is risk that residents can elope, and there is always the potential for harm with each elopement. In an interview on 06/11/2025 at 10:20 a.m. with LVN D, who said that she last worked at the facility in October of 2024 as a Unit Manager. She said that she worked on 07/20/2025 when CR#1 eloped. She said that a medication aide (MA A) was told by a visitator (name unknown) at 8:45pm that a resident that fit the description of CR#1 was seen walking down the street. She said that she was notified by the staffing coordinator (CNA B), that a medication aide (MA A) had started to search outside immediately, and the facility elopement code was initiated with a search inside the facility and outside the facility for 30 minutes. She said that when CR#1 was not located the search was expanded by car to the community by two medication aides (MA A and MA F), staffing coordinator (CNA B), the assigned CNA (CNA G), and herself. She said that CR#1 was located by a mobile response team sometime after 9pm and returned to the facility at 9:50pm. She said that she did not hear a door alarm to sound to indicate that CR#1's wander guard functioned to alert staff of the elopement. She said that CR#1's wander guard was tested prior to the elopement an upon returning to the facility and it was functioning but still replaced. She said that residents that are high risk for elopement must have orders in place to test for functioning and ensure placement every shift. She said that there is a policy and procedure in place to prevent elopement, if not followed the risk is elopement, and there can be harm with every elopement. Record review on 06/11/2025 at 12 pm of document titled QAPI and dated 08/15/2025 read in part, . Problem: Elopement risks Goal: Ensure all residents with wonder guards are monitored closely and all preventative measures are being followed. Root Cause: Staff aren't monitoring them close enough. Action Items: Ensure staff are doing daily checks of functionality of the wander guards. Person Responsible: Administrator/designee Follow up date: 7/18/2024. Date Resolved or reevaluated: ongoing Reviewed in QAPI: Monthly . Record review on 06/11/2025 at 12:05 pm of document titled PIP and dated 07/22/2024 read in part, .Focus Area: Resident Elopement Prevention Revie date: Random and PRN Background: A recent elopement incident involving a resident has highlighted the need for enhanced protocols and safe guards to prevent unauthorized departures. This PIP aims to address the gaps and reinforced safety measures, particularly with residents who wear wander guards. Goals: Prevent further residents elopement incidents. Ensure proper functioning and regular testing of wander guard devices. Reinforce staff awareness regarding high risk residents. Enhanced elopement risk assessment and response protocols. Action plan: Ensure all wander guard devices are tested for proper function and alarm response. Log results Conduct standardized elopement risk assessments upon admission, quarterly, and with any change in condition. Residents identified as elopement risks will have checks every 2 hours. Provide inservice on elopement protocols Record review on 06/11/2025 at 12:10 p.m. of document titled Wanderguard Functionality from 07/20/2024-09/30/2024 to indicated that wanderguards was checked for functioning and placement daily, but the document did not provide information as to which residents was assessed. In an interview on 06/11/2025 at 1:00 p.m. the DON, who said there was only two residents during the PIP that was at risk for elopement with a wanderguard, CR#1 and Resident #2. She said that CR#1 and Resident #2 would have been the only residents apart of the daily audit to test placement and functioning of wanderguards, and the nurses would have documented that the guards were placed and functioning on the MAR. She said that she documented the residents involved with the PIP in a written statement, she provided a copy, and the record was reviewed. She agreed to email the document with the MAR for each resident 07/20/2024-09/30/2024 as evidence that that task was completed as part of the PIP. She agreed to email the following policies Incident and accidents, Elopement/Wandering, and Wanderguard. In an interview and observation on 06/11/2025 at 2:15 p.m., with LVN H, who said that she started in January 2025 at the facility, and she works the 400 hall from 6:00am-2:00pm. She said that residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that there were two residents on 400 hall with a wanderguard to include Resident#2. She was observed to check Resident#2's electronic medical records and confirmed there were no orders in place until 06/10/2025 to check placement and functioning of the wanderguard. She said that she thought Resident#2 had orders, she checked daily, and thought she documented on the MAR. She said that Resident#2 had a wanderguard since she started working at the facility. In an interview and observation on 06/11/2025 at 2:20pm with RN I, who said that she started in March 2025 at the facility, and she works the 400 hall from 2:00pm-10:00pm. She said that residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that there were two residents on 400 hall with a wanderguard to include Resident#2. She was observed to check Resident#2's electronic medical records and confirmed there were no orders in place until 06/10/2025 to check placement and functioning of the wanderguard. She said that she thought Resident#2 had orders, she checked daily, and thought she documented on the MAR. She said that Resident#2 had a wanderguard since she started working at the facility. In an interview and observation on 06/11/2025 at 2:25 p.m. LVN J, said that she started at the facility in March 2025, and she works the 200 and 100 hall from 6:00am -2:00pm. She said that residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that there was one resident on 200 hall with a wanderguard, Resident #3. She was observed to check Resident#3's electronic medical records and confirmed there were no orders in place until 06/10/2025 to check placement and functioning of the wanderguard. She said that she thought Resident#3 had orders, she checked daily, and thought she documented on the MAR. She said that Resident#3 had a wanderguard since March or April of 2025. In an interview and observation on 06/11/2025 at 2:30pm with RN K, who said that she started at the facility 11 years ago, and she works the 200 and 100 hall from 2:00pm. She said that residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that there was one resident on 200 hall with a wanderguard, Resident #3. She was observed to check Resident#3's electronic medical records and confirmed there were no orders in place until 06/10/2025 to check placement and functioning of the wanderguard. She said that she thought Resident#3 had orders, she checked daily, and thought she documented on the MAR. She said that Resident#3 had a wanderguard since March of 2025. In an interview on 06/11/2025 at 3:20 pm with the DON, who said residents are assessed for elopement at admission, readmission, and quarterly for elopement. She said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. She said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. She said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. She said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. She said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. She said that Resident#2 did not have a wanderguard during the time of the QAPI and PIP. She said that Resident#2's order was discontinued because she was no longer exit seeking, and the order was received on 06/10/2025 when Resident#2 started showing behaviors of exit seeking. She did not provided answer when asked why Resident#3's orders started on 6/10/2025, when he has had a wanderguard since March of 2025. In an interview on 06/11/2025 at 3:30 p.m., the Administrator, who said residents are assessed for elopement at admission, readmission, and quarterly for elopement. He said that residents at high risk for elopement or with exit seeking behavior have orders for a wander guard. He said that residents with a wanderguard have orders for a nurse to check placement and function each shift, and the task is documented on MAR. He said that if a task is not documented it did not happen, and if there are no orders there is no way to document on the MAR. He said that if there is no monitoring for placement and functioning of a wanderguard a resident could elope if the wanderguard is taken off or it does not work. He said that the risk to a resident would be elopement, and there was a chance for harm for any elopement. He said that Resident #2 and Resident #3 had a wanderguard, both should have orders to check placement and function each shift, and both have had the guards in place for some time. He said that he did not know for how long Resident #2 had the guard, it was in place when CR#1 eloped last year, and Resident #2 should have been a part of the PIP to ensure monitoring for placement and functioning. He said that it would not be a true statement that Resident #2 only got the guard on 06/10/2025. He said that he did not know why the DON would say that Resident #2 only got the guard on 6/10/2025 and that was concerning for him to know. Requested the following policies were requested, Incident and accidents, Elopement/Wandering, and Wanderguard. The policies for Incident and Accidents, Elopement/Wandering, and Wanderguard on 06/10/2025 at 12:10 p.m., and on 06/11/2025 at 1:00pm and 3:30pm, and were not received prior to exit. A policy for testing wanderguards for placement and functioning on 06/11/2025 at 1:22 p.m. and was not received prior to exit. Record review of policy titled, Wandering Unsafe Resident, with a revised date of December 2008 read in part, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . Safety Interventions 4. Interventions to try to maintain safety will be included in the residents are plan. This was determined to be an Immediate Jeopardy (IJ) on 06/11/2025. The Administrator was notified on 06/11/2025. The IJ template was provided to the facility on [DATE] at 5:43pm. In an interview on 06/12/2025 at 9:49 a.m. the CO-Medical Director, who said that he was notified about the IJ being called, and he had been included on the POR. He said that all treatments and care should have orders, should be documented, and standard. The following Plan of Removal (POR) submitted by the facility was accepted on 06/12/2025 at 1:14 p.m. The plan of removal reflected the following: Facility Name: Date: June 12th, 2025 Plan of Removal F 689 Accidents/Hazards Facility submits the following Plan of Removal for the alleged failure to ensure the resident environment remained free of accidents, and hazards each resident received adequate supervision to prevent accidents for CR #1, Resident #2, and Resident #3. What corrective actions have been implemented for the identified residents? A. Resident CR#1 discharged from facility on 6/09/2025. B. On 6/11/2025, Resident #2 medical record was reviewed by the Clinical Services Director to ensure Wanderguard orders were in place, with instructions to verify proper placement every shift and ensure proper functioning daily. Care plans reviewed for residents with Wanderguards and updated if indicated. Wanderguard devices are in place and have been verified to be functioning correctly by the DON on 6/11/2025. C. On 6/11/2025, Resident #3 medical record was reviewed by the Clinical Services Director to ensure Wanderguard orders were in place, with instructions to verify proper placement every shift and ensure proper functioning daily. Care plans reviewed for residents with Wanderguards and updated if indicated. Wanderguard devices are in place and have been verified to be functioning correctly by the DON on 6/11/2025. D. On 6/11/2025 at 06:31 pm the Administrator notified the Medical Director of alleged deficient practice. E. On 6/11/2025 the DON/Nurse Managers completed a 100% elopement risk assessment of all residents residing in the facility for risk of elopement, and no new residents were identified to be at risk. F. On 6/11/2025 DON/Nurse Managers audited the residents' orders that require a Wanderguard, no concerns were identified. G. On 6/11/2025 the DON/Nurse Managers and Administrator were in-serviced on the Elopement Policy by the Regional [NAME] President of Operations and the Clinical Services Director. H. On 6/11/2025 the license nurses were trained on testing the Wanderguard device. I. On 6/11/2025 the DON received a written warning on the Elopement Policy by the Administrator. J. The Clinical Services Director reviewed facility Elopement Policy on 6/11/2025 no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. Residents that are at risk for elopement have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was initiated on 6/11/2025 by the Corporate Clinical Service Director, DON, and Nurse Managers with the licensed nursing staff on the Elopement Policy and obtaining orders for residents that requires a Wanderguard. Licensed nurses will not be allowed to return to work until they receive this in-service. Completion date 6/11/2025. B. An in-service was initiated on 6/11/2025 by the Nurse Managers and the Administrator with the facility frontline staff on the residents that requires a Wanderguard and obtaining orders. Completion date 6/11/2025. C. Newly hired nurses will be in-serviced by the DON/designee on the Elopement Policy and obtaining orders for residents that require a Wanderguard. Licensed nurses will not be allowed to work until they receive this in-service. Completion date 6/11/2025. D. Newly hired frontline staff will be in-serviced by the DON/designee on the residents that requires a Wanderguard. They will not be allowed to work until they receive this in-service. Completion date 6/11/2025. E. New Admissions and Readmissions Elopement Assessment and Risk Management will be reviewed daily in the morning meeting to identify residents at risk for elopement and ensure adequate supervision in place, monitoring of Wanderguard placement and proper functionality. The Charge Nurse will monitor the placement and functionality of the Wanderguard devices daily and document on the resident's MAR. The DON/designee will monitor the placement and functionality of the devices 3x week X 6 weeks and review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/11/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Plan of Removal was confirmed for the IJ by mon[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 2 of 11 residents (Resident #6 and CR #7) reviewed for accidents in that: -The facility failed to implement Resident #6 care plan to monitor resident to prevent fall from wheelchair developing a right frontal contusion and displaced fracture of the right frontal calvarium (section of the skull). -The facility failed to take proper precautions when CR #7 who x-ray results revealed loss of normal cervical lordosis (improper alignment of the neck) experienced an unwitnessed fall. CR #7 had a fractured C1 & C2 (neck region). An IJ was identified on 09/21/2023. While the IJ was removed on 09/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place other residents in the NF with unwitnessed falls with injuries at risk for unwanted hospitalization and death. Findings: Resident #6 Record review of Resident #6 face sheet revealed an 86year old male admitted to the NF on 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6 MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6 Care Plan revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6 Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21pm revealed in part: .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report revealed that Resident #6 CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27pm RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32pm LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Interview on 09/19/2023 at 7:17pm RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7 face sheet revealed a 73year old female admitted to the NF on 12/08/2021 diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heart beat), rheumatoid arthritis (disorder affecting many joints including the hands and feet), and muscle weakness. Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7 cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7 Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When sked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on 08/19/2023 at 10:24am revealed in part: .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Resident also reported biting her tongue. NP in the building and notified . At 10:34am New order for X-ray left elbow, radius, and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. Interview on 09/14/2023 at 10:54am the hospital staff RN-ZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20pm Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice Interview on 09/18/2023 at 11:23am LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00am. LVN G said she made rounds on the residents around 5:00am and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00am and went she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Interview on 09/18/2023 at 12:55pm LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55pm with LVN O said she had been in- serviced on falls to check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35pm LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. Interview on 09/19/2023 at 11:10am CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Record review of the NF Policy on Quality of Care: Safety and Supervision of Residents revised December 2007 revealed in part: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety . The * Administrator was notified on 09/21/00 at 3:04 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The *Administrator was provided the IJ template on 09/21/23 at 3:04 PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/23/20 at 3:00 PM and indicated: PLAN OF REMOVAL F689 Name of facility: Park Manor Cypress Station Date: 09/23/2023 Immediate Action Impact Statement: On 9/21/23 the state surveyor entered to continue an abbreviated survey at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/21/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure of the facility of developing and implementing a system ensuring that all nursing staff are in-serviced/trained on the importance of sending a resident to a higher level of care that experience an unwitnessed fall with head injuries via 911. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all unwitnessed falls in residents with head injury in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents with unwitnessed falls have the potential to be affected by this deficient practice, no other residents were identified as being affected. Audit completed on 9/21/2023 by Director of Nursing. What corrective actions have been implemented for the identified resident? Resident CR # 7 was discharged to hospital on 8/19/2023. Resident #6 readmitted to facility and is in stable condition. Resident's care plan was updated with fall incident and interventions to prevent further falls. Staff were educated on resident's updated plan of care for fall. Nurses on duty for the above residents received 1:1 in-service by Director of Nursing on unwitnessed fall protocol that included the assessment of resident and following the Care Path Fall Tool attached. CNAs were in-serviced by Director of Nursing on fall protocol that included not to move a resident post fall and to immediately notify the license nurse to assess resident. What corrective actions were taken? 5. The following actions were initiated immediately on 9/21/23. f. On 9/21/23 an audit was completed by the Director of Nursing and/or designee to identify all unwitnessed falls in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. Residents with falls in the last 30 days had their care plan for fall reviewed for interventions and effectiveness by Director of Nursing/designee on 9/21/2023. g. Director of Nursing was educated on 9/21/23 by Clinical Services Director on the protocol of unwitnessed fall with major/serious injury being sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. h. Initiated in-services on 9/21/23 with licensed nurses by Director of Nursing /Designee on protocol of unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until in-service is completed on protocol of unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. 6. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review falls in morning meeting starting on 9/22/23 and ongoing to ensure unwitnessed falls with/or suspected major/serious injury are appropriately addressed. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The weekend supervisor and/or designee was in-serviced on 9/21/23 by Director of Nursing/ Designee on identifying all residents experiencing falls on Saturdays and Sundays to ensure that any resident that experiences an unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. c. Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee to send residents that experience an unwitnessed fall with/or suspected major/serious injury to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed on protocol for unwitnessed falls with/or suspected major/serious injury. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/21/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated on neglect policy and fall protocol including unwitnessed falls with/or without injuries. Unwitnessed falls will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/24/2023 at 11:36am RN P said she worked the 6am-6pm shift and had been in-serviced on abuse and neglect, falls unwitnessed or witnessed and the resident on anticoagulants that experienced injury especially head injury to send resident out to the hospital via 911 services. Interview on 09/24/2023 at 11:42am LVN RR said she worked at the NF PRN on the 6am- 2pm shift. LVN RR said she had been in-serviced on abuse and neglect, falls assessing residents with witnessed and un-witnessed falls. LVN RR said after assessing the resident and there are complaints of pain do not move the resident, check to see if the resident is on any blood thinners, send to the hospital via 911 for further evaluation, notifying the doctor and the RP. Interview on 09/24/2023 at 11:50am LVN R said she worked at the NF full time 8am-5pm. LVN RR said she had been in-serviced on falls witnessed and unwitnessed to do a head-to-toe assessing for pain or any injuries. LVN R said if the resident hit their head neuro checks had to be initiated per facility protocol. LVN RR said she was in-serviced to check to see if the resident was on any blood thinners and prepare to send the resident to the hospital 911. LVN RR said if an injury is suspected, do not move the resident, and send to hospital 911 for further evaluation being sure to notify the doctor and RP and document all actions taken. Interview on 09/24/23 at 12:00pm CNA S said she worked at the NF full time on the weekends 6am-10pm and had been in-serviced on falls. CNA S said if a resident had fall that was witnessed or un-witnessed do not move the resident and get the nurse right away to assess the resident. Interview on 09/24/2023 at 12:05pm CNA V said she worked the 6am-2pm shift and had been in-serviced on abuse and neglect, falls, not to move the resident but alert the nurse so that the resident could be assessed for any injuries. Interview on 09/24/2023 at 12:08pm CNA K said she worked the 6am-2pm shift on certain days and the 2pm-10pm shift on certain days. CNA K said she had been in-serviced on abuse and neglect, falls, and the prevention of falls (keeping the resident call light in reach). CNA K said if a resident had a fall, she was not to move the resident instead stay with the resident and call for the nurse. CNA K said she had also been in-serviced on going into the computer to look at the resident POC to see what interventions had been put in place to care for the resident needs and follow the interventions. Interview on 09/24/2023 at 12:17pm CNA U said she worked the 6am-2pm and had been in- serviced on that when a resident fall to stay with the resident and call the nurse. CNA U said she had also been in-serviced on abuse and neglect. Interview on 09/24/2023 at 1:05pm CNA X said she worked the 2pm-10pm shift. CNA X said she had been in-serviced on falls and fall risk, keeping the resident's bed in low position, call lights in reach, fall matts on the floor at the bed side. CNA X said if she witnessed a fall or unwitnessed a fall, she was not to move the resident but stay with the resident and call the nurse right away. Interview on 09/24/2023 at 1:33pm CNA I said she worked various shifts pending where the staffing needs were. CNA I said she had been in-serviced on falls witnessed and unwitnessed not to move the resident, stay with the resident and alert the nurse. CNA I said she was also in-serviced that if she was not familiar with the resident care needs, she could look at the resident POC in the computer. Interview on 09/24/2023 at 8:10pm RN A (worked 6pm-6am) said he had been further in- service on falls to assess the resident for injuries and if so, do not to move the resident and call 911 to send the resident out to the hospital right away to be evaluated. Interview on 09/24/2023 at 8:20pm RN F said she worked the 2pm-10pm shift and had been in-serviced on abuse and neglect as well as falls. RN F said she had been further in-serviced on falls that if there were injuries or suspected injuries to not move the resident and call 911 to have resident sent out to the hospital 911. Interview on 09/24/2023 at 8:27pm CNA Y via phone said she worked the 10pm-6am shift and had been in-serviced on abuse and neglect and falls to not move the resident and call the nurse. Interview on 09/25/2023 at 10:30am LPN Z said she worked the 6am-2pm shift and sometimes the 2pm-10pm shift. LPN Z said she had been in-serviced on falls witnessed and un- witnessed. LPN Z said she had also been in-service on how to look on the computer to review the resident (s) plan of care and their interventions. LPN Z said if a resident had a fall, she would assess the resident for injuries, review the resident medications to see if they were on any blood thinners; LPN Z said if the resident had injuries or suspected injuries, she was in- serviced not to move the resident, call 911 to have resident transported to the hospital right away for further evaluation. LPN Z said she had also been in-serviced on abuse and neglect. Interview on 09/25/2023 at 10:36am LVN C said she had been further in-serviced on falls witnessed or unwitnessed assess range of motion. LVN c said if the resident complained of pain, do not move the resident, and arrange to have resident sent to the hospital via 911. Interview on 09/25/2023 at 10:42pm CNA AA said she worked the 6am-2pm shift and that she had received in-service on residents falling and to not leave the resident alone and call the nurse. CNA AA said she had also received in-services on abuse and neglect. Interview on 09/25/2023 at 10:47am CNA CC said she worked the 6am-2pm shift and had been in-serviced on abuse and neglect, falls witnessed and unwitnessed to not move the resident but stay with the resident and call the nurse. Interview on 09/25/2023 at 10:54am CNA DD said she worked the 6am-2pm shift and that she had been in-serviced on fall preventions, keeping the bed in the low locked position with the call light in reach. CNA DD said she had also been in-serviced that if a resident fell, to stay with the resident, don't move the resident and call the nurse. Interview on 09/25/2023 at 11:16am via phone LVN BB said she worked the 6pm-6am shift. LVN BB said she had been in-serviced on falls witnessed and un-witnessed. LVN BB said if the resident had fallen and was alert and oriented able to tell what happened and hit his head, she would not move the resident, checked to see if the resident was on any blood thinners, initiate neuro checks, call the physician and the RP, and prepare to send the resident to the hospital via 911. LVN BB said she had also been in-serviced on abuse and neglect and who to report it to which was the Administrator. Interview on 09/25/2023 at 11:30am CNA FF via phone said she worked the 10pm-6am shift. CNA FF she had been in-serviced on abuse and neglect and to report to the Administrator. CNA FF said she was in-serviced on falls when a resident had a fall to not move the resident and call foe the nurse. CNA FF said she had been in-serviced on fall preventions by keeping the resident bed in a low position with call light in reach. On 09/25/2023 at 12:26 p.m., the Administrator, Clinical Service Director was informed that the IJ was removed, however, the facility remained out of compliance at a scope of a isolated and severity of actual harm that is not IJ as the facility was continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents have the right to be free from neglect for 3 of 11 residents (Resident #1, Resident # 6, and CR #7) reviewed for neglect in that: -The facility system for obtaining medical care for un-witnessed falls was not effective in protecting the health & safety of residents as follows: -The facility failed to transfer Resident #1 to the hospital immediately when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. sustaining a head injury. Resident #1 was receiving the medication Eliquis (blood thinner) and was not transferred to the hospital until 8:00 a.m. Resident #1 is scheduled for surgery on 9/14/23 due to brain bleed. -The NF delayed in calling the physician and sending Resident #6 to a higher level of care to be evaluated when Resident #6 had an unwitnessed fall with head injury on 08/19/2023. -The NF delayed sending CR #7 to a higher level of care when CR #7 had an unwitnessed fall on 08/19/2023 at 6:28am. CR #7 was not sent to the hospital until 12:20pm where it was discovered that CR #7 had a fractured C1 & C2 (neck region). An IJ was identified on 09/21/2023. While the IJ was removed on 09/25/2023, the facility remained out of compliance at a scope of a pattern that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems This failure place residents who have unwitnessed falls at risk of increase injury, pain, and death. Findings: Record review of Resident #1 face sheet revealed a 64year old male admitted to the NF on 12/09/2022. Resident #1 diagnoses included the following: hemiplegia (paralysis that affects one side of the body) & hemiparesis (weakness) following cerebral infarction (disrupted blood to the brain), congestive heart failure (when the heart does not pump blood adequately), atrial fibrillation (irregular heartbeat), cognitive communication deficit (impairment in an individual's mental capacity), muscle weakness, hyperlipidemia (elevated cholesterol), and hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 11(signifying mild mental impairment). Further review revealed that resident required limited assistance with bed mobility, transfer, and personal hygiene. Further review revealed that resident required supervision with dressing, eating, and toilet use. Record review of Resident #1s' Physician Orders revealed the following orders: -aspirin oral tablet 325mg give 1 tablet by mouth every 6 hours as needed for pain, order date 08/04/2023, -Eliquis oral tablet 2.5mg give 1 tablet by mouth two times a day for atrial fibrillation, order date 02/17/2023. Record review of Resident #1's MAR dated September 2023 revealed that the NF was administering the medication aspirin and Eliquis as ordered by the physician. Record review of Resident #1's Nursing Progress Notes revealed the following: -dated 09/11/2023 documented by RN A at 5:50am the following: .Called NF transportation for patient pick up time within 1 to 1.5 hour arrival . -documented by LVN D on 09/11/2023 at 8:08am: .Resident left facility via EMS regular transportation with family member .swelling noted left .and skin tear to right knee .resident alert and responsive . Record review of Resident #1's hospital records dated 09/11/2023 revealed that a CT (computerized x- ray) of the head without contrast was done with the following: Intra orbital (foreign object inside of a space caused by a trauma) hemorrhage (bleeding) in the left orbit with periorbital tissue swelling and mild proptosis .mildly depressed left medial orbital wall fracture .bilateral nasal bone fracture with overlying soft tissue swelling. Interview on 09/13/2023 at 12:55 p.m., RN A said he worked on 09/10/2023 the 6pm-6am shift and was Resident #1's nurse. RN A said he found Resident #1 on the floor in his room at the foot of his bed laying on his right side. RN A said the time was around 4am-5am. RN A said Resident #1 told him that he was trying to transfer himself from his wheelchair to his bed. RN A said Resident #1 told him that he had hit his head. RN A said he did not see any signs of injury such as a knot on the head or any bleeding. RN A said resident was placed back in his wheelchair with the assistance of a CNA who name he could not remember. RN A said he called the family of Resident #1 as well as the doctor who gave the order to send resident to the hospital. RN A said regular transportation was call to transport resident to the hospital instead of 911 services because Resident #1 vital signs was stable, there was no bleeding, and resident was conscious. Further interview with RN A said he was not aware that Resident #1 was receiving the blood thinner Eliquis twice a day. RN A said if a resident experienced a fall with a head injury and receiving blood thinners should be transported to the hospital immediately for further evaluation because resident could be bleeding internally. Interview on 09/13/2023 at 1:40 p.m., family member of Resident #1 said resident was still at the hospital experiencing bleeding from the brain. The family member said Resident #1 was scheduled to have surgery on 09/14/2023 to relieve the pressure. The family member said the NF called her a little after 5:00 a.m. informing her that Resident #1 had fallen. The family member said she made it to the NF around 5:40 a.m. and that Resident #1 was complaining of pain to the right side of his neck and back, and left side of his head. The family member said Resident #1 left side of face was swelling extending from the forehead near the left eye. The family member said there was no sense of urgency to transport Resident #1 to the hospital. The family member said she went to let a male nurse know Resident #1 had swelling to his head. The family member said when the male nurse looked at Resident #1, he admitted resident had swelling to his head and told her that help was on the way. The family member said she then went to the nurse station and spoke to a female nurse asking when Resident #1 was going to be transported to the hospital. The family member said the female nurse told her that she had called transportation and was told that that they were in route to the NF. The family member said it was after 8:00am when Resident #1 left the NF on the way to the hospital. Interview on 09/13/2023 at 2:02 p.m., the Unit Manager said she worked at the NF from 8am-5pm. The Unit Manager said on 09/11/2023 she arrived at the NF around 7:45am and began making rounds on the Hallways. The Unit Manager said she saw Resident #1 family member at the nurse station asking when the ambulance was coming to take resident to the hospital because he had experienced a fall in his room. The Unit Manager said when she arrived at Resident #1's room, resident was sitting in his room in his wheelchair. The Unit Manager said Resident #1 was not able to tell her what had happen to him. The Unit Manager said she learned that Resident #1 had fallen on the 10pm-6am. The Unit Manager said the nurse on the night shift (10pm-6am) had already given report to the oncoming LVN D who was working the morning shift. The Unit Manger said in the event of an emergency the Nursing staff would call 911 services and not the NF transportation System (non-emergency). Interview on 09/14/2023 at 1:17 p.m., the DON said according to the Nursing Progress Notes, Resident #1 was in his wheelchair and tried to transfer on his own to his bed fell and hit his head. The DON said resident was transferred to the hospital and resident family member was with him. The DON said she spoke with RN A who said Resident #1 was yelling for help. The DON said when RN A arrived at Resident #1's room, resident was on the floor reporting that he had hit his head. The DON said RN A assessed Resident #1 and done ROM on resident along with offering the resident something for pain. The DON said based on the Nursing documentation, Resident #1 was not in any pain. The DON said she learned later from the hospital that Resident #1 CT scan of the head was positive for hemorrhage (bleeding). The DON said she informed the Administrator of the hospital findings, and the Administrator called the incident in to the state. The DON said the NF initiated in-service with the staff on fall precautions, abuse, and neglect based on the NF policy. The DON said she was aware that Resident #1 was on a blood thinner and was transported to the hospital via the NF transportation. The DON said it was a case by case (pending on the resident (s) level of consciousness, vital signs, pain, distress, etc.) that determined if a resident is sent out by normal transportation or 911 services. The DON said the NF transportation could take up to 1- 2 hours to transport a resident to the hospital. The DON said she was aware that it took the NF almost 4 hours to send resident to higher level of care. The DON said she could not say if the course of action taken regarding Resident #1's unwitnessed fall with a head injury receiving blood thinners was right or wrong course of action and again that it was a case-by-case situation. The surveyor asked the DON what was the NF policy regarding a resident on blood thinners experiencing a fall with head injuries? The DON said she did not know what the NF policy was on falls with head injuries in relation to residents taking anticoagulants/blood thinners and would have to go read it. Further interview with the DON said the NF did not have a policy regarding falls as it relates to blood thinners. The DON was asked for the NF Policy on Abuse and Neglect. The NF provided the surveyor a Policy on Abuse Investigation and Report. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift full time. LVN D said RN A gave her report on 09/11/2023 at 6:30 a.m. LVN D said RN A reported that Resident #1 had fallen in his room. LVN D said she asked RN A if he had called 911 services and RN A said no. LVN D said when she assessed Resident #1, resident left eye was swollen and he had a skin tear to his right knee. LVN D said Resident #1 could not tell her exactly what had happened just that he had fallen on the floor. Resident #6 Record review of Resident #6 face sheet revealed an [AGE] year-old male admitted to the NF on 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6's MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6's Care Plan dated 02/24/2023, revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6's Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21p.m., revealed in part: .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 indicated that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report dated 09/11/2023revealed that Resident #6's CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27 p.m., the RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32 p.m., LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Interview on 09/19/2023 at 7:17 p.m., RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7's face sheet revealed a [AGE] year-old female admitted to the NF on 12/08/2021 diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), rheumatoid arthritis(Disorder affecting many joints including the hands and feet), and muscle weakness. Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7's cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7's Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When asked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on 08/19/2023 at 10:24 a.m., revealed in part: .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Resident also reported biting her tongue. NP in the building and notified . At 10:34 a.m. New order for X-ray left elbow, radius and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. Interview on 09/14/2023 at 10:54 a.m., the hospital staff RNZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20 p.m., the Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice. Interview on 09/18/2023 at 11:23 a.m., LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00 a.m. LVN G said she made rounds on the residents around 5:00 a.m. and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00 a.m., and when she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that. LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Interview on 09/18/2023 at 12:55 p.m., LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55 p.m., LVN O said she had been in- serviced on falls to check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35 p.m., LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. Interview on 09/19/2023 at 11:10 a.m., CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Record revie of the NF Policy on Anticoagulant-Clinical Protocol revised April 2007 revealed in part: .The staff and physician will identify and address potential complications in individuals reveiving anticoagulation . Record review of the NF Policy on Falls revised September 2012 revealed in part: .The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls (for example, increase fracture risk in someone with osteoporosis or increase risk of bleeding in someone taking an anticoagulant). The Administrator was notified on 09/21/00 at 3:04 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 09/21/202300 at 3:04 PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/24/202300 at 3:00p.m. and indicated: PLAN OF REMOVAL F600 Name of facility: Park Manor Cypress Station Date: 09/21/2023 Immediate Action Impact Statement: On 9/21/23 the state surveyor entered to continue an abbreviated survey at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/21/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure of the to ensure each resident was free from neglect. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all unwitnessed falls in residents with head injury in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents with unwitnessed falls have the potential to be affected by this deficient practice, no other residents were identified as being affected. Audit completed on 9/21/2023 by Director of Nursing. What corrective actions have been implemented for the identified resident? Resident CR # 7 was discharged to hospital on 8/19/2023. Resident #6 readmitted to facility and is in stable condition. Resident #1 re-admitted to facility on 9/19/2023 in stable condition and had care plan updated with the fall preventions interventions. Nurses on duty for the above residents received 1:1 in-service by Director of Nursing on unwitnessed fall protocol that included the assessment of resident and following the Care Path Fall Tool attached. CNAs were in-serviced by Director of Nursing on fall protocol that included not to move a resident post fall and to immediately notify the license nurse to assess resident. What corrective actions were taken? 3. The following actions were initiated immediately on 9/21/23 c. On 9/21/23 an audit was completed by the Director of Nursing and/or designee to identify all unwitnessed falls in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. d. Director of Nursing was educated on 9/21/23 by Clinical Services Director on signs and symptoms of neglect, reporting neglect, Abuse Coordinator and protocol an unwitnessed fall with/or suspected major/serious injuries are sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. e. Initiated in-services on 9/21/23 with licensed nurses by Director of Nursing /Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until in-service is completed on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Nursing staff was in-serviced on fall interventions on 9/22/2023 by Director of Nursing. Fall interventions are entered for each resident in their care plan that is easily accessible to nurses via PCC care plan tab and for CNAs under Kardex in their POC documentation tool for each resident. Nursing staff was in-serviced on these tools on 9/22/2023 by Director of Nursing. 4. How will the system be monitored to ensure compliance? a. The Director of Nurses/Administrator will review falls in morning meeting starting on 9/22/23 and ongoing to ensure no neglect occurred on unwitnessed falls with/or suspected major/serious injury. Any identified concerns will be addressed immediately, and additional training will be provided as needed. b. The weekend supervisor and/or designee was in-serviced on 9/21/23 by Director of Nursing/ Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The Weekend Manager will monitor compliance during Saturdays and Sundays and ensure no neglect occurred on unwitnessed falls with/or suspected major/serious injury. c. Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Completed by 9/22/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed on signs and symptoms of neglect, reporting neglect, Abuse Coordinator, and protocol on unwitnessed fall with major/serious injury will be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/21/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated on neglect policy and fall protocol including unwitnessed falls with/or without injuries. Unwitnessed falls be sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse using the Care Path Fall Tool attached. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/24/2023 at 11:36am RN P said she worked the 6am-6pm shift and had been in-serviced on abuse and neglect, falls unwitnessed or witnessed and the resident on anticoagulants that experienced injury especially head injury to send resident out to the hospital via 911 services. Interview on 09/24/2023 at 11:42am LVN RR said she worked at the NF PRN on the 6am- 2pm shift. LVN RR said she had been in-serviced on abuse and neglect, falls assessing residents with witnessed and un-witnessed falls. LVN RR said after assessing the resident and there are complaints of pain do not move the resident, check to see if the resident is on any blood thinners, send to the hospital via 911 for further evaluation, notifying the doctor and the RP. Interview on 09/24/2023 at 11:50am LVN R said she worked at the NF full time 8am-5pm. LVN RR said she had been in-serviced on falls witnessed and unwitnessed to do a head-to-toe assessing for pain or any injuries. LVN R said if the resident hit their head neuro checks had to be initiated per facility protocol. LVN RR said she was in-serviced to check to see if the resident was on any blood thinners and prepare to send the resident to the hospital 911. LVN RR said if an injury is suspected, do not move the resident, and send to hospital 911 for further evaluation being sure to notify the doctor and RP and document all actions taken. Interview on 09/24/23 at 12:00pm CNA S said she worked at the NF full time on the weekends 6am-10pm and had been in-serviced on falls. CNA S said if a resident had fall that was witnessed or un-witnessed do not move the resident and get the nurse right away to assess the resident. Interview on 09/24/2023 at 12:05pm CNA V said she worked the 6am-2pm shift and had been in-serviced on abuse a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 11 residents (Resident #1) reviewed for quality of care in that: -The facility failed to transfer Resident #1 to the hospital in a timely manner when resident had an unwitnessed fall on 09/11/2023 at 4:23 a.m. and sustained a head injury. Resident #1 was receiving Eliquis (blood thinner). Resident #1 was not transferred to the hospital until after 8:00 a.m. Resident #1 is scheduled to have surgery on 9/14/23 due to brain bleed. - The facility failed to call 911 services to transport Resident #1 to a higher level of care instead, used their non-emergency transportation to send resident to the hospital. -The NF delayed in calling the physician and sending Resident #6 to a higher level of care to be evaluated when Resident #6 had an unwitnessed fall with head injury on 08/19/2023. -The NF delayed sending CR #7 to a higher level of care when CR #7 had an unwitnessed fall on 08/19/2023 at 6:28am. CR #7 was not sent to the hospital until 12:20pm where it was discovered that CR #7 had a fractured C1 & C2 (neck region). An Immediate Jeopardy (IJ) was identified on 09/14/2023. While the IJ was removed on 09/17/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place residents that sustain a fall with head injuries on blood thinners at risk for delayed treatment that could lead to severe injury, intracranial hemorrhage and/or death. Findings Record review of Resident #1 face sheet revealed a [AGE] year-old male admitted to the NF on 12/09/2022. Resident #1 diagnoses included the following: hemiplegia (paralysis that affects one side of the body) & hemiparesis (weakness) following cerebral infarction (disrupted blood to the brain), congestive heart failure (heart does not pump blood as well as it should), atrial fibrillation (irregular heartbeat), cognitive communication deficit (impairment in an individual's mental capacity), muscle weakness, hyperlipidemia (elevated cholesterol), and hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed that resident had a BIMS score of 11(signifying mild mental impairment). Further review revealed that resident required limited assistance with bed mobility, transfer, and personal hygiene. Further review revealed that resident required supervision with dressing, eating, and toilet use. Record review of Resident #1s' Physician Orders revealed the following orders: -aspirin oral tablet 325mg give 1 tablet by mouth every 6 hours as needed for pain, order date 08/04/2023, -Eliquis oral tablet 2.5mg give 1 tablet by mouth two times a day for atrial fibrillation, order date 02/17/2023. Record review of Resident #1's MAR for the month of September 2023 revealed the resident was receiving the medication aspirin and Eliquis as ordered by the physician. Record review of Resident #1's Care Plan revealed that resident was care planned for falls dated 02/24/2023 with an intervention to determine possible causative factors and implement interventions. Further review revealed that Resident #1 was care planned for anticoagulant therapy dated 01/31/2023 with interventions that included administer medication as ordered, labs as ordered, reporting abnormal lab results, and report skin abnormalities. Record review of Resident #1's Nursing Progress Notes revealed the following: -dated 09/11/2023 documented by RN A at 5:50 am the following: .Called NF transportation for patient pick up time within 1 to 1.5 hour arrival . -dated 09/11/2023 documented by Unit Manager at 6:28a.m. .This writer making rounds, observed resident sitting in his wheelchair on the side of his bed. Noted with raised area above left eye. Resident verbal and able to express needs at this time. EMS in route for transport to ER. -documented by LVN D on 09/11/2023 at 8:08 am: .Resident left facility via EMS regular transportation with family member .swelling noted left .and skin tear to right knee .resident alert and responsive . LVN D documentation did not specify what he meant when he documented left. Record review of Resident #1's hospital records dated 09/11/2023 [AGE] year-old admitted to the emergency department form NF for fall on Eliquis. Patient reports that he was standing up whenever he slipped on his socks and fell, hitting his head. Did not lose consciousness. Complaining of neck pain and right shoulder pain. Brought to the emergency department via EMS. No interventions prior to arrival. C-collar placed on arrival to the emergency department .CT (computerized x- ray) of the head without contrast was done with the following: Intra orbital (foreign object inside of a space caused by a trauma) hemorrhage (bleeding) in the left orbit with periorbital tissue swelling and mild proptosis .mildly depressed left medial orbital wall fracture .bilateral nasal bone fracture with overlying soft tissue swelling. Further review revealed that severe spinal stenosis secondary to DISH (Diffuse idiopathic skeletal hyperostosis-condition affecting the spine). Plan is tentatively for OR (Operating Room) tomorrow. Interview on 09/13/2023 at 12:55 p.m., RN A said he worked on 09/10/2023 the 6pm-6am shift and was Resident #1's nurse. RN A said he found Resident #1 on the floor in his room at the foot of his bed laying on his right side. RN A said the time was around 4am-5am. RN A said Resident #1 told him that he was trying to transfer himself from his wheelchair to his bed. RN A said he did range of motion on Resident #1 and that he could move his extremities without complaints of pain. RN A said he initiated neuro checks. RN A said Resident #1 told him that he had hit his head. RN A said he did not see any signs of injury such as a knot on the head or any bleeding. RN A said resident was placed back in his wheelchair with the assistance of a CNA who name he could not remember. RN A said he called the family of Resident #1 as well as the doctor who gave the order to send resident to the hospital. RN A said regular transportation was called to transport resident to the hospital instead of 911 services because Resident #1's vital signs was stable, there was no bleeding, and resident was conscious. Further interview with RN A said he was not aware that Resident #1 was receiving the blood thinner Eliquis twice a day. RN A said if a resident experienced a fall with a head injury and receiving blood thinners they should be transported to the hospital immediately for further evaluation because resident could be bleeding internally. Interview on 09/13/2023 at 1:40 p.m., family member of Resident #1 said resident was still at the hospital experiencing bleeding from the brain and that the hospital said they were going to have to do surgery on the neck to relieve some pressure. The family member said Resident #1 was scheduled to have surgery on 09/14/2023 to relieve the pressure. The family member said the NF called her a little after 5:00 a.m. informing her that Resident #1 had fallen. The family member said she made it to the NF around 5:40 a.m. and that Resident #1 was complaining of pain to the right side of his neck and back, and left side of his head. The family member said Resident #1 left side of face was swelling extending to the forehead near the left eye. The family member said there was no sense of urgency to transport Resident #1 to the hospital. The family member said she went to let a male nurse know Resident #1 had swelling to his head. The family member said when the male nurse looked at Resident #1, he admitted resident had swelling to his head and told her that help was on the way. The family member said she then went to the nurse station and spoke to a female nurse asking when Resident #1 was going to be transported to the hospital. The family member said the female nurse told her that she had called transportation and was told that that they were in route to the NF. The family member said it was after 8:00 a.m. when Resident #1 left the NF on the way to the hospital. Interview on 09/13/2023 at 2:02 p.m., the Unit Manager said she worked at the NF from 8am-5pm and had been working at the NF for 11 years. The Unit Manager said on 09/11/2023 she arrived at the NF around 7:45 a.m. and began making rounds on the Hallways. The Unit Manager said she saw Resident #1's family member at the nurse station asking when the ambulance was coming to take resident to the hospital because he had experienced a fall in his room. The Unit Manager said when she arrived at Resident #1's room, resident was sitting in his room in his wheelchair. The Unit Manager said Resident #1 was not able to tell her what had happened to him. The Unit Manager said she learned that Resident #1 had fallen on the 10pm-6am shift. The Unit Manager said the nurse on the night shift (10pm-6am) had already given report to the oncoming nurse LVN D who was working the morning shift. The Unit Manger said in the event of an emergency the Nursing staff would call 911 services and not the NF transportation System (non-emergency). An attempted interview and observation on 09/14/2023 at 10:31a.m. with Resident #1 was unsuccessful due to hospital staff informing the surveyor that Resident #1 was in surgery. Interview on 09/14/2023 at 1:17 p.m., the DON said according to the Nursing Progress Notes, Resident #1 was in his wheelchair and tried to transfer on his own to his bed fell and hit his head. The DON said resident was transferred to the hospital and resident family member was with him. The DON said she soke with RN A who said Resident #1 was yelling for help. The DON said when RN A arrived at Resident #1's room, resident was on the floor reporting that he had hit his head. The DON said RN A assessed Resident #1 and done ROM on resident along with offering the resident something for pain. The DON said based on the Nursing documentation, Resident #1 was not in any pain. The DON said she learned later from the hospital that Resident #1 CT scan of the head was positive for hemorrhage. The DON said she informed the Administrator of the hospital findings, and the Administrator called the incident in to the state. The DON said the NF initiated in-service with the staff on fall precautions and abuse and neglect based on the NF policy. The DON said she was aware that Resident #1 was on a blood thinner and was transported to the hospital via the NF transportation. The DON said it was a case by case (pending on the resident (s) level of consciousness, vital signs, pain, distress, etc.) that determined if a resident is sent out by normal transportation or 911 services. The DON said the NF transportation could take up to 1- 2 hours to transport a resident to the hospital. The DON said she was aware that it took the NF almost 4 hours to send resident to higher level of care. The DON said she could not say if the course of action taken regarding Resident #1's unwitnessed fall with a head injury receiving blood thinners was the right course of action and again that it was a case-by-case situation. The surveyor asked the DON what was the NF policy regarding a resident on blood thinners experiencing a fall with head injuries? The DON said she did not know what the NF policy was on falls with head injuries in relation to residents taking anticoagulants/blood thinners and would have to go read it. Further interview with the DON said the NF did not have a policy regarding falls as it relates to blood thinners. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift full time. LVN D said RN A gave her report on 09/11/2023 at 6:30 a.m. LVN D said RN A reported that Resident #1 had fallen in his room. LVN D said she asked RN A if he had called 911 services and RN A said no. LVN D said when she assessed Resident #1, the resident's left eye was swollen, and he had a skin tear to his right knee. LVN D said Resident #1 could not tell her exactly what had happened just that he had fallen on the floor. Resident #6 Record review of Resident #6 face sheet revealed an [AGE] year-old male admitted to the NF on 05/01/2019 with the following diagnoses that included: nontraumatic subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain-08/25/2023), cerebral infarction (disruption of blood flow to the brain, Parkinson's Disease (disorder that effects movement), contracture (shortening and hardening of the muscles), history of falling, heart failure, hypertension (high blood pressure), hypotension (low blood pressure), dementia (impairment of the brain causing memory loss and judgement), and metabolic encephalopathy (disorder of the brain caused by a chemical imbalance in the blood). Record review of Resident #6's MDS dated [DATE] revealed that resident had a BIMS score of 2 indicating that resident cognition level was severely impaired. Further review revealed that Resident #6 required extensive assistance with bed mobility, transfer, dressing, eating, and total assistance with toileting and personal hygiene. Record review of Resident #6's Care Plan dated 02/24/2023, revealed that resident was being care planned for falls related to poor balance dated 07/04/2023 with an intervention that included keep resident on visible area for close monitor. Record review of Resident #6's Nursing Progress Notes dated 08/19/2023 documented by LVN M at 5:21p.m., revealed in part: .Resident observed on the floor at the top of the 200 hallway. He is observed face down on the floor, in front of his wheelchair. He was assessed for injuries and pain, then assisted back into his wheelchair x 3 staff. He is noted with a small amount of running, bright red blood coming out of his nose, nose pinched together for a few seconds, bleeding stopped, no visible injuries noted. Family member arrived shortly afterward and were informed of the incident and requested an ice pack to apply to his nose. A few minutes later, family member requested would like for resident be transported to the hospital to have a CT SCAN. Regular EMS phoned to transport resident to hospital .5:53pm regular transportation here to transport resident to the hospital per family request . Record review of Resident #6 hospital records dated 08/19/2023 indicated that a CT of the head was done with the following impression: right frontal contusion (injured skin or tissue where blood vessels have burst suddenly) .small volume subarachnoid hemorrhage . Record review of the NF investigation report dated 09/11/2023revealed that Resident #6's CT scan at the hospital showed that resident had a displaced fracture in the right frontal calvarium (skull) with extension into the right orbital (bony space that contains the eyeball) roof. Interview on 09/19/2023 at 1:27 p.m., the RP of Resident #6 said she did not receive a call from the NF regarding resident fall. The RP said when she arrived at the NF, resident had redness, bruising, and swelling to the side of his eye, could not remember which eye it was. The RP said she had to request that Resident #6 be sent out to the hospital. The RP said it took the NF about 30 minutes to transport resident to the hospital. Interview on 09/19/2023 at 2:32 p.m., LVN M said she worked at the NF on weekends part time 6am-6pm shift. LVM M said on 08/19/2023 she was called by RN N telling her that Resident #6 was on the floor and that resident had been placed back in his wheelchair. LVN M said when she saw resident, he was sitting in his wheelchair with blood on the side of his nose as well as on the outside of his nose. LVN M said she pinched resident nostrils and cleaned it with a wet towel and the bleeding stopped. LVN M said she assessed resident for injuries and initiated neuro checks on resident. LVN M said she called the RP and the doctor. LVN M said the RP wanted to send resident out to the hospital. LVN M told the surveyor what all took place around Resident #6 fall on 08/19/2023 was documented in the nurse's notes. LVN M said the last time she received in-service on falls was last week but could not remember the last time she received in- services on unwitnessed falls. Interview on 09/19/2023 at 7:17 p.m., RN N said he observed Resident #6 on hall 200 near his room in the hallway close to the nurse station. RN N said resident was sitting in his wheelchair bleeding from his nostrils with LVN and a CNA standing around resident. RN N said he was trying to stop the bleeding coming from resident nostrils which he was able to stop the bleeding. RN N said Resident #6 was not complaining of pain, but his words were not clear, and that resident spoke in allow tone. RN N said he did not notify the doctor. RN N said he assumed that the primary care nurse called the doctor and the RP. Resident CR #7 Record review of CR #7's face sheet revealed a [AGE] year-old female admitted to the NF on 12/08/2021 diagnoses that included the following: Alzheimer's Disease, nontraumatic subarachnoid hemorrhage from right middle cerebral artery, encephalopathy (brain disease that alters the brain function), dementia (loss of memory and judgement), insomnia (difficulty falling asleep), hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), rheumatoid arthritis(Disorder affecting many joints including the hands and feet), and muscle weakness. Record review of CR #7's x-ray of the spine cervical 2-3 views dated 02/27/2023 impression revealed: mild arthritis and loss of the normal cervical lordosis (condition that pushes the neck further forward than it should be or usually is). Record review of CR #7's MDS dated [DATE] revealed that CR #7 had BIMS score of 5 indicating that CR #7's cognition was severely impaired. Further review revealed that CR #7 required supervision with bed mobility, transfer, eating, and toilet use. Further review revealed that CR #7 required limited assistance with dressing and personal hygiene. Record review of CR #7's Care Plan dated 12/15/2021 and revised 08/28/2023 revealed that resident was being care planned for falls and having an actual fall on 08/19/2023 and revised 08/28/2023 with an intervention that included the following: observe/document/report to MD as needed for s/sx (signs and symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Further record of CR #7's Care Plan did not reveal that CR #7 was being care planned for or loss of the normal cervical lordosis. Record review of CR #7's Nursing Progress Notes revealed in part: Documented by LVN G on 08/19/2023 at 6:28am .Resident noted lying on floor with blanket and pillow. When asked why she was on the floor, resident replied I am tired and want to sleep here .Resident educated to sleep in bed and not on floor. Resident assisted from floor to bed via staff .Resident resting quietly . Documented by LVN O on 08/19/2023 at 10:24 a.m., revealed in part: .Resident reported to this nurse that she fell on the floor during 10pm-6am shift. Resident is complaining of neck pain, bruises also noted on the left elbow. Resident also reported biting her tongue. NP in the building and notified . At 10:34 a.m. New order for X-ray left elbow, radius and humerus, left shoulder. X-ray called with the x-ray order . Documented by the DON dated 08/19/2023 at 10:52am revealed in part: .Resident was found sleep on the floor next to her bed .now she is complaining of pain .The NP at the facility give new order for place C-collar (cervical/neck brace) send to hospital for fall and c/o neck pain do not move pt/or stand . Documented by LVN O on 09/18/2023 at 12:20pm revealed in part: 911 call placed, EMS and transferred resident to the hospital .C collar in place . Record review of the NF Investigation report dated 08/19/2023 revealed that CR #7 was observed laying on floor, complained of pain, sent to the hospital and MRI revealed that that CR #7 had mildly displaced acute fractures of the anterior arch of C1 and C2. Interview on 09/14/2023 at 10:54 a.m., the hospital staff RNZZ said CR #7 was admitted to the hospital with a cervical fracture on 08/19/2023. RN ZZ said CR #7 was transferred to SICU and later to hospice services. RN ZZ said CR #7 passed away on 08/29/2023. Interview on 09/14/2023 at 12:20 p.m., the Administrator said CR #7 had a fall and was sent to the hospital. The Administrator said it was discovered at the hospital that CR #7 had a neck fracture. The Administrator said while CR #7 was at the hospital she developed pneumonia as well. The Administrator said CR #7 had been placed on in-patient hospice. Interview on 09/18/2023 at 11:23 a.m., LVN G said she worked on 08/19/2023 on the 10pm-6am shift. LVN G said when she arrived at work, CR #7 was sitting in her wheelchair at the front entrance and did not agree to go to bed until 3:00 a.m. LVN G said she made rounds on the residents around 5:00 a.m. and that CR #7 was resting in bed. LVN G said she made her last rounds on the residents at 6:00 a.m., and when she arrived at CR #7's room, CR #7 was on the floor on the left side of her bed wrapped in a blanket with a pillow resting under her head. LVN G said CR #7 said she wanted to lay on the floor. LVN G said she told CR #7 no and that she needed to get back in the bed. LVN G said she checked CR #7 for range of motion with no complaints of discomfort. LVN G said she called for help and that. LVN H with the assistance of the CNA, CR #7 was put back in bed. LVN G said she had been working at the NF for 3 years but practicing as a nurse for 7 months. LVN G said when a resident with confusion was found on the floor and no one know what happened, the course of action to take was to do range of motion assessing for pain. LVN G said she did not do a complete head to toe skin assessment before placing CR #7 back in bed. LVN G said she had been in- serviced on falls and that it was okay to move a resident with an unwitnessed fall after assessing their range of motion. LVN G said it was okay to move a resident that was conscious but not a resident that was unconscious. LVN G said she was not aware of the NF policy on un-witnessed falls. LVN G said she was just trying to keep CR #7 comfortable. LVN G said it was not normal behavior for CR #7 to lay on the floor. Interview on 09/18/2023 at 12:55 p.m., LVN O said she worked the weekend shift 6am-10pm and was the nurse that relieved LVN G on 08/19/2023. LVN O said she had received in report from LVN G letting her know that CR #7 was found on the floor with no injuries and that LVN G had initiated neuro checks. LVN O said when she arrived at CR #7 room, CR #7 was in bed and denied pain. LVN O said she continued the neuro checks per facility protocol and that when she returned to CR #7 room again, CR #7 was complaining of elbow pain. LVN O said she could not remember which elbow it was but noticed a little red bruise to the elbow. LVN O said at this time (could not remember the time), the NP was at the NF. LVN O said later, CR #7 started to complain of pain to her neck. LVN O said the NP assessed CR #7 asking resident to turn her neck, but CR #7 was unable to turn her neck. LVN O said the NP gave orders to place a C collar on resident neck and send to the hospital. Further interview on 09/18/2023 at 12:55 p.m., LVN O said she had been in- serviced on falls to check the resident status of orientation, if confused do not move the resident because resident may have injured themselves. LVN O said resident would be sent to the hospital for further evaluation. Interview on 09/18/2023 at 1:35 p.m., LVN H said she worked the night shift 10pm- 6am full time. LVN H said when CR #7 was found on floor in her room with pillow under head, she assisted LVN G along with the CNA in placing CR #7 back in bed. LVN H said CR #7 did not complain of pain. LVN G said the doctor and RP needed to be notified immediately about a fall witnessed or unwitnessed. Interview on 09/19/2023 at 11:10 a.m., CNA Q said she worked the 10pm-6am shift and was the CAN for CR #7. CNA Q said she was coming up the hallway around 5:45am-6:00am making her last rounds on the resident when she saw the nurse in CR #7 room. CNA Q said when she arrived at CR #7's room, CR #7 was on the floor with her bed in the. CNA Q said CR #7 was asked where she was going but CR #7 could not say. CNA Q said resident was not complaining of pain. CNA Q said right after she assisted with placing CR #7 back in bed, CR #7 began to complain of pain saying that her neck hurt. Record review of the NF Policy on Falls revised September 2012 revealed in part: .The physician will identify medical conditions affecting fall risk and the risk for significant complications of falls ( .increased risk of bleeding in someone taking an anticoagulant) . Record review of the NF Policy on Anticoagulation revised April 2007 revealed in part: The staff and physician will identify and address potential complications in individuals receiving anticoagulation; for example, someone with a fall risk . The Administrator and DON was notified on 09/14/2023 at 1:56 p.m., an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 09/14/2023 at 1:56 P.M. and a Plan or Removal (POR) was requested. The facility POR was accepted on 09/15/2023 at 10:14a.m. and indicated: PLAN OF REMOVAL F684 Name of facility: Park Manor Cypress Station Date: 09/14/2023 Immediate Action Impact Statement: On 9/14/23 an abbreviated survey was initiated at Park Manor of Cypress Station at 420 Lantern Bend Dr, Houston, Texas 77090. On 9/14/23 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy to resident health due to failure to ensure that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and resident choice. How were other residents at risk to be affected by this deficient practice identified? The facility completed an audit to address all falls in residents on blood thinners in the last 30 days to ensure the residents received treatment and care in accordance with professional standard of practice. All residents on blood thinners that had a fall have the potential to be affected by this deficient practice, no other residents were identified as being affected. What corrective actions have been implemented for the identified resident? Resident with deficient practice was discharged to hospital on 9/11/2023. Nurse on duty received 1:1 in-service on falls in residents receiving anticoagulant medications. What corrective actions were taken? 1. The following actions were initiated immediately on 9/14/23 a. On 9/14/23 an audit was completed by CSD (Clinical Services Director) and/or designee to identify all residents on anticoagulants who had a fall in the last 30 days to ensure these residents received treatment and care in accordance with professional standard of practice. No residents were identified to be affected by deficient practice. b. Director of Nursing was educated on 9/14/23 by Clinical Services Director on process of care for residents on anticoagulants when experience a fall with head injury are sent to a higher level of care for further evaluation via 911 based on resident assessment by licensed nurse. a) Initiated in-services on 9/14/23 with licensed nurses by Director of Nursing /Designee to send residents that are on anticoagulant medications and sustain a head injury to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse. Completed by 9/15/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed. 2. How will the system be monitored to ensure compliance? b) The Director of Nurses/Administrator will review falls in morning meeting starting on 9/15/23 and ongoing to ensure falls on residents taking anticoagulant medications are appropriately addressed. Any identified concerns will be addressed immediately, and additional training will be provided as needed. c) The weekend supervisor and/or designee was in-serviced on 9/14/23 by Director of Nursing/ Designee on identifying all residents experiencing falls on Saturdays and Sundays and ensure that any resident on anticoagulant medication that experiences a fall with head injury are sent to a higher level of care via 911 based on resident assessment by licensed nurse. d) Newly hired staff and PRN staff will be educated by the Director of Nursing/Designee on residents taking blood thinners that sustain a head injury are sent to a higher level of care for further evaluation care via 911 based on resident assessment by licensed nurse. Completed by 9/15/2023. Staff unable to come to receive education will not be allowed to provide direct care until training is completed. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 9/14/23 with the Medical Director. The Medical Director has reviewed and agrees with this plan that includes the Fall Policy updated with residents on anticoagulant medications will be send via 911 transport based on license nurse assessment. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 09/15/2023 at 12:11 p.m., LVN C who worked the morning shift 6am-2p.m. said she received in-service on falls with head injuries. LVN C said if a resident had a fall with head injuries, she was to call 911 to transport resident to the hospital to be further evaluated. Interview on 09/15/2023 at 12:14 p.m., LVN B who worked the morning shift 6am-p.m. said she had been in-serviced on the following: fall precautions and the new protocol that if resident had a fall with head injuries and on blood thinners, the resident had to be sent to a higher level of care to be further evaluated. LVN B said if the resident denied pain after the fall to continue doing neuro checks per NF protocol. LVN B said if the resident began to show a change in condition with the neuro checks, she was to call the physician and the RP. Interview on 09/15/2023 at 12:22 p.m., LVN D said she worked the morning shift 6am-2pl time. LVN D said she had been in-serviced on that when a resident experience a fall with head injuries and on blood thinners, she had to send resident to the hospital via 911 services. Interview on 09/15/2023 at 4:52 p.m., LVN E said she worked the 2pm-10pm shift full time Monday through Friday. LVN E said she had been in-serviced on falls. LVN E said if a resident fell with head injuries and was taking blood thinners, that resident had to be sent to the hospital via 911 services. Interview on 09/15/2023 at 4:55 p.m., RN F said she worked the 2pm-10pm shift full time. RN F said she had been in-serviced on falls. RN F said if a resident had fallen and hit their head and was taking blood thinners, the resident had to be transported to the hospital via 911 services[TRUNCATED]