**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision/assistance to prevent accidents for one (Resident #24) of four residents reviewed for accidents. The facility failed to ensure Resident #24 was free of accident hazard when HA (non-certified) C transferred Resident #24, without any assistance, for toileting. On [DATE] HA C transferred and toileted Resident #24 without any assistance. When transferring the resident from the toilet to the wheelchair, HA C heard a loud pop sound and the resident was not able to stand. The HA C lowered the resident to the floor. As a result of the transfer, Resident #24 sustained a fracture of left femur. Resident #24 required a surgical intervention. Resident #24 was required to be non weight bearing and have brace to the left leg after the incident. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:30 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm because the facility was still monitoring the effectiveness of the plan of removal. This failure could place residents at risk for accidents and harm. Findings included: Record review of Resident #24's Comprehensive MDS assessment dated [DATE] reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (damage to the brain from interruption of its blood supply), dysphagia (A condition that affects the ability to produce and understand spoken language), and hemiplegia and hemiparesis (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Resident #24's BIMS was 15, which indicated her cognition was intact. The MDS assessment indicated Resident #24 required extensive assistance of one-person physical assistance with transfer, and personal hygiene. GG functional section reflected the resident required substantial /maximal assistance with toilet transfer. Record review of Resident #24 care plan dated [DATE] reflected: Focus: Fall - [Resident #24] has the potential for falls related to . Gait/balance. Goal: The resident will be free of falls through the next review date. Interventions: Transfers with assist of 2 staff. Review of the Provider Investigation report for Resident #24 dated [DATE] reflected, .Incident date [DATE] at 8:30 PM .description of incident .Resident was being transferred by a non-certified aide and sustained an injury.Nurse assessed resident and noticed evidence of fracture. Resident was transported to hospital by EMS . HA C was suspended. MD and RP notified. Safe survey completed. In-service regarding abuse and neglect and fall prevention .Skin assessment performed on all resident who are unable to be interviewed. Staff educated regarding transfers . Review of the Nurses Notes for Resident #24 completed by LVN D and dated [DATE] reflected, . I was called to her room and found her lying in the bathroom floor. HA C stated she was transferring her back to wheelchair when there was a loud pop and she wasn't able to stand, HA C then lowered her to floor and got me. Left leg and foot were turned inward. Action: I notified DON and Doctor . Resident was transferred to the hospital . Review of Resident #24's hospital records, dated [DATE], reflected the following: .Female who presented to the emergency department from nursing home after a fall which occurred at the skilled nursing facility. She stated that she was using the commode when her left leg gave way and she fell. She began to experience pain in the left leg. She had imaging studies done at the local emergency department which revealed a complex comminuted fracture of the distal femur with mild displacement. She was therefore sent here for further management. Pre operation diagnoses: Left extra-articular distal femur fracture. Procedure: Intramedullary nailing of left distal femur fracture. During the course of the patient's operation, surgical assistance was provided. Record review of Resident #56's Quarterly MDS assessment dated [DATE] reflected Resident #56 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, elevated blood pressure, and osteoarthritis. Resident #56's BIMS score was 15, which indicated his cognition was intact. In an interview on [DATE] at 9:25 AM, Resident #56 (Resident #24's Family Member living with Resident #24 in the same room), stated on [DATE] HA C assisted Resident #24 to the toilet without help of another staff. He stated usually 2 staff helped Resident #24 with transfer. Resident #56 stated HA C went in to help Resident #24 get off the toilet. When she helped get her up and turned her to the wheelchair for the transfer, her knees gave out and there was a loud pop as she was lowered to the ground. Resident #56 stated he yelled for help and the nurse and other staff came in for help, somebody called the ambulance and Resident #24 was sent to the hospital. In an interview on [DATE] at 9:30 AM, Resident #24 stated HA C dropped her on the floor in the toilet. Resident #24 stated usually 2 people transferred her before and after the incident of [DATE]. In an interview on [DATE] at 2:42 PM, LVN D stated she was working the evening of the incident when she heard Resident #24's Family Member calling for help in the room. LVN D stated when she walked in, the resident's leg was turned outward and looked to be broken. LVN D stated she assessed the resident. Another staff called the 911. Resident #24 was transferred to the hospital. LVN D stated Resident #24 is 2 persons assist with transfer. LVN D stated hospitality aides were not allowed to transfer residents. In an interview on [DATE] at 3:17 PM, HA C stated on [DATE] at approximately 9 PM she reported to Resident #24's room, resident needed to go to the restroom. HA C stated she assisted Resident #24 to the toilet. When transferring the resident from toilet back to wheelchair, resident used grab bars to assist in standing up, HA C assisted resident with pulling up pants, in the middle of turning the resident's left knee buckled, HA C instructed the resident to try and stand up. Resident #24 reported she could not. HA C stated she heard a loud pop and assisted resident to the floor. Resident #56 called for assistance, the nurse and staff member reported to resident's room. HA C confirmed she was not a CNA (her certificate was expired since 2014), and stated she had to work with a certified nurse aide on the floor at all times. At the time of this interview HA C stated she had received an in-service on transfers of Resident #24 after the fall occurred on the evening of [DATE]. HA C stated she assisted Resident #24 to the toilet without assistance because the CNA was break. She stated she supposed to call the nurse because Resident #24 needed 2 persons for transfer. She stated she never transferred Resident #24 before, because as a HA she was not allowed to transfer Resident #24 or any other resident. In an interview with the DON on [DATE] at 3:30 PM, he stated hospitality aides were not allowed to provide any direct care to residents. He stated HA C should not transfer Resident #24. He stated if the CNA was not available the HA C should notify the nurse about Resident #24 needs. He stated hospitality aides were in-serviced on job description up on hire. The DON did not provide the in-service on job description for HA C to the surveyor. The DON stated Resident #24 was 2 persons assist with transfer. The DON stated the amount of assistance needed by a resident would be reflected in the [NAME] system for nursing staff. The surveyor asked if the care plan populated the [NAME] because the [NAME] did not show before and after the incident that Resident #24 was a two-person assist for transfer. The DON stated he was, and the ADONs, responsible to oversee the care plans for updates and the [NAME] to reflect the care plans. The DON stated charge nurses, ADONs himself did routine rounds to monitor to ensure transfers were being done appropriately. Record review of the facility's policy Transfers of Residents dated [DATE], reflected Transfers are defined as the act of moving a resident from one surface such as from the bed to the wheelchair or from the from the wheelchair to the toilet. The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident. Record review of the facility's policy titled Abuse, Neglect and Exploitation dated [DATE], reflected, .Neglect - means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of the facility's policy titled Comprehensive Care Plans, dated [DATE] reflected, .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Record review of the facility's job description for a Hospitality Aide revised on [DATE] revealed: . Responsible for providing resident related (no-hands-on) care in accordance with quality standards under the direction of a licensed charge nurse. The position is applicable prior to successfully receiving certification as a nursing assistant. Performs host/hostess type duties in accordance with accepted standards of non-hands-on resident care. Uses daily task assignments. Assist residents that are independent and residents that require minimal or supervision support with activities of daily living, set up bed bath and rinse and soap wash cloth handing to patient. Lay out clothes, hold clothes in position patient can dress self, button clothes, pull up pants, changes unoccupied bed linens, answers call lights assist within skill level, passing and serving water. Assists with resident's recreation programs and transports residents in wheelchairs. Labels personal care items. Keeps resident rooms tidy. Maintains clothing inventory. Reports changes of resident condition to nurse in charge, reports accidents and incidents, and provides support functions as directed by supervisor. The facility administrator was notified on [DATE] at 12:30 PM that an Immediate Jeopardy situation had been identified due to the above failures. IJ template provided at this time and a Plan of Removal was requested. The facility's plan of removal was accepted on [DATE] at 6:05 PM and included: 1.On [DATE] resident # 24 was immediately sent the emergency room. 2.On [DATE] the hospitality aide involved in this incident was suspended until further notice 3.On [DATE] the DON/Designee completed the investigation on incident involving resident # 24. 4. On [DATE] at 12:30 pm, the Regional Nurse Consultant provided in-service education with the DON on Job descriptions to include Hospitality Aides job duties, and Certified Aide job duties This was completed on [DATE]. The Regional Nurse Consultant will provide oversight on this process weekly x 4 weeks. 5. On [DATE] at 1:00 pm, the DON/Designee began in-service education with all clinical staff on Job descriptions to include Hospitality Aides job duties, and Certified Aide job duties to validate that each Aide had clear understanding of what was in their scope and practice. This was completed on [DATE] and no clinical staff will be allowed to work until this education has been completed. 6. On [DATE] the DON/Designee began in-service education with individual hospitality aides on their specific job duties and had the individual sign a new job description. This was completed on [DATE] either directly or by phone. This education included that at any time, a hospitality aide is performing care that is not in their job description, the DON/Administrator will be notified immediately, and staff will be asked to leave facility. This was completed on [DATE]. 7. On [DATE] at 12:30 pm, the Regional Nurse Consultant provided in-service education with the DON/Designee on transfers which guides staff on how to properly and safely transfer residents according to their plan of care and type of device if needed. This was completed on [DATE] at 1:00 pm. The Regional Nurse Consultant will provide oversight on this process weekly x 4 weeks. 8. On [DATE] at 2:00 pm the DON/Designee began in-service education with all clinical staff on transfers which guides staff on how to properly and safely transfer residents according to their plan of care and type of device if needed this included skills competency on Transfers (Hoyer and gait belts). This was completed on [DATE] and no staff will be allowed to work until this education has been completed. DON/Designee will complete weekly hoyer skills validations and gait belt skills validation on 5 C.N.A. weekly, rotation shifts x 90 days. The Regional Nurse consultant will provide oversight for this process and will review monthly. 9. On [DATE] at 12:30 pm, the Regional Nurse Consultant provided in-service education with the DON/Designee On use of PCC [NAME] to determine type and amount care residents require, including reporting to Charge Nurse if ADLS are not present and or accurate on [NAME]. This was completed at completed on [DATE]. The Regional Nurse Consultant will provide oversight on this process weekly x 4 weeks. 10. On [DATE] at 1:00 pm the DON/Designee began in-service education with all clinical staff on use of PCC [NAME] to determine type and amount care residents require, including reporting to Charge Nurse if ADLS are not present and or accurate on [NAME]. This was completed on [DATE], and no clinical staff will be allowed to work until this education has been completed. 11. On [DATE] the Regional Nurse Consultant provided 1:1 education to the Center's DON and two ADONS on care plans that they are responsible to review all incident reports including falls, updating care plan with appropriate interventions for each fall and make sure interventions are appropriate, ensuring timely completion and that interventions are reflective on [NAME]. This was completed on [DATE]. 12. On [DATE] the facility conducted and Ad Hoc QAPI meeting to discuss Incidents/Accidents and Hazards and on sustaining compliance. On [DATE], the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observation on [DATE] at 11:15 AM CNA G and CNA K transferred Resident #24 from bed to wheelchair, using the gait belt. Observation on [DATE] at 10:15 AM ADON A transferred Resident #9 from bed to wheelchair, using the gait belt. Record review of in-service reflected the Regional Nurse Consultant provided: - On [DATE] 1:1 education to the DON on the Incident/Accident Policy to include report and investigate all incident and accidents that occur in the facility in a timely manner, including appropriate interventions, updating care plans with appropriate interventions related to falls. - On [DATE] education with the DON on job descriptions to include Hospitality Aides job duties and Certified Aide job duties. - On [DATE] education with the ADONs and the DON on care plans that they are responsible to review all incident reports including falls, updating care plan with appropriate interventions for each fall and make sure interventions are appropriate, ensuring timely completion and that interventions are reflective on [NAME]. Record review of in-service reflected DON or designee provided: - On [DATE] education with all clinical staff on job descriptions to include Hospitality Aides job duties and Certified Aide job duties. - On [DATE] education with individual hospitality aides on their specific job duties and had the individual sign a new job description. - On [DATE] education with all clinical staff on transfers which guides staff on how to properly and safely transfer residents according to their plan of care and type of device if needed. - On [DATE] education with all clinical staff on use of PCC [NAME] to determine type and amount care residents require, including reporting to charge nurse if ADLS are not present and or accurate on [NAME]. Interviews conducted on [DATE] from 11:03 AM to 3:30 PM with 4 nurses (LVN M, LVN O, LVN Q, and LVN U), 6 hospitality aides (HA N, HA P, HA R, HA S, HA T, HA V), and 6 CNAs (CNA CC, CNA FF, CNA HH, CNA EE, CNA GG, and CNA KK) which represented all shifts revealed they had been in-serviced on abuse and neglect, they would check the [NAME] system or ask their nurse to determine what level of care a resident required. Review of in-service records revealed they had been in serviced on the use of the [NAME]/Plan of Care system and on transfers. Interviews with nursing management staff on [DATE] between 5:16 PM and 5:26 PM included ADON A and ADON B, revealed they had been in-serviced on neglect, resident transfer types and where to locate a resident's transfer status in the [NAME], which came from the care plan. Interview on [DATE] at 5:35 PM with the MDS Coordinator revealed she had been in-serviced on her job responsibilities as MDS Coordinator which included the different types of MDS's including comprehensive, annual, quarterly, and significant change. She stated that the MDS's trigger the care plan and [NAME]. She stated that any acute changes are care planned and addressed in morning meeting with the interdisciplinary team, Monday through Friday. Interview on [DATE] at 5:00 PM with Regional Nurse Consultant revealed there were only 9 residents that needed an updated [NAME]. Record review on [DATE] at 5:53 PM of 10 residents (Resident #3, #24, #6, #16, #33, #34, #36, #42, #54, and #58) [NAME]'s reflected their transfer status matched their MDS. Interview on [DATE] at 6:02 PM with the DON revealed he had been in-serviced on care plans and updating acute and comprehensive care plans including falls, fractures, and transfer assistance level. Interview on [DATE] at 6:15 PM with the Administrator revealed during morning meetings they will care plan immediately any resident changes including falls, fractures, and transfers assistance changes. She stated the DON was responsible for acute and comprehensive care plans. She stated the MDS Coordinator was responsible for quarterly and change of condition care plans were completely. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 6:30 PM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 2 (Resident #9 and #24) of 24 residents reviewed for care plans. 1. The facility failed to develop and implement a comprehensive care plan for Resident #24 to address the left femur fracture sustained on [DATE] and current transfer status. 2. The facility failed to update Resident #24's Kardex (a brief digital overview of the resident's needs) to reflect she required 2 people to transfer her. As a result, the resident was transferred on [DATE] by a hospitality aide. Resident #24 was sent to the hospital and sustained a femur fracture. 3. The facility failed to develop a comprehensive care plan for Resident #9 to address her non-compliance with asking for assistance with transfers and failed to follow Resident #9 transfer status. As a result, staff were not aware of the transfer status of Resident #9 and she experienced an unwitnessed fall on [DATE], [DATE], and [DATE]. 4. The facility failed to update Resident #9's care plan to address the nasal bone fracture on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:30 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm because all staff had not been trained comprehensive care plans These failures could place residents at risk for not receiving care required to meet their individualized needs and place them at risk for falls and injury. Findings included: Resident #24 Record review of Resident #24's Comprehensive MDS assessment dated [DATE] reflected Resident #24 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction (damage to the brain from interruption of its blood supply), dysphagia (difficulty swallowing), and hemiplegia and hemiparesis (partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Resident #24's BIMS was 15, which indicated her cognition was intact. The MDS assessment indicated Resident #24 required extensive assistance of one-person physical assistance with transfer, and personal hygiene. GG functional section reflected the resident required substantial /maximal assistance with toilet transfer. Record review of Resident #24 care plan dated [DATE] reflected: Focus: Fall - [Resident #24] has the potential for falls related to . Gait/balance. Goal: The resident will be free of falls through the next review date. Interventions: Transfers with assist of 2 staff. Record review of the Post-Fall Risk assessment dated [DATE] revealed Change in Functional Ability . New Interventions: 2 persons lift with Hoyer. Review of the Provider Investigation report, dated [DATE], for Resident #24 reflected, .Incident date [DATE] at 8:30 PM .description of incident .Resident was being transferred by a non-certified aide and sustained an injury.Nurse assessed resident and noticed evidence of fracture. Resident was transported to hospital by EMS . HA C was suspended. MD and RP notified. Safe survey completed. In-service regarding abuse and neglect and fall prevention .Skin assessment performed on all resident who are unable to be interviewed. Staff educated regarding transfers . Review of the Nurses Notes completed by LVN D and dated [DATE] reflected, . I was called to her room and found her lying in the bathroom floor. HA C stated she was transferring her back to wheelchair when there was a loud pop and she wasn't able to stand, HA C then lowered her to floor and got me. Left leg and foot were turned inward. Action: I notified DON and Doctor. Resident was transferred to the hospital . Review of Resident #24's hospital records, dated [DATE], reflected the following: .Female who presented to the emergency department from nursing home after a fall which occurred at the skilled nursing facility. She stated that she was using the commode when her left leg gave way and she fell. She began to experience pain in the left leg. She had imaging studies done at the local emergency department which revealed a complex comminuted fracture of the distal femur with mild displacement. She was therefore sent here for further management. Pre operation diagnoses: Left extra-articular distal femur fracture. Procedure: Intramedullary nailing of left distal femur fracture. During the course of the patient's operation, surgical assistance was provided. Record review of Resident #24's care plan dated [DATE] did not reflect the fall with the facture and did not reflect the new intervention of 2 persons lift with Hoyer. Record review of Resident #24's MDS Kardex report, dated [DATE], revealed Resident Care . Transfers: Extensive 1 staff . Toileting: Extensive assist 1 staff. In an interview on [DATE] at 9:25 AM, with Resident #56 revealed he was in Resident #24's room during the incident on [DATE]. He stated HA C assisted Resident #24 to the toilet without help of another staff. He stated usually 2 staff helped Resident #24 with transfer. Resident #56 stated HA C went in to help Resident #24 get off the toilet. When she helped get her up and turned her to the wheelchair for the transfer, her knees gave out and there was a loud pop as she was lowered to the ground. Resident #56 stated he yelled for help and the nurse and other staff came in for help, somebody called the ambulance and Resident #24 was sent to the hospital. In an interview on [DATE] at 9:30 AM, Resident #24 stated HA C dropped her on the floor in the toilet. In an interview on [DATE] at 2:42 PM, LVN D stated she was working the evening of the incident when she heard Resident #24's Family Member calling for help in the room. LVN D stated when she walked in, the resident's leg was turned outward and looked to be broken. LVN D stated she assessed the resident. Another staff called the 911. Resident #24 was transferred to the hospital. LVN D stated Resident #24 is 2 persons assist with transfer. LVN D stated hospitality aides were not allowed to transfer residents. In an interview on [DATE] at 3:17 PM, HA C stated on [DATE] at approximately 9 PM she reported to Resident #24's room, resident needed to go to the restroom. HA C stated she assisted Resident #24 to the toilet because the CNA was on break. HA C stated she was able to access the Kardex. When transferring the resident from toilet back to wheelchair, resident used grab bars to assist in standing up, HA C assisted resident with pulling up pants, in the middle of turning the resident's left knee buckled, HA C instructed the resident to try and stand up. Resident #24 reported she could not. HA C stated she heard a loud pop and assisted resident to the floor. Resident #56 called for assistance, the nurse and staff member reported to resident's room. HA C confirmed she was not a CNA (her certificate was expired since 2014), and stated she had to work with a certified nurse aide on the floor at all times. At the time of this interview HA C stated she had received an in-service on transfers of Resident #24 after the fall occurred on the evening of [DATE]. HA C stated she assisted Resident #24 to the toilet without assistance because the CNA was break. In an interview with the DON on [DATE] at 3:30 PM, he stated hospitality aides were not allowed to provide any direct care to residents. He stated HA C should not transfer Resident #24. He stated hospitality aides were in-serviced on job description up on hire. The DON did not provide the in-service on job description for HA C to the surveyor. The DON stated Resident #24 was 2 persons assist with transfer. The DON stated the amount of assistance needed by a resident would be reflected in the Kardex system for nursing staff. The surveyor asked if the care plan populated the Kardex because the Kardex did not show before and after the incident that Resident #24 was a two-person assist for transfer. The DON did not provide any answer. The DON stated he was, and the ADONs, responsible to oversee the care plans for updates and the Kardex to reflect the care plans. Resident #9 Record review of Resident #9's face sheet, printed date [DATE], revealed she was a [AGE] year-old female initially admitted on [DATE], and readmitted on [DATE] with diagnoses of fracture of nasal bones, metabolic encephalopathy (metabolic disorder), sepsis (life threatening complication of infection), muscle weakness, repeated falls, type-2 diabetes (high blood sugar), congestive heart failure, major depressive disorder (persistent feelings of sadness or loss of interest), chronic obstructive pulmonary disease (lung disease causing restricted airflow), and anxiety disorder (persistent feelings of worry or fear). Record review of Resident #9's Quarterly MDS, dated [DATE], revealed she required partial/moderate assistance for transfers, and she had a BIMS score of 15 (intact cognition). Review of Resident #9's MDS Kardex report, undated, revealed she required setup help and supervision for transfers and was not steady when moving from seated to standing, moving on and off the toilet, or with surface-to-surface transfers and the section for accidents and fall risk was blank. Review of Resident #9's care plan revealed there were functional limitations in range of motion or decreased mobility, impaired balance and impaired coordination, dated initiated and revised on [DATE]. Interventions included her transfer status was limited x 1 dated initiated [DATE] and revised [DATE]. Review revealed Resident #9 had the potential for falls related to incontinence, gait/balance problems and was unaware of safety needs, dated initiated [DATE] and revised on [DATE]. Interventions included educate resident to let staff know when she was going to the bathroom so they could check on her date initiated, [DATE]; medication review to be performed by psych for fall eval, dated initiated [DATE]; Resident #9's care plan did not reflect she had a fall on [DATE], [DATE] with fracture, or [DATE]. Review of the incident report dated [DATE] at 9:40 PM, completed by LVN U, revealed Resident #9 had an unwitnessed fall. Resident #9 was found sitting on the floor in the bathroom and stated she had fallen asleep on the toilet and then had fallen and bumped her head and left shoulder on the wall and floor. LVN U assessed Resident #9 for injuries and there were none observed, range of motion was normal, she complained of pain to her left shoulder, displayed no visual signs of pain, and was assisted into her wheelchair and into bed. Review of the incident report dated [DATE] at 2:05 AM completed by RN DD, revealed Resident #9 had an unwitnessed fall. RN DD was called to Resident #9's room by a CNA and witnessed Resident #9 was on her stomach on the floor beside her bed with a considerable amount of blood coming from a laceration above the right eyebrow and from her nose. Resident #9 had urinated in her bed and appeared to have gotten out of bed and fell on her stomach and face. RN DD called 911 and Resident #9 was taken to the hospital around 2:30 AM. Review of Resident #9's hospital visit documentation, dated [DATE] revealed she was seen for a nasal bone fracture, laceration of face, and forehead contusion. Review of Resident #9's the CT report dated [DATE] at 5:26 AM revealed she had a comminuted displaced bilateral nasal fractures (multiple broken nasal bones) and right facial and nasal swelling with lacerations. Review of the Post-Fall Evaluation dated [DATE] at 11:18 AM and signed by ADON A revealed Resident #9 had no falls within the last 6 months and had incontinence and decline in ability due to COVID-19 and was added to incontinent rounds and placed on 2-hour checks for assistance toileting. Review of the progress notes dated [DATE] at 7:02 AM by RN DD revealed Resident #9 returned from the hospital at 6:35 AM with Dermabond to the bridge of her nose laceration (cut), contusion (bruising) to forehead, and multiple nose fractures (broken nasal bones) with no deviations (deformity). Review of the Post-Fall Evaluation dated [DATE] at 1:04 PM by RN I revealed Resident #9 had a fall from the toilet and was instructed to use her call light for transfers. The root cause analysis indicated the resident was sleepy and did not use her call light and resident was educated on need for increased help while recovering from COVID-19. Review of the incident report dated [DATE] at 3:25 AM by LVN U revealed Resident #9 had an unwitnessed fall and was found face down on the floor in her bathroom and was not able to respond to verbal commands or conversation and was unable to describe what happened or to lift up her head. Resident #9 was placed on a swing so she would be lifted to the stretcher and the paramedics transported her to the hospital. LVN U stated that Resident #9 complained of pain to the top of her head. Review of Resident #9s hospital visit documentation, dated [DATE] revealed she had no fractures. Review of Resident #9's Physical Therapy evaluation and plan of treatment dated [DATE] revealed she was referred to physical therapy services due to having 2 falls in one week after having COVID-19. Resident #9's previous level of function with transfers was moderately independent and she currently required minimal assistance. The evaluation revealed Resident #9 had fallen 2 times in the past year, had an injury of bruising to face and toes, felt unsteady while standing, walking, and worried about falling. Review of Resident #9's Occupational Therapy Evaluation and Plan of Treatment dated [DATE] revealed she was referred to occupational therapy due to a new onset of COVID-19 with two recent falls that resulted in a significant number of contusions to her face and elsewhere on her body and a fracture of her nose with a recent fall. Resident #9 had a decrease in strength, functional mobility, transfer ability, reduced functional activity tolerance, reduced static and dynamic balance, decreased judgment, increased need for assistance from others, reduced ADL participation and pain. She required minimal assistance with toilet transfers. Observation and interview on [DATE] at 10:28 AM with Resident #9 revealed she was seated in her power wheelchair in her room and had dark purple, brown, and yellow, bruises around her eyes, nose, and cheeks and medical tape on the bridge of her nose. She stated she had a fall two weeks prior, she broke her nose when she fell out of bed when she attempted to transfer herself to her wheelchair. She stated she had another fall on [DATE] when she fell asleep on the toilet and fell and hit her head which resulted in a big bump on her head. She stated that she did not have a prior history of falls before and thought it was due to taking melatonin and had requested it be discontinued. She stated that she was able to transfer herself, did not need staff assistance, and staff were responsive to her when she asked for assistance. Interview on [DATE] at 11:42 AM with CNA K revealed she was familiar with Resident #9 and was not working the day she fell and broke her nose or when she hit her head. She stated that Resident #9 was independent and required verbal cueing during toileting but did not require any physical assistance during transfers. She stated that Resident #9 did not refuse care and they got along well. Interview on [DATE] at 1:11 PM with CNA X revealed she was familiar with Resident #9. She stated Resident #9 was independent and used her call light to ask for assistance. She stated that she worked the day before Resident #9 fell and broke her nose. CNA X stated that after Resident #9 returned from the hospital she was incontinent and was required to stay in bed for a short time. CNA X stated she was currently unsure what level of assistance Resident #9 required with transfers and would typically ask CNA K if she had questions. CNA X stated that Resident #9 only required standby assistance when toileting. Interview on [DATE] at 1:49 PM with RN I revealed Resident #9 was independent and she was not working when she had the fall where she hit her head or broke her nose. She stated that after Resident #9 returned from the fall where she broke her nose, she was a two person assist, and now only required standby assistance. Interview on [DATE] at 3:07 PM with the MDS Coordinator revealed she had worked at the facility for less than a month. She stated she was responsible for completing MDS assessments that included the annual and quarterly MDS, which reflected a resident's abilities and needs. She stated that there was a look back period of 7 days where the IDT submitted their assessments of the resident's abilities, and the most severe or limited rating was entered into the system. The MDS Coordinator was shown Resident #9's MDS, dated [DATE], and she stated she was not sure what the number 3- partial/moderate assistance level meant and reviewed the legend. She stated that it might mean that they needed some sort of assistance such as putting on their shirt or cueing with touch. She stated for bed transfers a partial/moderate assistance coding might mean that they required verbal cuing, or light touch cuing. Interview on [DATE] at 3:24 PM with the Rehabilitation Director revealed he was familiar with Resident #9 and she was started on physical therapy and occupational therapy services on [DATE]. He stated that she was previously on physical and occupational therapy services in [DATE], and she was discharged on [DATE] due to not participating consistently. He stated upon discharge from therapy services she was able to transfer independently. He stated that after she had a fall where she broke her nose, they did not discuss bringing her back onto therapy services because of her previous refusals and she required minimal assistance with transfers which meant one person with a gait belt. Interview on [DATE] at 3:57 PM with ADON A revealed Resident #9 was fairly independent and her goal was to move into the community, so they tried to encourage her to be independent. ADON A stated that she was not sure what the MDS partial/moderate assistance meant, and she looked at the Kardex to find a resident's transfer status and the nurses informed each other of changes of condition during morning meetings. Interview on [DATE] at 4:10 PM with LVN U revealed on [DATE] she responded to Resident #9's call light and she was sitting on the floor of the bathroom. She stated Resident #9 told her that she fell asleep on the toilet and hit her head and shoulder on the wall. She stated on [DATE] she was called to the Resident's room by the roommate and Resident #9 had fallen off of the toilet and had an injury to the top of her head and was not responsive, so she was sent to the hospital. LVN U stated she was not working on [DATE] when resident fell and broke her nose. She stated that the MDS was accurate and reflected she required partial/moderate assistance with transfers and Resident #9 used to be able to transfer herself safely. Interview on [DATE] at 6:00 PM with the DON revealed Resident #9's had a history of falls, and they were care planned. The DON stated Resident #9 had never had a fracture before and was noncompliant with medication and care. He stated he was responsible for care plans and Resident #9's noncompliance might not be documented under falls but was documented under other care areas and was also noted in the progress notes. The DON stated that Resident #9 was able to transfer independently, and they discontinued the melatonin medication. The DON stated that he did not remember if he did an in-service with staff because they did what they were supposed to do, and she was able to tell them what happened. The DON stated that Resident #9 was previously on physical and occupational therapy services and was discontinued due to noncompliance and started again recently. Interview on [DATE] at 6:09 PM with the Administrator revealed Resident #9 had more falls lately and they thought it was due to medications such as melatonin made her drowsier. The Administrator stated that Resident #9 had a high BIMS score and was able to tell them what happened and did not do an in-service regarding her fall. Record review of facility's policy titled, Transfers of Residents, dated reviewed [DATE] reflected .The goal is to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident, to prevent injuries to staff member assisting the resident, and to enable the resident to as independent during the transfer as possible . Record review of facility's policy titled, Comprehensive Care Plans, dated [DATE], reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . will be prepared by an interdisciplinary team .The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative . Record review of the facility's job description for a Hospitality Aide revised on [DATE] revealed: . Responsible for providing resident related (no-hands-on) care in accordance with quality standards under the direction of a licensed charge nurse. The position is applicable prior to successfully receiving certification as a nursing assistant. Performs host/hostess type duties in accordance with accepted standards of non-hands-on resident care. Uses daily task assignments. Assist residents that are independent and residents that require minimal or supervision support with activities of daily living, set up bed bath and rinse and soap wash cloth handing to patient. Lay out clothes, hold clothes in position patient can dress self, button clothes, pull up pants, changes unoccupied bed linens, answers call lights assist within skill level, passing and serving water. Assists with resident's recreation programs and transports residents in wheelchairs. Labels personal care items. Keeps resident rooms tidy. Maintains clothing inventory. Reports changes of resident condition to nurse in charge, reports accidents and incidents, and provides support functions as directed by supervisor. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 12:30 PM. The Administrator, DON, and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on [DATE] at 12:30 PM. The Immediate Jeopardy plan of removal was accepted on [DATE] at 6:05 PM and the Regional Nurse Consultant was notified of the acceptance. Immediate Jeopardy Removal Plan: Issue Cited: The facility failed to develop and implement a comprehensive care plan for Resident # 24 to address the left femur fracture sustained on [DATE] The facility failed do develop a comprehensive care plan for resident # 9 to address the nasal bone fracture and failed to follow resident # 9 transfer status 1. Immediate Action Taken A. On [DATE] the MDS nurse/Designee completed a comprehensive care plan for resident # 24 to address left femur fracture, and falls care plan to reflect appropriate interventions. This was completed [DATE] B. On [DATE] the MDS nurse/Designee completed an acute care plan for resident # 9 to address the nasal bone fracture, update the fall care plan to reflect appropriate interventions and resident # 9 right to refuse care with education provided at each point of contact. This was completed [DATE] C. On [DATE] a review of resident # 9 and resident # 24 care plan and Kardex was reviewed by Regional Reimbursement Consultant and validated that the care plan was accurate. This was completed on [DATE] D. On [DATE] the Regional Nurse consultant provided education to the MDS nurse on completion of, correct and timely care plan interventions, and that appropriate intervention(s) is reflective on the Kardex to include Activities of Daily Living. This was completed on [DATE]. The Regional Reimbursement Nurses will provide oversight on this process weekly x 4 weeks. E. On [DATE] the Regional Nurse consultant provided 1:1 education to the center's DON on care plan policy which defines the responsibility of the DON to complete acute care plans within 48 hours and with appropriate interventions, and that if applicable, the intervention(s) are reflective on the C.N.A. Kardex. This was completed on [DATE] at 12:00 pm. The Regional Nurse Consultant will provide oversight on this process weekly x 4 weeks F. On [DATE] the Regional Nurse consultant provided 1:1 education to the center's MDS nurse that reflects that the MDS nurse is responsible for weekly care plan reviews, and that completed MDS's (ADL section) is correct on the ADL care plan, and that the resident's ADL's flow over to C.N.A. Kardex. This was completed on [DATE]. The Regional Reimbursement nurse will provide oversight on this process weekly x 4 weeks. 2. Identification of Residents Affected or Likely to be Affected: A. On [DATE] the Regional Reimbursement Nurse and MDS nurse conducted 100% audit of all residents MDS regarding ADL's. MDS nurse and Regional Reimbursement Consultant then validated that the ADL's coded on the MDS was accurate on each resident's care plans that the ADL's from each resident's care plan flowed over to the C.N. A. Kardex. This was completed on [DATE] and the Regional Reimbursement Consultant will provide oversight on this process weekly x 4 weeks. 3.Actions to Prevent Occurrence/Recurrence: o MDS nurse or Designee will review all residents with changes of conditions, including transfers, falls, daily in the morning meeting and will review/revise care plans as needed. o The Weekend Supervisor or Designee will review all residents with changes of conditions, including transfers, falls, on weekends and will review/revise care plans as needed On [DATE] the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related Comprehensive Care Plans and reviewed plan to sustain compliance On [DATE] the facility conducted and Ad Hoc QAPI meeting to discuss Care Plans and on sustaining compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ________[DATE] Monitoring for Plan of Removal: Record review of the MDS in-service, provided by Regional Nurse Consultant, dated [DATE], topic- MDS will be responsible for the completion of comprehensive, annual, and significant changes care plans in a timely manner to ensure the care et [and] services a resident will need signed by MDS Coordinator. Record review of the nursing management in-service, provided by Regional Nurse Consultant, dated [DATE], topic-care plans, Kardex, and activities of daily living signed by the DON, ADON A and ADON B. Record review of the nursing management in-service, provided by Regional Nurse Consultant, dated [DATE], topic- Transfer of Residents 1. Gait belt 2. Standby assist 3. Hoyer 4. Transfer residents according to Kardex with comes from the care plan signed by the DON, ADON A and ADON B. Record review of the in-service, provided by RN I, dated [DATE]- Topic Nursing Aides Kardex . direct all aides (CNA, NA, HA) to review Kardex for appropriate assistance needed per resident . aides are to review Q [every] shift prior to being of shift . aides are to provide care to resident according to Kardex signed by 6 Hospitality Aides (Hospitality Aide P, R, S, T, V), 1 CNA (CNA FF), and 2 LVN's (LVN O and Q). Observation and interview on [DATE] at 10:10 AM with Resident #9 revealed she was lying in bed watching television. She stated she self-transfers herself from the bed to the wheelchair and planned to get up in about an hour. She stated she would not need assistance and stated no one had spoken with her about transfers. Observation and interview on [DATE] at 10:25 AM of Resident #9's care plan with the DON revealed there was no updated care plan for resident assistance with transfers or refusing assistance. The DON stated he had not attempted to educate Resident #9 between [DATE] and [DATE] because he had educated her in the past multiple times. The DON stated that Resident #9's noncompliance with transfers had not been care planned and he was unable to find a recent progress note that showed she refused assistance with transfers. Interview on [DATE] at 10:55 AM with the Administrator and the DON revealed Resident #9 had been educated to ask for assistance during transfers and provided an updated care plan. Record review of Resident #9's updated care plan revealed she was non-compliant with transfers, date initiated [DATE] and interventions included education on allowing staff to assist with transfers and respect resident's wishes regarding transfers; had potential for injury due to use of electric wheelchair with interventions of physical therapy assessment, reassess as needed, report any incidents to therapy and doctor, date initiated [DATE]; had potential for complications related to fractured nose with interventions of follow orders for treatment and report any changes in condition regarding the fracture to the doctor, date initiated [DATE]; transfer status was to limited x 1, date initiated [DATE] and revised on [DATE]; use gait belt with transfers, date initiated [DATE]. Record review of the nursing management in-service, provided by Regional Nurse Consultant, dated [DATE], topic-care plans, Kardex, and activities of daily living signed by the DON, ADON A and ADON B. Record review of the nursing management in-service, provided by Regional Nurse Consultant, dated [DATE], topic- Transfer of Residents 1. Gait belt 2. Standby assist 3. Hoyer 4. Transfer residents according to Kardex with comes from the care plan signed by the DON, ADON A and ADON B. Record review of in-service, provided by RN I, dated [DATE]- Topic Nursing Aides Kardex . direct all aides (CNA, NA, HA) to review Kardex for appropriate assistance needed per resident . aides are to review Q [every] shift prior to being of shift . aides are to provide care to resident according to Kardex signed by 6 Hospitality Aides (Hospitality Aide P, R, S, T, V), 1 CNA (CNA FF), and 2 LVN's (LVN O and Q). Observation on [DATE] at 1:45 PM of transfer of Resident #9 revealed she was seated in her wheelchair facing the bed at a 45-degree angle. ADON A was standing off to the side of Resident #9 and did not place a gait belt or prompt resident with a count down. Resident #9 stood up, stepped down from her wheelchair to the floor. ADON A placed her hand under Resident #9's elbow and Resident #9 turned and sat down on the bed. Resident #9 stayed seated for a minute and then stood up, leaned forward, and grabbed the handle of her wheelchair with her left hand,[TRUNCATED]