**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, and record review, the facility failed to ensure correct installation, use, and maintenance of bed rails, for 3 of 7 residents (Residents #70, #87, and #102) reviewed for bed rails. The facility did not have the manufacturers' recommendations and specifications to follow for installing and maintaining the bed rails to prevent large gap in Resident #70's bed rail. The facility failed to develop care plans to address the risk of entrapment and interventions to prevent entrapment due to the use of bed rails for the residents who had histories of falling out of the bed for Residents #70, #87, and #102 The facility did not follow their Bed Mobility Assessments indicating the bed rails were not recommended for use for Residents #70, #87, and #102. The facility did not provide maintenance and monitoring of the bed rails per the manufacturer specifications/recommendations for residents with bed rails. The facility failed to maintain a copy of a manufacturer manual available for reference. An Immediate Jeopardy (IJ) was identified on 04/23/25. The IJ template was provided to the facility on [DATE] at 6:43 p.m. While the IJ was removed on 04/25/25, the facility remained out of compliance at a scope of a pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on bed rails and reporting broken rails. These failures placed residents at risk for entrapment with serious injury or death. Findings included: 1. Record review of a face sheet for Resident #70 dated 04/23/25, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses including dementia, anxiety, and hereditary ataxia (group of neurological disorders caused by genetic mutations and characterized by progressive decline in coordination of movement and speech). Record review of Physician Orders, dated 04/23/25, indicated Resident #70 had 1/2 bed rails x 2 on the bed to facilitate with turning and repositioning every shift for bed mobility with a start date of 11/08/23. Review of Resident #70's quarterly MDS, dated [DATE], indicated she had a BIMS score of 11 indicated moderately impaired cognitive skills for daily decision making. Resident #70's functional status indicated she was non-ambulatory and required a one person assist for bed mobility. Review of Resident #70's care plan, revised 04/08/25, indicated the resident had a history of falls and was at a high risk for fractures from the falls. The care plan indicated Resident #70 required extensive assistance for bed mobility and required 2 persons with the mechanical lift for transfers. The care plan addressed the use of bed rails with interventions to evaluate and reevaluate for ½ bed rails quarterly on the quarterly assessment. The interventions included monitor for proper positioning and circulatory concerns any significant changes to physician promptly. The care plan did not include the risk of entrapement. Record review of Resident #70's Bed Rail Mobility Device Assessment, dated 10/14/24, indicated no concerns for risks of entrapment and bed rails were installed for bed mobility post falls following prior interventions of a floor mat and bed in low position. Record review of Resident #70's Bed Rail Mobility Device Assessment, dated 04/14/25, indicated bed rails were not recommended. Record review of Resident #70' consent for bed rails had been signed on 08/02/21 by her family. During an observation on 04/06/25 at 08:38 a.m., Resident #70 was in her with the bed rails on the left side of Resident #70's bed had a gap approximately 14 inches - 18 inches between the scoop mattress on the bed and the rail. During an observation and interview on 04/06/25 at 09:00 a.m., CNA A grabbed the left bed rail on Resident #70's bed and wiggled the rail. She said the left rail had been loose for 2-3 months. She said she thought the loose bed rail was reported 2-3 months ago but said she did not report. She said the bed rail would need to be reported to maintenance. She said the risk of the bed rail being loose and having a gap was the resident could fall from the bed. During an interview on 04/06/25 at 09:30 a.m., the DON said Resident #70 bed rails were used to assist during care with turning and repositioning the resident. She said the rails needed to be fixed to prevent falls. The DON said she was not aware of the bed rail for Resident #70 was loose and a large gap. During an interview on 04/07/25 at 10:30 a.m., the Director of Plant Operations said he was not aware Resident #70 bed rails were loose yesterday (04/06/25). He said after surveyor intervention, he had tightened the bed rails which fixed the gap in Resident #70 bed rails. He said he was responsible to check the bed rails in the facility and keep them secure. He said the bed rails should not have large gaps between the bed rail and the mattress. During an interview on 4/8/25 at 11:00 a.m., the Executive Director of Operations said the Director of Plant Operations was responsible to check the side rails every quarter for need of repairs or gaps. He said they were checked last in February 2025. The Executive Director denied knowing that Resident #70 bed rail was loose and had a large gap. During an observation and interview on 04/23/25 at 8:30 a.m., the Director of Plant Operations said he was responsible for checking bed rails quarterly. He said after surveyor intervention, he tightened the loose rail, and the rail had no gap on Resident #70's bed on 04/06/24. He said yesterday (04/22/25) a staff member had reported the bed rail was loose again. He said he did not remember which staff had told him the bed rail was loose again. He said he was going to work on the bed rail for Resident #70 and said he had forgot. He said he did not have work order documentation and he did not use a log of any needed repair. He said most of the time the staff just tells him what needs to be fixed. Resident #70 was in her bed and there was 9-inch gap between the mattress and the left bed rail. He looked at Resident #70's bed rail and said there should not have that large of gap between the rail and the mattress. He got underneath Resident #70's bed and he said the bolts were stripped out on the bed rails. He said he would have to get new bed rails, or he would have to replace Resident #70's bed. During an observation on 04/23/25 at 9:45 a.m. Resident #70 was in a new bed with assist bar and with her scoop mattress in low position with fall mats. Record review of the incident report dated 05/15/24 indicated Resident #70 had an unwitnessed fall at 3:45 p.m., she told nurse she had fell from her bed. Record review of the incident report dated 06/04/24 incident Resident #70 had an unwitnessed fall at 8:00 p.m., She was found bedside her bed and said she slid off the bed. During an interview on 4/23/25 at 10:00 a.m., the Director of Plant Operations said he did not maintain records of what he had fixed before. He said he did not keep any documentation of the maintenance requests made by staff or residents. He said he did not use a log or documented when he repaired items. He said Resident #70's bed and bed rails were the property of the facility. He said he did not have the manuals for the bed or bed rails. 2. Record review of face sheet for Resident #87, dated 04/23/25, indicated she was a [AGE] year-old female admitted on [DATE] and had diagnoses hemiplegia (weakness on one side of the body), muscle wasting (muscles thinning and loss of strength), and anxiety disorder. Record review of Resident #87's Significant Change MDS assessment, dated 01/21/25, indicated she was severely cognitively impaired with a BIMS score of 03. Resident #87's functional status indicated she was non-ambulatory and the assistance of 2 or more helpers was required for bed-to-chair transfer. Record review of Physician Orders, dated 04/23/25, indicated Resident #87 had 1/2 bed rails x 2 on the bed to facilitate with turning and repositioning every shift for bed mobility with a start date of 03/12/25. Record review of Resident #87's care plan, revised 12/18/24, indicated she had an ADL self-care performance deficit. She required extensive assistance of 2 persons with bed mobility. Interventions included the half siderails to be in the up position for safety during care provision and to assist with bed mobility, and to observe for injury or entrapment related to siderail use. Staff were to reposition the resident as necessary to avoid injury. Record review of Bed Mobility Device Assessment for Resident #87, dated 11/27/24, indicated the resident was totally dependent on staff for bed mobility and the use of a bedrail, grab/assist bar was not recommended. Record review of Bed Mobility Device Assessment for Resident #87, dated 02/27/25, indicated the resident was totally dependent on staff for bed mobility and the use of a bedrail, grab/assist bar was not recommended. Record review of an incident report dated 11/23/24 at 4:40 p.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 11/26/24 at 8:48 p.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 12/12/24 at 12:30 a.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 12/19/24 at 1:30 a.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 12/22/24 at 7:00 a.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 12/25/24 at 4:08 p.m., indicated Resident #87 fell from her bed. Record review of an incident report dated 01/13/25 at 9:35 a.m., indicated Resident #87 fell from her bed. Record review of Resident #87' consent for bed rails indicated the form had been signed on 03/12/25 by her family. During an observation on 04/23/25 at 11:10 a.m., Resident #87 had two 1/2 bed rails, which were fitted with no gap greater than 4 inches. 3. Record review of face sheet for Resident #102, dated 04/23/25, revealed he was a [AGE] year-old male admitted on [DATE] and had diagnoses of intracranial injury (brain dysfunction due to injury), contractures to bilateral lower extremities (when muscles and tendons shorten), and was a functional quadriplegic (paralysis of all four extremities). Record review of Physician Orders, dated 04/23/25, indicated Resident #102 bed rails to assist with bed mobility with a start date of 04/02/24. Record review of Resident #102's Annual MDS assessment, dated 04/11/25, indicated he had severe cognitive impairment with a BIMS score of 03. Resident #102's functional status indicated he was non-ambulatory and dependent on 2 or more staff for ADLs. Record review of Resident #102's care plan, revised 06/07/24, indicated the resident required the use of ½ side rails to assist with bed mobility. The intervention was to evaluate and re-evaluate for ½ siderail use quarterly and as needed. The care plan did not address the resident's risk of entrapment. The care plan addressed the falls was revised on 01/23/25 indicated Resident #102 was high risk for increased falls and fractures and the goal was for resident to be free from falls. Record review of Resident #102's consent for bed rails indicated the form had been signed on 04/02/24 by his family. Record review of Bed Mobility Device Assessment for Resident #102, dated 01/04/25, indicated the use of a bed rail, grab/assist bar was not recommended. Record review of Bed Mobility Device Assessment for Resident #102, dated 04/04/25, indicated the use of a bed rail, grab/assist bar was not recommended. Record review of an incident report dated 05/10/24 at 4:00 p.m., indicated Resident #102 fell from his bed. Record review of an incident report dated 05/12/24 at 11:00 p.m., indicated Resident #102 fell from his bed. During an observation on 04/23/25 at 10:45 a.m., Resident #102 was in his bed and had ½ bed rails to both sides of the bed with no gaps. During an interview on 04/23/25 at 11:00 a.m., the DON said if the bed mobility assessment indicated the resident was not recommended for the use bed rails. The DON said the nurse should have reported it to her (the DON) and the maintenance to remove the bed rails. Review of facility policy, titled Bed Safety, effective 04/2021, indicated the following: Policy will strive to provide a safe sleeping environment for the resident. PROCEDURE 1.The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. An inspection should be done by the Director of Plant Operations at installation/before use and quarterly thereafter of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position. c. Ensure that when bed system components are worn and need to be replaced, they are replaced with compatible components that meet manufacturer specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and . 10. When using side rails for any reason, the staff shall take measures to reduce related risks. The Executive Director of Operations was notified of the Immediate Jeopardy on 04/23/25 at 6:43 p.m. and was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal was accepted on 04/24/25 at 5:36 p.m. and reflected the following: On 04/23/2025 The Director of Plant Operations changed the bed for resident #70 with properly operating bed rails. On 04/23/2025 The Charge Nurse reassessed resident #70 for bed mobility and the bed mobility assessment for resident #70 was updated. The use of side rails was recommended per assessment. On 04/23/2025 The Charge Nurse reassessed resident #102 for bed mobility and the bed mobility assessment for resident #102 was updated. The use of side rails was not recommended per assessment. The Director of Plant Operations removed the assist bar for resident #102 per recommendations from assessment. On 04/23/2025 The Charge Nurse reassessed resident #87 for bed mobility and the bed mobility assessment for resident #87 was updated. The use of one bed rail for turning and repositioning recommended per assessment. The Director of Plant Operation removed the right bed rail from resident #102's bed. Bed Rail Entrapment Assessment on 4/24/2025 The Director of Plant Operations was educated according to Manufacturers Guidelines on proper installation of bed rails. The Director of Plant Operations conducted a Bed Rail Entrapment Assessment throughout the building to identify any bed rail posing a risk of entrapment. The Executive Director of Operation obtained the manufacturer's guidelines for each type of bedrail in the facility, and they are compatible for use with the beds that we have. The bed rails are not universal they are made for the model of bed we have. Any non-compliant bed rail was either fixed or replaced to meet assessment standards and proper installation according to the manufactures guide. The Director of Plant Operations will complete the Bed Rail Entrapment Assessment weekly x 4 weeks and quarterly thereafter. Completion date: 4/23/2025 Clinical Audits, The Director of Clinical Operations and/or designee will conduct a 100% audit of bed mobility assessments to ensure proper evaluation and documentation. If the bed mobility assessment indicated that bed rails were not needed, they were removed by the Director of Plant Operations. Completion date: 4/24/2025 Staff Education & In-Service Training. The Director of Clinical Operations and/or designee will lead training sessions to ensure team members understand proper procedures for identifying and addressing bed rail concerns. Topics included: Equipment Maintenance & Reporting, Team members must immediately report malfunctioning, broken, or non-working equipment to their Supervisor and the Director of Plant Operations via phone and on maintenance log. New team members will be educated regarding reporting any broken equipment during orientation. 1.The Executive Director completed educational training with the Director of Plant of Operations regarding the completion of the Bed Rail Entrapment Assessment quarterly per company policy. The assessment details what gaps in zones of the bed are acceptable. Zone 1 FDA recommended space is less that-less than 4-3/4 and Zone 3 FDA recommended space is less that 4-3/4. Zone 2, 4, and 5 are not used at our facility due to no bottom rails on any of our beds. Nursing staff and department managers educated on acceptable gaps for zone 1 and zone 3. Nursing staff will document on the licensed medication administration record daily the checks have been completed. Any gaps larger than 4-3/4 will be reported to the on-call phone and the maintenance log. Documentation will be completed on the company form for the assessment. The Assessment was previously completed on 2/10/2025 and 4/23/2025 by the Director of Plant Operations. The Executive Director of Operations completed educational training with the Director of Plant Operations on the manufacturer's guidelines on bed rails installation for the Medline (FCE1232RSRN) and Joerns beds (F14SC). Completion date: 4/24/2025 2. Proper Bed Rail Assessment Procedures Charge nurses must accurately complete bed rail assessments and determine if rails are suitable for resident use. Charge Nurses educated on how to accurately complete bed rail assessments. New charge nurses will be educated regarding completing an accurate bed rail assessment during orientation according to manufacturers' recommendation. If an assessment indicates bed rails are recommended, the team member must notify both the Director of Clinical Operations and the Director of Plant Operations immediately. New charge nurses will be educated regarding immediate notification to the Director of Clinical Operations and the Director of Plant Operations during orientation. Completion date: 4/24/2025 Accident/Incident Prevention: The Director of Clinical Operation and/or Designee will complete training on accident/incident prevention, including types of interventions put into place to prevent any further fall. Completion date: 4/24/2025 Care Plan Updates & Compliance The Clinical Reimbursement Coordinator will conduct a 100% audit of resident care plans, ensuring appropriate documentation of bed rail concerns. Care plans will be updated to specify bed rail risks and potential entrapment hazards. Completion date: 4/24/2025 Medical Director Notification On 4/23/2025 The Director of Clinical Operations notified the Medical Director of immediate jeopardy and reviewed bed rail policy and procedure. Plan of action reviewed with the Medical Director with no changes to the current policy. This practice will be reviewed monthly with the QA Committee to ensure no changes are needed to the current policy. Commitment to Resident Safety All actions outlined in this plan will be monitored for ongoing compliance, reinforcing our commitment to providing a safe environment for residents. On 04/25/25 at 1:45 p.m., the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 04/23/25 at 1:00 p.m., Resident #70 was on new low bed with just the grab bars with less than a 4-inch gap between each side of the mattress. During an observation on 4/23/25 at 1:30 p.m., Resident #102 was in his bed with left bed rail removed. Record review of the in-service dated 04/23/25 indicated all licensed staff were trained on care plans updates and included entrapment risk for residents with assist bars and bed rails indicated all licensed staff were trained. Record review of the in-services dated 04/23/25 indicated all licensed staff were trained which included assessments and the training included demonstration and staff demonstrating knowledge and location of bed mobility assessments in the electronic record. Record review of the in-service dated 04/24/25 indicated all staff were trained on bed mobility zone gap recommendations and reporting broken or loose bed rails. During an interview and record review on 04/25/25 at 8:35 a.m., the Executive Director of Operations said the interdisciplinary team (the DON, MDS Coordinators, Activity Director, Social Worker, Director of Therapy, and the ADONs and himself) were retrained on the manufacturer's guidelines for the bed rails. The Executive Director of Operations said he downloaded the manufacturer's guidelines for the bed rails for the two types of beds in used in the facility and pulled the online manual up on his computer to review. He said the Director of Plant Operations was in-serviced on the recommendations of the mattress to bed rail gap in Zone 3 (the area on each side of the bed between the side rail and the mattress) of the mattress being less than 4 and 5/8 inches as he pointed to the diagram of a bed on his computer with bed rails and measurements. The Executive Director of Operations said it was important for staff to report any concerns with the assist bars/bed rails to the Director of Plant Operations and the DON. The Executive Director of Operation said the facility reassessed residents who had assist bars/bed rails to determine which residents were able to use assist bar/bed rail based on their ability to use the bar for bed mobility and if bed rails were not recommended due to entrapment risks. He said for the residents who no longer needed the bed rail/assist bar, which included Resident #70 who was using ½ bed rails, was placed in a new bed with just the grab bars. He said education was provided to all residents and representatives with side rails on the bed and risk of using them. He said the residents, families and physicians were notified prior to removing or changing the type of bed rails. He said physicians' orders and consent would be obtained by the nurses before applying bed rails. The Executive Director of Operations said all staff were trained on the recommendations of the mattress to bed rail gap in Zone 3 of the mattress being less than 4 and 5/8 inches. During an interview on 04/25/25 at 9:10 a.m., the Director of Plant Operations said he received one-on-one in-services regarding the completion of the Bed Rail Entrapment Assessment quarterly per company policy. The assessment details what gaps in zones of the bed are acceptable. Zone 1 FDA recommended space is less that-less than 4-3/4 and Zone 3 FDA recommended space is less that 4-3/4. The Zone 2, 4, and 5 were not used at our facility due to no bottom rails on any of our beds He voiced a clear understanding of the risks related to gaps in the bed rails, on how to properly install the assist bars, and ensure the resident's safety. He said the facility would follow the manufacturer's guidelines. The Director of Plant Operations said he was checking beds weekly for proper installation and the need for repairs and all bed rails x 4 weeks to make sure the bed rails were not loose and there were no gaps greater than 4 and 5/8 inches from the mattress to the bed rail. During an interview and record review on 04/25/25 at 10:00 a.m., the DON said she completed an audit of all the residents to obtain a list of which residents used an assist bar or bed rails and if their assessment to determine if were safe to use the bed rail. The DON said the MDS nurses updated the residents with assist bars/bed rails care plans to include the risk of entrapment. She said the bed rails/assist bars were removed from the beds of the residents who were identified as not recommended for using a bed rail for safety. Record review with the DON reflected the audit was performed for all residents with assist bars/bed rails to include the list of resident care plans that were updated to reflect the use of the bed rails. The residents' physician orders were updated to reflect the use of the bed rails on those residents identified in the audit. Record review of the bed rail assessments had been updated for Residents #70, #87 and #102. She said Resident #70's bed rail assessment was not correct. She said the nurses have been retrained completing the bed rails assessement. She said all residents who have bed rails have consents, orders and correct assessments. During an interview on 04/25/25 at 10:30 a.m. MDS J said she was retrained and had completed updating care plans on all the residents who have or had bed rails. She said she included the risk of entrapment for the residents who remained with bed rails. During an interview on 04/25/25 at 10:50 a.m., the Medical Director said the facility notified him of the IJ related to bed rails and he confirmed the Administrator had notified him. Record review of in-services, dated 04/24/25, indicated the licensed nursing staff were trained on the proper use of assist bars/bed rails to include assessments for assist bars on care plan prior to usage. Record review of the in services dated 04/24/25 indicated all staff were trained on reporting broken equipment and included the gap recommendation of less than 4-5/8 for Zone 3 located between bed rail and mattress. During interviews on 04/25/24 from 10:30 a.m. to 11:30 a.m. indicated RN L, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, LVN S, LVN T, LVN U, LVN B, AND LVN V were trained on bed mobility assessments, care plans and how to report broken or bed rails with gaps. They were able to voice the dangers of improperly used or broken bed rails. They were knowledgeable about the consent, orders, and care plans. They all voiced if the bed rail needed repair or replaced and maintenance was not there, they would place the resident in a new bed if the bed rail could not be repaired would and notify the DON and the Executive Director of Operations. The LVNs were able to voice the space between the mattress and the bed rails could not be more than 4 and 5/8 inch. During interviews on 04/25/24 from 11:35 a.m. to 12:30 p.m., indicated CNA G, CNA W, CNA X, CNA Y, CNA Z, CNA A, CNA AA, CNA BB, CNA CC, CNA DD, CNA EE, CNA FF, CNA GG, CNA HH, CNA JJ, CNA KK, CNA LL, CNA MM, CNA PP, CNA QQ, CNA F, CNA RR, CNA SS, AND CNA TT were trained on reporting broken or gapping bed rails. They were able to voice the positive uses for bed rails as to enable the resident to participate with turning and maintain their mobility and the staff were aware of the dangers of bed rails. They all said they would report to the charge, if they saw the bed rails not being appropriate for the residents or problems with the bed rails. The CNA staff said the bed rails should be no more than 4 and 5/8 inch away from the mattress and the rail should fit snug and not wiggle. During an interview on 4/25/25 at 1:00 p.m., the DON said all staff who had not received the in-services and trainings, would be trained prior to their next shift and new hires would be trained as part of the new hire training. She said new admissions would be assessed for bed rails before they were placed in a bed with rails. The Executive Director of Operations was informed the Immediate Jeopardy was removed on 04/25/25 at 2:15 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. 1. The facility failed to administer Resident #1 the appropriate dose of morphine. Resident #1 was administered 1ml (20mg) of morphine every 3 minutes from 11:15 a.m. to 11:39 a.m. (180mg) instead of 1ml (20mg) every 30 minutes. 2. The facility failed to ensure Resident #1's morphine order was properly transcribed. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for harm or death relating to being administered too much medication. Finding Include: 1. Record review of Resident #1's face sheet dated [DATE] indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), epilepsy (brain condition that causes reoccurring seizures), diabetes with neuropathy (nerve damage that occurs as a complication of diabetes), paranoid schizophrenia (intense paranoia and delusional thinking), legally blind (severely impaired vision), and pain. Record review of Resident #1's physician orders dated [DATE] through [DATE] indicated she had an order morphine sulfate (concentrate) oral solution 100mg/5ml give 1ml by mouth every 2 hours as needed starting [DATE]. Record review of Resident #1's quarterly MDS dated [DATE] indicated she usually understood others and was usually understood by others. The MDS indicated she had a BIMS of 7 (severely impaired cognitively). The MDS indicated she required total dependence with self-care, bed mobility, transfers, and dressing. The MDS indicated she received scheduled pain medication regimen, and she is taking high-risk drug of opioid. Record review of Resident #1's care plan last revised [DATE] indicted she was at risk for experiencing discomfort or pain with interventions including administer medication to relieve pain as ordered and discuss with the physician and review medications as indicated to ensure she was on the least amount of medication at the lowest dose to treat her pain. Record review of Resident #1's MAR dated [DATE] indicated Resident #1 had been administered 1ml (20mg) of morphine on [DATE] at 10:30 a.m. and 2:00 p.m. by LVN A. Record review of Resident #1's morphine sulfate prescription label dated [DATE] indicated morphine sulfate 100mg/5ml give 1ml by mouth or under tongue every 30 minutes as needed until comfortable and then every 2 hours for pain or shortness of breath. Record review of Resident #1's Nurse Progress Note dated [DATE] at 11:58 a.m. authored by LVN A indicated Resident #1's sitter approached the nurse's station with the resident's family member on the phone stating Resident #1 was in pain. Resident #1 had received routine Norco 7.5mg/325mg one tablet at 7 a.m. and prn morphine 1ml at 10:30 a.m. LVN A assessed the resident to have increased respirations and heart rate, and she was noted to be with sounds of distress, grimacing and stating she was hurting and saying Lord Help Me. LVN A contacted Hospice RN and received orders to administer morphine 1ml (20mg) every 3 minutes until the resident was at comfort level and pain subsided, then start morphine 1ml (20mg) every 2 hours routinely around the clock. The note indicated morphine 1ml every 3 minutes was initiated. Morphine was administered every 3 minutes for 9 doses with the resident's subjective and objective signs and symptoms of pain resolved after the 9th dose. Hospice RN notified of morphine on hand and status of resident needing more morphine. Record review of Resident #1's undated Narcotic Count Sheet for morphine sulfate 100mg/5ml bottle indicated the dosage was give 1ml by mouth/under tongue every 2 hours as needed for pain or shortness of breath. The Narcotic Count Sheet indicated the initial amount of morphine received was 45ml. The Narcotic Count Sheet indicated Resident #1 received 1ml of morphine on [DATE] at 10:30 a.m., 1ml of morphine on [DATE] at 11:15 a.m., 1ml of morphine on [DATE] at 11:18 a.m., 1ml of morphine on [DATE] at 11:21 a.m., 1ml of morphine on [DATE] at 11:24 a.m., 1ml of morphine on [DATE] at 11:27 a.m., 1ml of morphine on [DATE] at 11:30 a.m., 1ml of morphine on [DATE] at 11:33 a.m., 1ml of morphine on [DATE] at 11:36 a.m., 1ml of morphine on [DATE] at 11:39 a.m., 1ml of morphine on [DATE] at 12:00 p.m., and 1ml of morphine on [DATE] at 2:00 p.m. all doses administered by LVN A. During an interview on [DATE] at 3:51 p.m., LVN A said on [DATE] around 11:00 a.m. Resident #1's sitter, who was on the phone with Resident #1's family member, notified her of Resident #1 being in pain. She said Resident #1 received her dose of Norco 7.5mg/325mg earlier that morning at 7:00 a.m. and prn morphine 1ml (20mg) at 10:30 a.m. She said Resident #1, remained tensed, crying, moaning, grimacing and stating she was hurting. She said she contacted Hospice RN and received new orders to administer morphine 1ml (20mg) every 3 minutes until the resident was comfortable and then start morphine 1 ml (20mg) every 2 hours routinely around the clock. She said she clarified and confirmed the order 2 or 3 times with Hospice RN. She said she initiated the morphine 1ml (20mg) every 3 minutes and administered a total of 9 doses over a 24-minute period to Resident #1 with pain resolved. She said she remained in Resident #1's room at her bedside and set an alarm on her cell phone to monitor her pain every 3 minutes and administered the morphine when she continued to complain of pain. She said after the 9th dose of morphine, Resident #1 was resting comfortably with no complaints of pain or signs of discomfort. She said she notified Hospice RN at around 12:00 p.m. of Resident #1's morphine supply running low, and Hospice RN told her she would deliver more morphine when she came to assess the resident. She said she administered Resident #1 morphine 1ml (20mg) again at 12:00 p.m. for complaints of pain with effectiveness. She said she administered another dose of morphine at 2:00 p.m. to follow the ordered routine dosing of morphine to be given every 2-hours. She said around 2:30 p.m., Hospice RN arrived at the facility during report, identified the morphine order was transcribed wrong. She said Resident #1 was supposed to have received morphine 1ml (20mg) every 30 minutes not every 3 minutes. She said Hospice RN notified Resident #1's RP and family of the incident and offered Narcan to reverse the effects and/or transfer to the ER for evaluation, but the RP and family denied the treatment. She said Hospice RN assessed Resident #1 with no abnormal findings and directed her and LVN D to hold all medications for 4 hours and assess the resident's vital signs every 30 minutes for 4 hours and to notify hospice with any changes. She said she notified the DON of the incident with Resident #1's morphine dosage, and she was instructed to complete a medication error incident. She said she received 1:1 training from the DON and ADON regarding if orders received did not seem correct or if she was uncomfortable with administering a medication, she needed to contact the DON for clarification before administering. She said she clarified the order with Hospice RN 2-3 times, and Hospice RN was communicating with the physician via text while on the phone with her and she administered what the physician ordered. She said LVN B was at the nurses' station when she received the orders and heard the conversation. She said she was not familiar with the hospice service company providing Resident #1's care and thought the morphine dose was a new pain management treatment plan specific to this hospice. She said she was alarmed with the dosing which was why she clarified the order with the hospice nurse 2-3 times. She said she was aware of signs of overdose of morphine to include decrease respirations, decrease heart rate, drowsiness, and confusion. Record review of Resident #1's Nurse Progress Note dated [DATE] at 3:20 p.m. late entry authored by LVN A indicated Resident #1 was being fed by sitter at this time, no concerns noted, resident stable, staff will continue to monitor. Weekend Supervisor aware of events. At 1:00 p.m. family member arrived, resident reassessed and VS WNL. The resident was alert, and the family member fed the resident. Resident #1 had no verbal complaints of pain/ discomfort or non-verbal signs and symptoms of pain/discomfort. The resident was resting at this time and the nurse would continue to monitor. At 2:30 p.m., Hospice RN arrived to deliver Resident #1's Morphine, and assessed the resident indicating the vital signs were WNL. Hospice RN gave orders to hold all medications for 4 hours and assess vital signs every 30 minutes for 4 hours. Hospice RN offered Resident #1's family member to administer Resident #1 Narcan or send to the ER for accidental overdose of morphine and the family member declined. During an interview on [DATE] at 2:22 p.m., Hospice RN said she received a report from LVN A Resident #1 was having a pain crisis and she had already had her Norco 7.5mg/325mg around 7:00 a.m. and a dose of morphine 1ml (20mg) around 10:30 a.m. She said she contacted the hospice physician with the report and assessment and was given new orders to administer morphine 1ml (20mg) every 30 minutes until pain subsides or comfortable and then every 2 hours as needed. She said LVN A repeated back the order and instead of every 30 minutes she said every 3 minutes and she corrected LVN A and instructed the medication needed to be provided every 30 minutes not 3 minutes. She said she received a call from LVN A regarding Resident #1's morphine supply was low. She said when she arrived at the facility around 2:15 p.m. to drop of the morphine prescription and assess Resident #1, during conversation and narcotic count, she discovered Resident #1 was administered morphine 1ml (20mg) every 3 minutes starting at 11:15 a.m. through 11:39 a.m. totaling 9 doses (180mg) in 24 minutes and additional morphine 1ml (20mg) given and 12:00 p.m. and 2:00 p.m. She said when she learned of the morphine overdose, she assessed Resident #1 and contacted the hospice physician. She said the hospice physician provided options of the antidote of Narcan and/or send the resident to ER for evaluation. She said she informed Resident #1's RP of the accidental overdose and the options suggested by the hospice physician. She said the RP stated she felt Resident #1 was comfortable and did not want an antidote administered. She said the RP was informed of the potential effects if antidote not given and she verbalized understanding. She said facility staff was notified to contact hospice of any changes. She said she was contacted by LVN D around 5:00 p.m., indicating Resident #1's respirations were more labored and decreased, and family was requesting hospice to reassess the resident. She said she returned to the facility and completed an assessment on Resident #1 and reported findings of respiratory rate of 6 breaths per minute to the hospice physician. She said she rediscussed the antidote and ER evaluation options and effects if administered and RP declined. She said she provided end of life counseling with RP and family. She said she was contacted around 4:30 a.m. on [DATE] Resident #1 had no signs of life and requested RN to facility and pronounce time of death. Record review of Resident #1's hospice assessment dated [DATE] time in at 2:15 p.m. authored by Hospice RN indicated the resident's facility nurse called indicating the resident was having pain after already receiving Norco 7.5/325 mg two hours ago around 8:00 a.m. and a dose of morphine 1ml (scheduled every two hours) 30 minutes ago at 10:35 a.m., Hospice MD was notified, and new orders were received for morphine 1ml to be given every 30 minutes as needed for pain or shortness of breath until patient was comfortable and then every two hours. LVN A was given new orders and verbalized understanding. LVN A called back and stated Resident #1 would not have enough medication of morphine to last through the day and new orders/directions were sent to pharmacy. The morphine prescription would be picked up and delivered to the facility (by Hospice RN). Upon arriving to the facility, Resident #1's pain status and morphine doses given was verified when LVN A reported she had given 9 doses of morphine and last dose given was at 2:00 p.m. Hospice RN reviewed the resident's Morphine Narcotic Count Sheet and the times it was administered, and morphine had been given every 3 minutes and not every 30 minutes. The note indicated LVN A stated she had transcribed the order incorrectly for every 3 minutes. Resident #1 was assessed (by Hospice RN), and vital signs were taken, and Hospice MD was notified of the medication error and patient status. New orders given for the facility to hold the resident's pain medications for four hours, to obtain vital signs every 30 minutes, and to call Hospice if any changes occurred. The note indicated Hospice RN spoke with the resident's family member as well as the facility staff nurse with additions to the plan of care with verbalization of understanding. Record review of Resident #1's hospice assessment dated [DATE] time in at 5:00 p.m. authored by Hospice RN indicated LVN D called around 4:45 p.m. and Resident #1's family member requested for Hospice RN to return to the facility and assess Resident #1 because her respirations had changed and were more labored. Hospice nurse returned to reassess Resident #1. Family members were notified of options at the facility or send the resident to ER since this was not related to the Hospice diagnosis, but for treatment for symptoms from facility nurse giving incorrect frequencies of morphine Hospice RN discussed with Resident #1's family members regarding what happened if Narcan was administered to reverse the medication and the resident's pain could return and pain medications would still be held until patient was stable prior to resuming pain medication or send the resident to ER where they would likely give the Narcan as treatment. Hospice RN informed family members at bedside if Narcan was not given she could very well pass soon. Family member asked why Narcan would be given, and other family member responded because the morphine given was too much. Family members said she looked comfortable and would rather her be comfortable and pass rather than give her medications could cause her to be in pain again. Hospice RN gave direction for family members to contact additional immediate family because with her decreased respirations and pauses between breaths as the resident may soon pass. During an interview on [DATE] at 12:53 p.m., LVN D said she worked the 2-10 p.m. shift on [DATE] and during shift change she was made aware the Resident #1 had received an accidental overdose of morphine during the previous shift. She said Resident #1 was monitored throughout her shift and obtained vital signs every 30 minutes starting around 3:30 p.m. for 4 hours ending around 7:30 p.m. She said she did contact the hospice RN at the request of Resident #1's family because her respirations were labored and decreased at around 5:00 p.m. She said Resident #1's alertness and respiratory rate decreased throughout the shift. She said when she made her last rounds with oncoming nurse LVN C around 10 p.m. Resident #1's respiratory rate was down to 3 breaths per minute. Record review of Resident #1's Nurse Progress Note dated [DATE] at 5:05 a.m. authored by LVN C indicated nurse was called to resident room by Resident #1's sitter and no signs of life was present this nurse called hospice nurse, she arrived, assessed Resident #1, and pronounced time of death. During an interview on [DATE] at 2:18 p.m., LVN C said she worked the 10 p.m.-6 a.m. shift on [DATE] - [DATE] and during shift change she was made aware the Resident #1 had received an accidental overdose of morphine during the morning shift and she was being monitored. She said Resident #1 was not responding to verbal or tactile stimuli during her assessments and respiratory rate was at 3 -4 breathes a minute with periods of apnea. She said Resident #1's RP and family was at bedside most of the night. She said around 4:15 a.m., Resident #1's family member reported the resident was not breathing and had no signs of life. She said she went to assess Resident #1 and found no signs of life and contacted Hospice RN. She said Hospice RN arrived at the facility and pronounced Resident #1 deceased around 4:30 a.m. Record review of Resident #1's hospice assessment dated [DATE] time in at 4:38 a.m. authored by Hospice RN indicated Resident #1 expired on [DATE] at 4:38 a.m., death was pronounced by Hospice RN, after no pulse, respirations or other signs of life noted for 2 full minutes. During an interview on [DATE] at 2:13 p.m., LVN B said she was present at the nurses' station when LVN A was receiving the morphine orders for Resident #1, but she only heard LVN A's side of the conversation and heard her verify morphine 1ml every 3minutes until pain subsided and ask for the nurse's name and prescribing MD's name. She said she did acknowledge to LVN A this order for morphine seemed to be a lot. She said she left the nurses' station during the phone call but if she was transcribing the order she would have questioned the order or contacted the weekend supervisory before administering. During an interview on [DATE] at 10:20 a.m., the Hospice Physician said Hospice RN called her on [DATE] at 11:08 a.m. reporting Resident #1 was having a pain crisis and had received Norco 7.5mg and 1ml of morphine (20mg) over the last 2 hours with no relief. She said she gave orders for Resident #1 to have Morphine 1ml (20mg) every 30 minutes until her pain subsided or comfortable and then continue Morphine 1ml (20mg) every 2 hours for pain. She said around 2:57 p.m. Hospice RN contacted her and reported facility nurse (LVN A) transcribed the order incorrectly and had administered Resident #1's morphine 1ml (20mg) every 3 minutes for 9 doses (total of 180 mg in 24 minutes) instead of every 30 minutes. She said Hospice RN reported vital signs, assessment, and last dose of morphine 1ml (20mg) was at 2:00 p.m. and resident's vital signs were stable. She ordered for Narcan to be administered or to transfer the resident to the ER for evaluation which was declined by RP. She said she ordered for facility staff to continue to monitor Resident #1 and report to hospice with any changes. She said Hospice RN notified her around 4:30 p.m. of Resident #1's respiratory rate decreasing, and she returned to the facility to complete an assessment. She said Hospice RN reported the resident's decrease in responsiveness and respiratory rate. She said she advised Hospice RN to offer the resident's family the Narcan to be administered or sending the resident to the ER for evaluation, again the RP declined. She said morphine should never be given every 3 minutes because with liquid morphine it takes 20-30 minutes to take affect which is why it was ordered every 30 minutes during a pain crisis. She said the morphine could remain in the body's system for up to 6 hours depending on the body's metabolism. She said she had never ordered morphine 1ml (20mg) every 3 minutes as it would cause respiratory distress or failure if multiple doses given which could lead to death. During an interview on [DATE] at 12:42 p.m., the Attending NP said she was not contacted regarding Resident #1's morphine accidental overdose/medication error. The Attending NP said if she had been notified of the morphine overdose, she would have ordered for an antidote like Narcan to be administered and to monitor respirations or given an order for Resident #1 to be sent to the hospital due to her being on hospice. The Attending NP said she had never heard of morphine 20mg be given every 3 minutes and a large dose administered would cause respiratory distress or failure leading to death if antidote was not administered. During an interview on [DATE] at 2:30 p.m., RN E said she was the RN supervisor during the previous weekend (time of the incident), and she was not notified of the medication discrepancy until around 2:15 p.m. when she was asked for the DON's phone number to discuss the incident with her. She said if she was made aware of the medication discrepancy, she would have contacted Hospice RN or the hospice physician for clarification because the transcribed dose was not within the standard morphine prescribing guidelines. During an interview [DATE] at 2:47 p.m., the facility contracted Pharmacist said the effects of morphine overdose was respiratory depression, confusion, disorientation, fatigue, and sleepiness. She said she had never heard of morphine 20mg be given every 3 minutes and that was a concerning high dosage. The Pharmacist said the order should have been clarified before administering. During an interview on [DATE] at 5:00 p.m., the DON said she was not made aware of the incident with Resident #1's morphine incorrect dosage until [DATE] around 2:45 p.m. She said she contacted the consulting pharmacy, had LVN A complete medication error incident, verified hospice was aware, took statements, interviewed involved staff, and visited with Resident #1 and family. The DON said if licensed staff received an order that did not seem correct, outside of prescribing guidelines, or if they were not comfortable giving a medication, they should contact her, for further discussion and clarification from the pharmacist and the ordering or attending physician. The DON said the morphine overdose could have caused respiratory depression and death. The DON said Resident #1's RP was offered an antidote but declined. The DON said vital signs would be monitored more often or longer if an order was given by the physician. The DON said she contacted their pharmacist consultant regarding the overdose and was advised to complete a medication error incident report. She said the facility pharmacy consultant scheduled an in-person training for all licensed facility staff next week for continued training and the consultant would be providing staff a resource to have available for narcotic minimal and maximal dosage (not to exceed). The DON said she had provided training on [DATE] to licensed staff about clarification of verbal orders, completed medication pass competency checks with scheduled staff since the incident, and performed a chart audit of all residents on pain medication verifying adequate frequency/duration. The DON said she was performing medication pass review competency checkoffs on the licenses staff as they return to work and will not allow them to work if competency check not passed. The DON said she expected the licensed staff to use their professional judgement and not to provide medications they did not feel comfortable administering or to contact her prior to administering for additional clarification. Record review of the facility's Preventing and Detecting Adverse Consequences and Medication Error policy- dated [DATE] indicated, 2. When a resident receives a new medication the medication order is evaluated for the following a. the dose route of administration duration and monitoring are in agreement with the current clinical practice clinical guidelines and or manufacturers specifications for use Record review of an In-Service training report dated [DATE], with LVN A one on one training, with contents or summary of the training session included: if you receive a verbal order from MD or nurse that you do not feel comfortable following through with contact the DON immediately to discuss the orders received and MD or nurse will be contacted after discussion of order to verify or clarify order received. Record review of an In-Service training report dated [DATE], with facility charge nurses with contents or summary of training session included: if you receive a verbal order from MD or nurse that you do not feel comfortable following through with contact the DON immediately to discuss the orders received and MD or nurse will be contacted after discussion of order to verify or clarify order received, indicated 26 charge nurses signed the in-service record or received the training via phone conversation. Record review of Medication Pass Review Competency Checkoffs dated [DATE] -[DATE] indicated 8 charge nurses had completed and passed medication pass competency check off. Record review of a facility audit dated [DATE] at 9:30 a.m. indicated all residents with pain medication were reviewed for correct frequency and/duration of pain medications. Record review of Incident logs from [DATE] through [DATE] indicated there were no other medication error incidents at the facility. During interviews on [DATE] from 11:30 a.m. - [DATE] to 5:00 p.m., 2 RNs (RN E, RN F), and 9 LVNs (LVN A, LVN B, LVN C, LVN D, LVN G, LVN H, LVN I, LVN J, and LVN K) were able to identify correct protocol for receiving verbal orders, clarifying and repeating the order back to the prescriber and if orders were not within the prescribing guidelines or if they did not feel comfortable following or administering the orders, they were to contact the DON immediately to discuss the issues and the DON would contact the MD or nurse to verify/clarify the order received. All staff were able to identify the signs and symptoms of accidental overdosing of morphine and protocols to follow. On [DATE] at 05:25 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began.

**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 person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 17 residents (Resident #5) reviewed for care plans. The facility failed to ensure Resident #5's care plan ADL interventions were implemented on 09/22/24 resulting in serious injury. An Immediate Jeopardy (IJ) situation was identified on 01/23/25 at 3:23 p.m. While the IJ was removed on 01/24/25 at 6:37 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for staff not being aware of the resident needs and not receiving the care and services to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of Resident #5's face sheet indicated a [AGE] year old female, admitted to the facility on [DATE] (initially admitted on [DATE]). Resident #5 had diagnoses which included unspecified convulsions (seizures), displaced intertrochanteric fracture of left femur (thigh bone), dysphagia (swallowing difficulty), gastrostomy (feeding tube access), contracture of muscle (permanently shortened muscles), cervicalgia (neck pain), traumatic brain injury (usually results from a violent blow or jolt to the head or body), other abnormalities of gait and mobility (gait disorder), unilateral primary osteoarthritis of left hip (degenerative joint condition that primarily affects one side of the body), need for assistance with personal care, scoliosis (spine deformity) and muscle wasting and atrophy (loss of muscle mass). Record review of Resident #5's quarterly MDS assessment, dated 08/16/24, indicated she sometimes was able to make herself understood and understood others, she had severe cognitive impairment with a BIMS of 1, she had impairment on both sides of upper and lower extremities, and she was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLS. Resident #5 was always incontinent of bladder and bowel. Record review of Resident #5's quarterly MDS assessment, dated 12/26/24, indicated she sometimes was able to make herself understood and understood others, she had severe cognitive impairment with a BIMS of 1, she had impairment on both sides of upper and lower extremities, and she was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLS. Resident #5 was always incontinent of bladder and bowel. Record review of Resident #5's care plan, dated 02/27/18 revised 09/15/19, indicated she had an ADL performance deficit. Interventions indicated Resident #5 was totally dependent on 2 staff to provide bed bath, required extensive assist by 2 staff for bed mobility, and required total assistance by 2 staff for toileting. Record review of Resident #5's care guide, dated 01/13/25, indicated Resident #5 was totally dependent on 2 staff to provide bed baths, she required extensive assist by 2 staff to turn and reposition in bed as necessary and she required total assistance by 2 staff for toileting. Record review of Resident #5's progress note, dated 09/22/24 at 10:50 p.m., completed by the DON indicated Resident #5 rolled off the bed. Resident #5 was o.k. PRN pain medication administered. On-call notified and an order for left leg and hip x-ray was received. Record review of Resident #5's care record, for 09/22/24, indicated CNA C provided care without a second staff. Record review of progress note, dated 09/23/24 at 3:03 a.m., competed by LVN H, indicated CNA C informed LVN H she needed help with Resident #5 because she rolled out of the bed when CNA C was adjusting her in the bed at 10:50 p.m. on 09/22/24. Upon entering Resident #5's room, LVN H noted Resident #5 on the floor beside her bed. Resident #5 did not give a description. Resident #5 stated, My leg hurts. Resident had her hand resting on her left leg. LVN H did not see any impairment. LVN H, CNA C, LVN I and LVN J assisted Resident back to bed. Record review of Resident #5's x-ray, dated 09/24/24, indicated no acute fracture or dislocation. Record review of a progress note, dated 10/03/24 at 3:04 p.m., and completed by the DON, indicated PT G informed the DON of Resident #5 sometimes crying, she was not sure if Resident #5 was crying due to her roommate constantly hollering out or if it was due to her being in pain. The DON informed PT G that Resident #5 could tell staff when she was in pain. PT G agreed with the DON and that Resident #5 informed her she was hurting, and she was going to apply a cold pack to Resident #5's leg to see if it helped. PT G stated Resident #5 even told her (PT G) about the fall she had. The DON contacted NP F and order was given for repeat X-ray. Record review of Resident #5's x-ray, dated 10/03/24, of left hip indicated age indeterminate, transverse, comminuted, mildly displaced intertrochanteric fracture femur with varus deformity (hip fracture where the bone is broken across its width (transverse) in multiple pieces (comminuted) slightly shifted out of place (mildly displaced) and angled inwards at the fracture site creating a varus deformity typically seen in the area between the greater and lesser trochanters of the femur (the inter trochanteric region). Record review of hospital records, dated 10/07/24, indicated Resident #5 had surgical repair of left hip fracture. Record review of Resident #5's fall assessment ,dated 06/27/24, indicated she was a moderate fall risk. Record review of Resident #5's fall assessment, dated 09/23/24, indicated she was a high fall risk. Record review of Resident #5's Admit/Readmit Screener, dated 10/08/24, completed by LVN A, indicated Resident #5 was totally dependent for all ADLS. Record review of the facility investigation, dated 10/11/24, indicated the facility determined Resident #5 had a fall on 09/22/24 and the fractured hip was most likely to have occurred at that time. During an interview on 01/13/25 at 10:56 a.m., CNA C said she was providing toileting care to Resident #5 on 09/22/24. She said she rolled Resident #5 over to remove the soiled brief and Resident #5 rolled off the bed onto the floor. She said she always provided care to Resident #5 without a second staff. She said Resident #5 did not have hold of the side rail for repositioning. She said Resident #5 complained of pain to her left leg after she fell. She said she was trained to provide care for Resident #5 without a second staff. She could not recall who had trained her. She said she did not check Resident #5's care guide and had not seen the care guide which indicated Resident #5 required 2 staff for bed bath bed mobility, or toileting. She said residents were at risk of injury if they did not receive care as required. During an interview on 01/13/25 at 11:15 a.m., the DON said Resident #5 fell from the bed during care. She said she was assessed with no injury. She said Resident #5 required only 1 staff to provide care because Resident #5 could assist with turning and repositioning by holding on to the side rails. She said the care plan should say 1 person and not 2 persons for care. She said residents were at risk of injury if their care guide was not accurate or if staff did not follow the care guide. She said the care guide was dated 10/08/24 on Resident #5's readmission from hospital. During an interview on 01/13/25 at 11:36 a.m., MDS LVN E said Resident #5's MDS dated [DATE] and 12/26/24 were completed using the previous 7 days of documentation by staff. She said if there were two staff providing care one time in the previous 7 days then the MDS would indicate 2 staff were required. She said the care plan was based on the MDS. She said the care plan populated the resident care guide. She said the care plan was not revised to indicate 1 staff could provide Resident #5's care. She said she did not update Resident #1's care plan when she returned from the hospital. She said residents were at risk of injury if they did not receive care as required. During an interview on 01/14/25 at 9:20 a.m., CNA P said Resident #5's care guide indicated 2 staff were required for bed bath, bed mobility, and toileting. She said she would ask a second aide or nurse to assist if she was providing care when she (Resident #5) fell out of the bed. During an interview on 01/14/25 at 11:15 a.m., CNA ZZ said he provided Resident #5's care without a second staff. He said Resident #5 assisted with repositioning and turning during care by holding the side rail. He said she was never in distress or exhibited signs of pain when he provided care. He said he did not see she was 2-person assist on the care guide. He said he was trained to provide her care without a second staff. He said was able to access the care guide to determine the level of care a resident required. During an interview on 01/14/25 at 11:24 a.m., RN B said Resident #5 was normally a 1-person assist with care because she (Resident #5) could assist with repositioning and turning and would hold the side rail. She said she did not know why the care plan or care guide indicated 2 person assist. During an interview on 01/14/25 at 11:30 a.m., Resident #5 said no when asked if she had hold of the rail for repositioning when she fell off the bed. Resident #5 said yes when asked if only 1 staff provided care when she fell out of the bed and said yes when asked if usually 1 staff provided her care. During an interview on 01/15/25 at 9:48 a.m., LVN Q said she did not know why 1 staff would provide care for any resident if the care guide said 2 staff were required. She said she would assist any aide who requested assist with Resident #5. During an interview on 01/15/25 at 10:11 a.m., NP F said it was her opinion Resident #5 required 2 staff for care due to Resident #5's physical condition and being immobile in bed. During an interview on 01/15/25 at 1:30 p.m., CNA O said she would take care of Resident #5 without a second staff. She said she did not know Resident #2's care guide indicated she required 2 staff for care. She said she never noticed the indication for 2 staff. She was able to to access resident care guide but never noticed the required two staff. During an interview on 01/15/25 at 1:50 p.m., the DON said staff looked at the resident care guide to know how to care for residents. Staff should check the care guide to know if the residents' care was changed. Residents were at risk of potential harm or injury if 1 person did their care and 2 staff were required. During an interview on 01/23/25 at 12:00 p.m., the DON said on 09/22/24, Resident #5's care plan indicated she required 2 staff for bathing, repositioning and toileting. She said she was responsible for implementing interventions post incident. She said she would review the incident report and if interventions were decided on, she would get an order and implement the interventions. She said fall mats were implemented after Resident #5 fell out of her bed on 09/22/24. She said she did not evaluate the need for 2 staff for resident safety because CNA C reported she was walking past Resident #5's room and saw her leg hanging out of the bed. She said CNA C attempted to reposition Resident #5 and Resident #5 continued to roll out of the bed. During an interview on 01/23/25 at 12:35 p.m., CNA C said she did not remember exactly what happened on 09/22/24 when Resident #5 fell out of the bed. She said she assumed it was because she was changing Resident #5 but when asked about repositioning Resident #5's leg she said Resident #5 fell out of the bed when she pulled the draw sheet. She said she may have put Resident #5's leg up and checked her for wetness and that was when Resident #5 rolled out of the bed. Record review of the facility's Comprehensive Care Plan Policy, dated 01/20/21, indicated the resident will have an individualized interdisciplinary plan of care in place . The Care Plan is revised every quarter, significant change of condition, annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. Record review of the facility's Incident and Accident Policy, dated 03/01/17, indicated . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; Ensuring that interventions are implemented; and documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently. Record review of the facility's Safety and Supervision of Residents policy, dated 2001 (revised July 2017), indicated . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. This was determined to be an Immediate Jeopardy (IJ) on 01/23/25 at 3:23 p.m. The facility's Administrator and DON were notified. The Administrator was provided the IJ template on 01/23/25 at 3:23 p.m. The following Plan of Removal (POR) submitted by the facility was accepted on 01/24/25 at 4:27 p.m.: Plan of Action Immediate action taken by staff: Physical Therapy evaluated Resident #5 to ensure appropriate staff assist to prevent further accidents. The Director of Clinical Operations implemented floor mats for Resident #5 on 9/22/2024. The MDS nurse updated the level of assist to 1-2 person for ADL's for Resident #5 to prevent further injuries on 1/13/2025. Physical Therapy determines the level of assistance required. The MDS Nurse implemented scoop mattress for Resident #5 to prevent further injuries on 1/24/2025. The above change in care is discussed in the morning clinical meeting with the update being added to the [NAME] to keep staff informed. The MDS Nurse is responsible for making the update on a quarterly basis, or as needed if a change occurs, after the IDT has discussed the resident. The IDT determines the number of staff (increase/decrease) that is needed for ADL's. On 1/24/2025 at 3:30 pm the EDO had the therapist go re-evaluate Resident #5 for ADL care. The evaluation showed that Resident #5 was a 1 person assist for bed mobility. The IDT met and are in agreeance will make the change on the care plan effective 1/24/2025. The Director of Clinical Services will perform an in-service education to the staff immediately on the level of care during of this assessment of Resident #5. The MDS Nurse and/or designee will review fall care plans on all residents to ensure that they are appropriate and will help prevent injuries by ensuring the appropriate level of assistance needed for ADL's by team members. Completion date 1/24/2025 by 10:00am. All care plans will be reviewed to ensure the appropriate level of assistance for ADL's by staff is accurate by the MDS Nurse and/or designee. The care plan will update the [NAME] to show the level of assistance needed to all nursing staff. Completion date 1/24/2025 by 10:00am. All incidents/accidents will be reviewed in the morning clinical meeting by the Director of Clinical of Operations and/or designee to ensure that care plan is updated to reflect any changes in level of care and appropriate interventions are in place after each fall. Completion date 1/24/2025 by 10:00am and ongoing. In-service Education will be provided to all nursing staff by the Director of Clinical Services and/or designee. Staff will not be allowed to work until in-service education has been provided which includes: 1. How to use the [NAME] to determine the level of staff assistance needed to care for the residents. The change in level of assistance will be communicated in the morning clinical meeting and the [NAME] is updated at that time. Completion Date of all in-service 1/24/2025 by 10:00am. The Director of Clinical Services and/or the Assistant Director of Clinical Services will randomly monitor two nurse aides weekly times 10 weeks to ensure that they are utilizing the [NAME] for resident care. Any aide that is not utilizing the [NAME] system will be re-trained immediately. Completion date 1/24/2025 at 12:00 pm and on-going. The Regional Clinical Reimbursement Coordinator will perform in-service education with the MDS Nurses on personalizing the care plan for falls with interventions and level of care provided by team members. The Director of Clinical Services and/or the Assistant Director of Clinical Services will monitor during the morning clinical meeting, during the review of incidents/accidents, that the interventions and level of care provided by team members are being reviewed and care plan changed as needed. Completion date 1/24/2025 by 10:00am. The incident/accident care plans will be monitored by the Director of Clinical Services and/or by the Assistant Director of Clinical Services in the morning clinical meeting with the IDT to ensure appropriate fall interventions are in place for the resident's care plan. The fall interventions will be monitored for 72 hours by the Director of Clinical Operation and/or designee to ensure that the intervention is effective. If the fall intervention is not effective the IDT will make other recommendations for a new approach and the care plan will be updated. Completion date by 1/24/2025 by 10:00am and ongoing. Monitoring of the Plan of Removal included the following: Observations conducted on 01/24/25 between 4:27 p.m. and 6:37 p.m. indicated staff (CNA W and CNA C) were able to access the [NAME] (resident care guide) to determine level of staff require as required. Resident #5 had a scoop mattress, floor mats, low bed, and call light in reach. There were no observed concerns. Interviews with staff (DON, ADON DD, ADON EE, RN B, RN CC, MDS LVN E, LVN A, LVN H, LVN I, LVN J, LVN K, LVN L, CNA C, CNA M, CNA N, CNA O, CNA P, CNA W, CNA X, CNA Y, and CNA Z), who represented all shifts (6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m.) indicated they were aware of and able to give examples of how to use the [NAME]/care guide (level of care required for ADLS included bed mobility, incontinent care/toileting, and bathing). Nursing staff indicated they observed and monitor staff every shift to ensure care was provided per each resident's care plan and care guide and would immediately intervene and retrain staff if necessary. During an interview on 01/24/25 at 5:22 p.m., MDS LVN E indicated she was responsible for making the care plan updates on a quarterly basis or as needed if a change occurred. She said the IDT determined the number of staff (increase/decrease) that were needed for ADLS. Record review of Resident #5's PT assessment dated [DATE] indicated she used both hands to help with rolling and only required 1 staff to provide safe hygiene, ADLS, bathing and repositioning. Record review of Resident #5's care plan indicated a scoop mattress was implemented as of 01/24/25 and she required 1 person staff assist for ADLS. Record review of incident and accident reports from 12/24/24 through 01/24/25, indicated care plans were appropriate and personalized for 7 of 7 residents (Residents #13, #14 #15, #16, #17, #18, #19) reviewed. Record review of Incidents and accident reports from 12/24/24 through 01/24/25, indicated there was adequate staff assistance as indicated in the care plan recommendations for 7 of 7 residents (Residents #13, #14 #15, #16, #17, #18, #19) reviewed. Record review of the facility's monitoring indicated the Director of Clinical Operation and/or designee reviewed incident/accident reports in the morning clinical meeting with the IDT to ensure appropriate interventions were in place for the resident. There were no concerns noted. Record review of incidents/accidents reviewed in the morning clinical meeting on 01/24/25 by the Director of Clinical Operations and/or designee indicated care plans were updated to reflect any changes in the level of care and appropriate interventions were in place. Record review of readmissions on 01/24/25 from the hospital indicated there was no re-admission to the facility. Record review of staff training dated 01/24/25 indicated staff training included how to use the [NAME]/care guide to determine level of staff assistance needed to care for the residents, the change in level of assistance would be communicated in morning meeting and the resident [NAME]/care guide updated during the morning meeting. Record review of staff training dated 01/24/25 indicated the MDS nurse was trained on personalizing resident care plans for falls with interventions and level of care required for ADLS. The Administrator was informed the Immediate Jeopardy was removed on 01/24/25 at 6:37 p.m. The facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review the facility failed to provide supervision and assistance devices to prevent accident for 1 of 17 (Resident #5) residents reviewed for accidents/supervision. The facility failed to ensure CNA C provided ADL care with 2 person assistance. Resident #5 fell out of her bed and sustained a fractured left femur during care on 09/22/24. An Immediate Jeopardy (IJ) situation was identified on 01/23/25 at 3:23 p.m. While the IJ was removed on 01/24/25 at 6:37 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents and injuries. Findings include: Record review of Resident #5's face sheet indicated a [AGE] year old female, admitted to the facility on [DATE] (initially admitted on [DATE]). Resident #5 had diagnoses which included unspecified convulsions (seizures), displaced intertrochanteric fracture of left femur (thigh bone), dysphagia (swallowing difficulty), gastrostomy (feeding tube access), contracture of muscle (permanently shortened muscles), cervicalgia (neck pain), traumatic brain injury (usually results from a violent blow or jolt to the head or body), other abnormalities of gait and mobility (gait disorder), unilateral primary osteoarthritis of left hip (degenerative joint condition that primarily affects one side of the body), need for assistance with personal care, scoliosis (spine deformity) and muscle wasting and atrophy (loss of muscle mass). Record review of Resident #5's quarterly MDS assessment, dated 08/16/24, indicated she sometimes was able to make herself understood and understood others, she had severe cognitive impairment with a BIMS of 1, she had impairment on both sides of upper and lower extremities, and she was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLS. Resident #5 was always incontinent of bladder and bowel. Record review of Resident #5's quarterly MDS assessment, dated 12/26/24, indicated she sometimes was able to make herself understood and understood others, she had severe cognitive impairment with a BIMS of 1, she had impairment on both sides of upper and lower extremities, and she was dependent (Helper does all the effort. Resident does none of the effort to complete the activity, or, the assistance of 2 or more helpers is required for the resident to complete the activity) on staff for all ADLS. Resident #5 was always incontinent of bladder and bowel. Record review of Resident #5's care plan, dated 02/27/18 revised 09/15/19, indicated she had an ADL performance deficit. Interventions indicated Resident #5 was totally dependent on 2 staff to provide bed bath, required extensive assist by 2 staff for bed mobility, and required total assistance by 2 staff for toileting. Record review of Resident #5's care guide, dated 01/13/25, indicated Resident #5 was totally dependent on 2 staff to provide bed baths, she required extensive assist by 2 staff to turn and reposition in bed as necessary and she required total assistance by 2 staff for toileting. Record review of Resident #5's progress note, dated 09/22/24 at 10:50 p.m., completed by the DON indicated Resident #5 rolled off the bed. Resident #5 was o.k. PRN pain medication administered. On-call notified and an order for left leg and hip x-ray was received. Record review of Resident #5's care record, for 09/22/24, indicated CNA C provided care without a second staff. Record review of progress note, dated 09/23/24 at 3:03 a.m., competed by LVN H, indicated CNA C informed LVN H she needed help with Resident #5 because she rolled out of the bed when CNA C was adjusting her in the bed at 10:50 p.m. on 09/22/24. Upon entering Resident #5's room, LVN H noted Resident #5 on the floor beside her bed. Resident #5 did not give a description. Resident #5 stated, My leg hurts. Resident had her hand resting on her left leg. LVN H did not see any impairment. LVN H, CNA C, LVN I and LVN J assisted Resident back to bed. Record review of Resident #5's x-ray, dated 09/24/24, indicated no acute fracture or dislocation. Record review of a progress note, dated 10/03/24 at 3:04 p.m., and completed by the DON, indicated PT G informed the DON of Resident #5 sometimes crying, she was not sure if Resident #5 was crying due to her roommate constantly hollering out or if it was due to her being in pain. The DON informed PT G that Resident #5 could tell staff when she was in pain. PT G agreed with the DON and that Resident #5 informed her she was hurting, and she was going to apply a cold pack to Resident #5's leg to see if it helped. PT G stated Resident #5 even told her (PT G) about the fall she had. The DON contacted NP F and order was given for repeat X-ray. Record review of Resident #5's x-ray, dated 10/03/24, of left hip indicated age indeterminate, transverse, comminuted, mildly displaced intertrochanteric fracture femur with varus deformity (hip fracture where the bone is broken across its width (transverse) in multiple pieces (comminuted) slightly shifted out of place (mildly displaced) and angled inwards at the fracture site creating a varus deformity typically seen in the area between the greater and lesser trochanters of the femur (the inter trochanteric region). Record review of hospital records, dated 10/07/24, indicated Resident #5 had surgical repair of left hip fracture. Record review of Resident #5's fall assessment, dated 06/27/24, indicated she was a moderate fall risk. Record review of Resident #5's fall assessment, dated 09/23/24, indicated she was a high fall risk. Record review of Resident #5's Admit/Readmit Screener, dated 10/08/24, completed by LVN A, indicated Resident #5 was totally dependent for all ADLS. Record review of the facility investigation, dated 10/11/24, indicated the facility determined Resident #5 had a fall on 09/22/24 and the fractured hip was most likely to have occurred at that time. During an interview on 01/13/25 at 10:56 a.m., CNA C said she was providing toileting care to Resident #5 on 09/22/24. She said she rolled Resident #5 over to remove the soiled brief and Resident #5 rolled off the bed onto the floor. She said she usually provided care to Resident #5 without a second staff because she was trained to provide care to Resident #5 without a second staff. She said Resident #5 did not have hold of the side rail for repositioning. She said Resident #5 would usually hold the side rail and assist with repositioning. She said an unnamed nurse assessed Resident #5 with no injuries then the nurse and other aides picked Resident #5 up and put her back in bed. She said Resident #5 complained of pain to her left leg. She said she was trained to provide care for Resident #5 without a second staff. She could not recall who trained her. She said she did not check Resident #5's care guide and did not realize the care guide indicated Resident #5 required 2 staff for bed bath bed mobility, or toileting. She said if she needed a second staff, she would ask an aide or a nurse for assistance. She said she was not aware of Resident #5 having any history of falling from the bed during care. She said residents were at risk of injury if they did not receive care as required. During an interview on 01/13/25 at 11:15 a.m., the DON stated Resident #5 fell from the bed during care. She said she was assessed with no injury. She said the physician was notified and ordered an x-ray of the left hip and leg. She said the first x-ray completed on 09/24/24 indicated no injury. She said on 10/03/24, PT G notified her (the DON) of Resident #5 being in pain during therapy. She said she notified the physician and N/O were obtained for a repeat x-ray. She said the x-ray completed on 10/3/24 indicated Resident #5 had a fractured left femur. She said Resident #5 was sent to the hospital for further evaluation and treatment. She said Resident #5 had surgical repair of her left hip. She said it was likely caused from the fall on 09/22/24 since there was no other identified cause of the fracture. She said Resident #5 required only 1 staff to provide care because Resident #5 could assist with turning and repositioning by holding on to the side rails. She said Resident #5 did not have any history of falling from the bed during care. She said residents were at risk of injury if their care guide was not accurate or if staff did not follow the care guide, or if they did not receive care as required. During an interview on 01/13/25 at 11:36 a.m., MDS LVN E said Resident #5's, MDS dated [DATE] and 12/26/24, were completed using the previous 7 days of documentation by staff. She said if there were two staff providing care one time in the previous 7 days then the MDS would indicate 2 staff were required. She said the care plan was based on the MDS. She said the care plan populated the resident care guide. She said the care plan was not revised to indicate 1 staff could provide Resident #5's care. She said residents were at risk of serious injury if they did not receive care as required. During an interview on 01/14/25 at 9:20 a.m., CNA P said Resident #5's care guide indicated 2 staff were required for bed bath, bed mobility, and toileting. She said she would ask a second aide or nurse to assist if she was providing care when she fell out of the bed. During an interview on 01/14/25 at 11:15 a.m., CNA ZZ said he provided Resident #5's care without a second staff because he was trained to provide care without a second staff. He said he could not recall who trained him to provide Resident #5's care. He said Resident #5 assisted with repositioning and turning during care by holding the side rail. He said she was never in distress or exhibited signs of pain when he provided care. He said he did not see she was 2-person assist on the care guide. He said he was trained to provide her care without a second staff. During an interview on 01/14/25 at 11:24 a.m., RN B said Resident #5 was normally a 1-person assist with care because she (Resident #5) could assist with repositioning and turning and would hold the side rail. She said she did not know why the care plan or care guide indicated 2 person assist. During an interview on 01/14/25 at 11:30 a.m., Resident #5 said no when asked if she had hold of the rail for repositioning when she fell off the bed. Resident #5 said yes when asked if only 1 staff provided care when she fell out of the bed and said yes when asked if usually 1 staff provided her care. She did not respond when asked who was the staff who provided care. She said yes when asked if her left leg hurt after the fall. During an interview on 01/14/25 at 1:55 p.m., PT G said it was her opinion 1 staff could provide Resident #5's care if Resident #5 was in the correct position and had hold of the side rail. She said Resident #5 sometimes could move her arm and her hand would grab the bed rail but sometimes the staff would have to move her arm and place her hand on the rail. She said she screened Resident #5 after her fall on 09/22/24 and was informed there was no fracture. She said she instructed the unnamed CNAs to be aware of Resident #5's position before rolling her in the bed. She said she attempted therapy on 10/03/24 with Resident #5 but Resident #5 was in pain and crying. During an interview on 01/15/25 at 9:48 a.m., RN B said she did not know why 1 staff would provide care for any resident if the care guide said 2 staff were required. She said she would assist any aide who requested assist with Resident #5. During an interview on 01/15/25 at 10:11 a.m., NP F said it was her opinion Resident #5 required 2 staff for care due to Resident #5's physical condition and being immobile in bed. She said it was probable the fractured femur occurred when Resident #5 fell from her bed on 09/22/24 but did not show in the first x-ray. She said the fractured femur became pronounced and visible on the second x-ray due to normal ADLS and physical therapy. During an interview on 01/15/25 at 1:30 p.m., CNA O said she would take care of Resident #5 without a second staff. She said she was trained to take care of her with 1 staff. She said Resident #5 would hold the side rail to assist with turning and repositioning. She said if she needed a second staff, she would ask an aide or a nurse for assistance. She said she did not realize Resident #2's care guide indicated she required 2 staff for care. She said she was not aware of Resident #5 having any history of falling from the bed during care. During an interview on 01/15/25 at 1:50 p.m., the DON said staff look at the resident care guide to know how to care for residents. Staff should check the care guide to know if the residents' care was changed. Residents were at risk of potential harm or injury if 1 person did their care and 2 staff were required. During an interview on 01/23/25 at 10:18 a.m., PT G said residents dependent for care or required 2 staff for ADLS did not always mean the resident was supposed to have 2 staff at all times. She said having two staff would make completing ADLS easier and require less time. She said staff would have to ensure the resident was in the correct position and centered in the bed at all times to ensure the resident was safe and not in danger of falling out of the bed during ADLS or repositioning. During an interview on 01/23/25 at 12:00 p.m., the DON said on 09/22/24, Resident #2's care plan indicated she required 2 staff for bathing, repositioning and toileting. She said she was responsible for implementing interventions post incident. She said she would review the incident report and if interventions were decided on, she would get an order and implement the interventions. She said fall mats were implemented after Resident #5 fell out of her bed on 09/22/24. She said she did not evaluate the need for 2 staff for resident safety because CNA C reported she was walking past Resident #5's room and saw her leg hanging out of the bed. She said CNA C attempted to reposition Resident #5 and Resident 5 continued to roll out of the bed. During an interview on 01/23/25 at 12:35 p.m., CNA C said she did not remember exactly what happened on 09/22/24 when Resident #5 fell out of the bed. She said she assumed it was because she was changing Resident #5 but when asked about repositioning Resident #5's leg she said Resident #5 fell out of the bed when she pulled the draw sheet. She said she may have put Resident #5's leg up and checked her for wetness and that was when Resident #5 rolled out of the bed. Record review of the facility's Incident and Accident Policy, dated 03/01/17, indicated Our facility strives to make the environment as free from hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; Ensuring that interventions are implemented; and documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently. Record review of the facility's Safety and Supervision of Residents policy, dated 2001 (revised July 2017), indicated 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 . 1. Our individualized, resident-centered approach to safety addressed safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. This was determined to be an Immediate Jeopardy (IJ) on 01/23/25 at 3:23 p.m. The facility's Administrator and DON were notified. The Administrator was provided with the IJ template on 01/23/25 at 3:23 p.m. The following Plan of Removal (POR) submitted by the facility was accepted on 01/24/25 at 4:27 p.m.: Plan of Action Immediate action taken by staff: The nurse entered the room after being notified by aide that Resident #5 was on the floor beside her bed. The resident was assessed by the nurse and assisted back to bed with four staff members. The resident complained of pain to the left leg. The nurse did not see any impairment at this time. The nurse administered pain medication, notified attending physician, and family of fall. Attending physician ordered X-ray to the left hip and left leg. The nurse left the room with the bed in low position and call light within reach. X-ray results showed no fracture. The nurse will continue to assess and monitor for pain. Physical Therapy evaluated Resident #5 to ensure appropriate staff assist to prevent further accidents. The Director of Clinical Operations implemented floor mats for Resident #5 on 9/22/2024. The MDS Nurse implemented scoop mattress for Resident #5 to prevent further injuries on 1/24/2025. The above change in care are discussed in the morning clinical meeting with the update being added to the [NAME] to keep staff informed. The MDS Nurse is responsible for making the update on a quarterly basis, or as needed if a change occurs, after the IDT has discussed the resident. The IDT determines the number of staff (increase/decrease) that is needed for ADL's. On 1/24/2025 at 3:30 pm the EDO had the therapist go re-evaluate Resident #5 for ADL care. The evaluation showed that Resident #5 was a 1 person assist for bed mobility. The IDT met and are in agreeance will make the change on the care plan effective 1/24/2025. The Director of Clinical Services will perform an in-service education to the staff immediately on the level of care during of this assessment of Resident #5. The Director of Clinical Operations and/or the Assistant Director of Clinical Operations will review incidents and accidents within the last 30 days with a focus on falls to ensure care plans were appropriate and personalized with interventions after each fall. Completion date 1/24/2025 by 10:00am. The Director of Clinical Operations and/or designee will review incident/accidents reports in the morning clinical meeting to ensure that there was adequate staff assistance as indicated in the care plan recommendations. Completion date 1/24/2025 by 10:00am and ongoing. The Director of Clinical Operation and/or designee will review incident/accident reports in the morning clinical meeting with IDT to ensure appropriate intervention in place for the resident. The intervention will be monitored for 72 hours by the Director of Clinical Operation and/or designee to ensure that the intervention is effective. If the intervention is not effective the IDT will make other recommendations for a new approach. Completion date 1/24/2025 by 10:00am. Morse fall risk assessments were reviewed on all residents by the Director of Clinical Operations and/or the Assistant Director of Clinical Operations. Residents identified as having a high fall risk will have care plans and [NAME] updated with interventions and reflect any changes to their personalized plan of care. Completion date 1/24/2025 by 10:00am. All incidents/accidents will be reviewed in the morning clinical meeting by the Director of Clinical Operations and/or designee to ensure that care plan is updated to reflect any changes in level of care and appropriate interventions are in place. Completion date 1/24/2025 by 10:00am and ongoing. All readmissions from the hospital will be reviewed in the morning clinical meeting by the Director of Clinical Operations and Assistant Director of Clinical Operations for any changes in the level of care. The care plan will be updated for any noted changes in the level of care. Completion date 1/24/2025 by 10:00am and ongoing. In-service Education will be provided to all nursing staff by the Director of Clinical Services and/or designee. Staff will not be allowed to work until in-service education has been provided which includes: 1. Fall interventions (referral to therapy, fall mats, low bed, change in level of assistance, etc.) and prevention of falls. 2. Appropriate interventions based on the resident's individualized assessment that are added to care plan after each fall. 3. How to use the [NAME] to determine fall interventions put in place to ensure interventions are followed. Completion Date of all in-service 1/24/2025 by 10:00am. The Director of Clinical Services and/or the Assistant Director of Clinical Services will randomly monitor two nurse aides' weekly times 10 weeks to ensure that they are utilizing the [NAME] for resident care. Any aide that is not utilizing the [NAME] system will be re-trained immediately. Completion date 1/24/2025 at 10:00am and on-going. The Regional Director of Clinical Operations performed in-service education with DCO and ADCO's on personalizing of interventions put into place to prevent falls. Completion date 1/24/2025 by 10:00am. The Director of Clinical Services and/or Assistant Director of Nursing will refer any resident that exhibits pain or injury related to a fall to be screen/evaluated by physical therapy for changes in ADL care. The care plan will be updated with therapy recommendations. Completion Date on 1/24/2025 at 10:00am and ongoing. Monitoring of the Plan of Removal included the following: Observations conducted on 01/24/25 between 4:27 p.m. and 6:37 p.m. indicated staff were able to access the [NAME] (resident care guide) to determine the level of staff require as required. There were no observed concerns. Observation conducted on 01/24/25 at 5:00 p.m. indicated Resident #5 laid on a scoop mattress. Her bed was in the low position and the fall mats were on each side of her bed. There were no observed concerns. Interviews on 01/24/25 from 4:27 p.m. through 6:35 p.m. with staff (DON, ADON DD, ADON EE, RN B, RN CC, MDS LVN E, LVN A, LVN H, LVN I, LVN J, LVN K, LVN L, CNA C, CNA M, CNA N, CNA O, CNA P, CNA W, CNA X, CNA Y, and CNA Z), who represented all shifts (6:00 a.m.-2:00 p.m., 2:00 p.m. -10:00 p.m., and 10:00 p.m.-6:00 a.m.) indicated they were aware of and able to give examples of how to use the [NAME]/care guide (level of care required for ADLS included bed mobility, incontinent care/toileting, and bathing). Staff were aware of Resident #5's level of assistance needs. Nursing staff indicated they observed and monitor staff every shift to ensure care was provided per each resident's care plan and care guide and would immediately intervene and retrain staff if necessary. During an interview on 01/24/25 at 5:22 p.m., MDS LVN E indicated she was responsible for making the care plan updates on a quarterly basis or as needed if a change occurred. She said the IDT determined the number of staff (increase/decrease) that were needed for ADLS. Record review of Resident #5's PT assessment dated [DATE] indicated she used both hands to help with rolling and only required 1 staff to provide safe hygiene, ADLS, bathing and repositioning. Record review of Resident #5's care plan indicated a scoop mattress was implemented as of 01/24/25 and she required 1 person staff assist for ADLS. Record review of incident and accident reports from 12/24/24 through 01/24/25 indicated care plans were appropriate and personalized for 7 of 7 residents(Residents #13, #14 #15, #16, #17, #18, #19) reviewed. Record review of Incidents and accident reports from 12/24/24 through 01/24/25 indicated there was adequate staff assistance as indicated in the care plan recommendations for 7 of 7 residents (Residents #13, #14 #15, #16, #17, #18, #19) reviewed. Record review of the facility monitoring date 01/24/25 indicated the Director of Clinical Operation and/or designee reviewed incident/accident reports in the morning clinical meeting with the IDT to ensure appropriate intervention in place for the resident. There was no concerns noted. Record review of residents' Morse fall risk assessments reviewed on 01/24/25on all residents by the Director of Clinical Operations and/or the Assistant Director of Clinical Operations. 7 of 7 residents (Resident #3, #13, #14, #15, #19, #20, and #21) identified as high fall risk care plans and [NAME] were updated with interventions and reflected any changes to their personalized plan of care. Record review of incidents/accidents reviewed in the morning clinical meeting on 01/24/25 by the Director of Clinical Operations and/or designee indicated care plans were updated to reflect any changes in the level of care and appropriate interventions were in place. Record review of readmissions on 01/24/25 from the hospital indicated there was no re-admission to the facility. Record review of staff training dated 01/24/25 indicated staff training included: 1. Fall interventions (referral to therapy, fall mats, low bed, change in level of assistance, etc.) and prevention of falls. 2. Appropriate interventions based on the resident's individualized assessment that are added to care plan after each fall. 3. How to use the [NAME] to determine fall interventions put in place to ensure interventions are followed. Record review of staff training dated 01/24/25 indicated the DCO and ADCO's were trained on personalizing of interventions put into place to prevent falls. The Administrator was informed the Immediate Jeopardy was removed on 01/24/25 at 6:37 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.