**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 that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans. * The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. * The facility failed to update Resident #2's care plan after she had 2 falls. * The facility failed to develop a person-centered care plan with interventions that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall. An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50 p.m., the facility remained out of compliance at a scope of pattern 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 who were assessed as high risk for falls at risk of serious harm and injury. Findings included: 1. Record review of face sheet dated 09/19/2024 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (head injury causing damage to the brain by external force or mechanism) from a MVA 30 years ago; paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body); arterial ulcers (skin injuries caused by inadequate blood supply to the affected area) to heel, ankle, and toe; intracranial injury (any injury occurring within the skull) with loss of consciousness; lack of coordination; osteoarthritis (inflammation of one or more joints); and abnormalities of gait and mobility. Record review of Fall Risk Assessments dated 07/06/24 and 08/04/24 indicated Resident #1 was a high risk for falls. Record review of Resident #1's comprehensive care plans initiated on 07/08/24 did not address Resident #1's Fall Risk Assessment of high risk with interventions to implement to prevent falls or injuries from falls. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS score of 6 indicating Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance for transfers and all ADLs. He used a manual wheelchair. He had no falls since admission. Record review of Nurse Notes indicated an entry on 08/16/24 at 02:00 p.m. that Resident #1 was placed on a low air loss mattress due to open area to his sacrum. There was no documentation of interventions to prevent potential falls after placement. Record review of Nurse Notes indicated an entry on 08/17/2024 01:40 p.m. that Resident #1 was on his right side on the floor by his bed. He was assisted back to the bed. Resident #1 said he did not know how he fell. He just knew he was on the floor. He had a 5cm x 3cm swollen area right side of head, 3cm x 2cm skin tear on the lateral aspect of the right elbow, and the right side of his face had swelling. Record review of a telehealth noted dated 08/17/24 indicated Resident #1 had unwitnessed fall with a knot to right side of forehead and redness to right side of face. Record review of an incident report dated 08/17/24 indicated Resident #1 was found on the floor. According to the incident report, he was put back in the bed and a head-to-toe assessment was done with a 5cm x 3cm swollen area to the right side of head, a 3cm x 2cm skin tear on the lateral aspect of his right elbow, and the right side of his face had swelling. The NP saw Resident #1 via telehealth and ordered him to be sent to the hospital ER. Record review of the hospital CT scan report of the neck dated 08/17/24 showed Resident #1 had a question age-indeterminate non-displaced type 3 (extend into the body of the vertebra) odontoid (a bony element extending superiorly from the second cervical vertebra) fracture (break). He returned to the facility with an order to wear a neck brace for 8 weeks. Record review of a Bed Rail/Assist Bar Evaluation dated 08/18/24 indicated Resident #1 had assessment done for post fall. A. Evaluation Factors 1. Resident has expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort. 1A. If selected, explain: Resident will use for turning and repositioning 6. Resident has a history of falls. 7. The resident is having problems with balance or poor trunk control. 7A. If yes, explain: Resident is on low air loss mattress and needs the rails for support C. Summary of Findings 1. Summary of findings: Resident will use rails as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress. Resident uses call light for assistance and historically has not tried to get up alone. Resident #1 had been discharged to the hospital on [DATE], did not return to the facility, and was not available for interview. During an interview on 04/22/25 at 03:15 p.m. DON J said she was working at the facility when Resident #1 had his fall that ended with the fractured neck. She said she remembered he could be non-compliant at times. She said the resident had no issues with any falls prior to the fall but if he was a high risk according to the assessment then interventions should have been in place. She said she did not remember if there were fall mats placed. She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back on the bed and he fell the next day. She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them. 2. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and had no falls since last assessment. Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was not a high risk for falls. Record of the Incident Log from 07/21/24 through 12/07/24 indicated Resident #2 had an unwitnessed fall on 12/07/24. Record review of a care plan initiated on 12/07/24 indicated Resident #2 was a high risk for falls. She had a fall with no injury on 12/07/24. The only intervention was sent to ER for eval and treat of unrelieved pain. No other interventions to prevent falls or potential injuries from falls were developed. Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was a high risk for falls. Record of the Incident Log from 07/21/24 through 02/11/25 indicated Resident #2 had an unwitnessed fall on 02/11/25. i Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 had a fall and was a high risk for falls. Record review of a care plan revised on 02/22/25 indicated on 02/11/25 Resident #2 had a fall with no injury and intervention was FNP review of medications, lab work, psych notified, notified PASRR LA for behavioral assessment. No other interventions to prevent falls or potential injuries from falls were developed. During an observation and interview on 04/23/25 at 11:25 a.m., Resident #2 was in her room in a wheelchair. Her bed had ¼ side rails. She was not able to answer questions. 3. Record review of a face sheet dated 04/23/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included end stage renal disease (last stage of long-term kidney disease), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hypertension (condition in which the force of the blood against the artery walls is too high), atrial fibrillation (a type of irregular heartbeat), cardiac arrhythmia (occurs when the electrical signals that tell the heart to beat do not work properly), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). Record review of the current MDS dated [DATE] indicated Resident #3 was cognitively intact, required partial/moderate assistance for bed mobility, was dependent with transfers, required substantial/maximal assistance with most ADLs, used a manual wheelchair, and had no falls since prior assessment. Record review of a Fall Risk assessment dated [DATE] indicated Resident #3 was not a high risk for falls. Record review of an incident report dated 01/22/25 indicated Resident #3 said she was sitting in her wheelchair getting a breathing treatment. She saw a bug crawling up the wall. She rolled to the wall, leaned forward. She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom. Her back and tail bone hurts, 9/10 rating. Record review of an x-ray result for Resident #3 dated 01/22/25 indicated 1) x-ray of lumbar spine impression: No acute fracture or dislocation of the lumbar spine. 2) x-ray of sacrum/coccyx impression: No acute fracture or dislocation of the sacrum/coccyx. Record review of Resident #3's Fall Risk assessment dated [DATE] indicated the assessment was done due to a fall and she was at high risk for falls. Record review of Resident #3's care plan dated 01/24/25 indicated revisions to the care plan on 01/30/25 for ¼ rails on the bed for safety/enabler. There was no care plan for the fall she had on 01/22/25. During an observation and interview on 04/23/25 at 09:20 a.m., Resident #3 was in her bed. She said she had a fall a few months ago. She said the rails on her bed to help her with being able to turn in the bed. During an interview on 04/23/25 at 12:40 p.m., DON H said the MDS Nurse, the CN, the ADON, or herself were responsible for completing comprehensive care plans and updating the care plan as needed. DON H said her expectation would be for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions. She said an air mattress would not increase a resident's risk for falls. She said interventions would be based on the resident's needs. During an interview on 04/23/25 at 01:30 p.m., the Administrator said nursing was responsible to complete all the care plans and updating them for the residents. Record review of a Falls and Fall Risk Managing policy revised March 2018 indicated: Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Fall Risk Factors: 2. Resident conditions that may contribute to the risk of falls include: a. fever; b. infection; c. delirium and other cognitive impairment; pain; d. lower extremity weakness; e. poor grip strength; f. medication side effects; g. orthostatic hypotension; h. functional impairments; i. visual deficits; and j. incontinence. 3. Medical factors that contribute to the risk of falls include: a. arthritis; b. heart failure; c. anemia; d. neurological disorders; and balance and gait disorders; etc. Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling The Administrator and DON H were notified of the Immediate Jeopardy on 04/23/25 at 04:44 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 following Plan of Removal was submitted by the facility and accepted on 04/23/25 at 8:30 p.m. F656- All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff. 1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25. 3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. 4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall. This action started on 4/23/25. 5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions. This action started on 4/23/2025. 6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer. This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up. Monitoring: Record review and interviews of completed: * Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. * Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25. * Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25. * Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. * Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies. During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any discrepancies. During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

**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 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents/supervision. * The facility failed to ensure Resident #1 had interventions in place that addressed Resident #1's Fall Risk Assessment which indicated he was a high risk for falls. Resident #1 had a fall and was sent to the emergency room for assessment. A CT scan of the neck determined he had a fracture of one of the cervical vertebrae. * The facility failed to ensure Resident #2 had interventions in place after she had 2 falls. * The facility failed to ensure Resident #3 had interventions in place that addressed Resident #3's Fall Risk Assessment which indicated she was a high risk for falls after she had a fall. An Immediate Jeopardy (IJ) was identified on 04/23/25 at 04:44 p.m. and the IJ template was provided to the Administrator. While the immediacy was removed on 04/24/25 at 02:50 p.m., the facility remained out of compliance at a scope of pattern 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 who were assessed as high risk for falls at risk of at risk of potential accidents, serious injuries, serious harm, or death. Findings included: 1. Record review of face sheet dated 09/19/2024 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included traumatic brain injury (head injury causing damage to the brain by external force or mechanism) from a MVA 30 years ago; paraplegia (injury to the spinal cord or brain that stops signals from reaching the lower body); arterial ulcers (skin injuries caused by inadequate blood supply to the affected area) to heel, ankle, and toe; intracranial injury (any injury occurring within the skull) with loss of consciousness; lack of coordination; osteoarthritis (inflammation of one or more joints); and abnormalities of gait and mobility. Record review of Fall Risk Assessments dated 07/06/24 and 08/04/24 indicated Resident #1 was a high risk for falls. Record review of Resident #1's comprehensive care plans initiated on 07/08/24 did not address Resident #1's Fall Risk Assessment of high risk with interventions to implement to prevent falls or injuries from falls. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated a BIMS score of 6 indicating Resident #1 had severely impaired cognition. Resident #1 required substantial/maximal assistance for transfers and all ADLs. He used a manual wheelchair. He had no falls since admission. Record review of Nurse Notes indicated an entry on 08/16/24 at 02:00 p.m. that Resident #1 was placed on a low air loss mattress due to open area to his sacrum. There was no documentation of interventions to prevent potential falls after placement. Record review of Nurse Notes indicated an entry on 08/17/2024 01:40 p.m. that Resident #1 was on his right side on the floor by his bed. He was assisted back to the bed. Resident #1 said he did not know how he fell. He just knew he was on the floor. He had a 5cm x 3cm swollen area right side of head, 3cm x 2cm skin tear on the lateral aspect of the right elbow, and the right side of his face had swelling. Record review of a telehealth noted dated 08/17/24 indicated Resident #1 had unwitnessed fall with a knot to right side of forehead and redness to right side of face. Record review of an incident report dated 08/17/24 indicated Resident #1 was found on the floor. According to the incident report, he was put back in the bed and a head-to-toe assessment was done with a 5cm x 3cm swollen area to the right side of head, a 3cm x 2cm skin tear on the lateral aspect of his right elbow, and the right side of his face had swelling. The NP saw Resident #1 via telehealth and ordered him to be sent to the hospital ER. Record review of the hospital CT scan report of the neck dated 08/17/24 showed Resident #1 had a question age-indeterminate non-displaced type 3 (extend into the body of the vertebra) odontoid (a bony element extending superiorly from the second cervical vertebra) fracture (break). He returned to the facility with an order to wear a neck brace for 8 weeks. Record review of a Bed Rail/Assist Bar Evaluation dated 08/18/24 indicated Resident #1 had assessment done for post fall. A. Evaluation Factors 1. Resident has expressed a desire to have bed rails/assist bar while in bed for their own safety and/or comfort. 1A. If selected, explain: Resident will use for turning and repositioning 6. Resident has a history of falls. 7. The resident is having problems with balance or poor trunk control. 7A. If yes, explain: Resident is on low air loss mattress and needs the rails for support C. Summary of Findings 1. Summary of findings: Resident will use rails as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress. Resident uses call light for assistance and historically has not tried to get up alone. Resident #1 had been discharged to the hospital on [DATE], did not return to the facility, and was not available for interview. During an interview on 04/22/25 at 03:15 p.m. DON J said she was working at the facility when Resident #1 had his fall that ended with the fractured neck. She said she remembered he could be non-compliant at times. She said the resident had no issues with any falls prior to the fall but if he was a high risk according to the assessment then interventions should have been in place. She said she did not remember if there were fall mats placed. She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back on the bed and he fell the next day. She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them. 2. Record review of a face sheet dated 04/23/2025 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture due to abnormal brain development), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), chronic osteomyelitis of the left tibia and fibula (bone infection of the 2 bones of the lower leg), and lymphedema (a condition characterized by swelling caused by an accumulation of protein-rich fluid in the body's tissues primarily affecting the arms or legs). Record review of the current MDS dated [DATE] indicated Resident #2 had severely impaired cognition, required substantial/maximal assistance for all ADLs, and had no falls since last assessment. Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was not a high risk for falls. Record of the Incident Log from 07/21/24 through 12/07/24 indicated Resident #2 had an unwitnessed fall on 12/07/24. Record review of a care plan initiated on 12/07/24 indicated Resident #2 was a high risk for falls. She had a fall with no injury on 12/07/24. The only intervention was sent to ER for eval and treat of unrelieved pain. No other interventions to prevent falls or potential injuries from falls were developed. Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 was a high risk for falls. Record of the Incident Log from 07/21/24 through 02/11/25 indicated Resident #2 had an unwitnessed fall on 02/11/25. Record review of a Fall Risk assessment dated [DATE] indicated Resident #2 had a fall and was a high risk for falls. Record review of a care plan revised on 02/22/25 indicated on 02/11/25 Resident #2 had a fall with no injury and intervention was FNP review of medications, lab work, psych notified, notified PASRR LA for behavioral assessment. No other interventions to prevent falls or potential injuries from falls were developed. During an observation and interview on 04/23/25 at 11:25 a.m., Resident #2 was in her room in a wheelchair. Her bed had ¼ side rails. There were no fall mats on the floor by the bed and the bed was not in the lowest position. She was not able to answer questions. 3. Record review of a face sheet dated 04/23/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included end stage renal disease (last stage of long-term kidney disease), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (A chronic condition that affects the way the body processes blood sugar), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), hypertension (condition in which the force of the blood against the artery walls is too high), atrial fibrillation (a type of irregular heartbeat), cardiac arrhythmia (occurs when the electrical signals that tell the heart to beat do not work properly), and heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs). Record review of the current MDS dated [DATE] indicated Resident #3 was cognitively intact, required partial/moderate assistance for bed mobility, was dependent with transfers, required substantial/maximal assistance with most ADLs, used a manual wheelchair, and had no falls since prior assessment. Record review of a Fall Risk assessment dated [DATE] indicated Resident #3 was not a high risk for falls. Record review of an incident report dated 01/22/25 indicated Resident #3 said she was sitting in her wheelchair getting a breathing treatment. She saw a bug crawling up the wall. She rolled to the wall, leaned forward. She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom. Her back and tail bone hurts, 9/10 rating. Record review of an x-ray result for Resident #3 dated 01/22/25 indicated 1) x-ray of lumbar spine impression: No acute fracture or dislocation of the lumbar spine. 2) x-ray of sacrum/coccyx impression: No acute fracture or dislocation of the sacrum/coccyx. Record review of Resident #3's Fall Risk assessment dated [DATE] indicated the assessment was done due to a fall and she was at high risk for falls. Record review of Resident #3's care plan dated 01/24/25 indicated revisions to the care plan on 01/30/25 for ¼ rails on the bed for safety/enabler. There was no care plan for the fall she had on 01/22/25. During an observation and interview on 04/23/25 at 09:20 a.m., Resident #3 was in her bed and the bed had ¼ rails. There were no fall mats on the floor next to the bed and the bed was not in the lowest position. She said she had a fall a few months ago. She said the rails on her bed to help her with being able to turn in the bed. During an interview on 04/23/25 at 12:40 p.m., DON H said the MDS Nurse, the CN, the ADON, or herself were responsible for completing comprehensive care plans and updating the care plan as needed. DON H said her expectation would be for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions. She said an air mattress would not increase a resident's risk for falls. She said interventions would be based on the resident's needs. During an interview on 04/23/25 at 01:30 p.m., the Administrator said nursing was responsible to complete all the care plans and updating them for the residents. Record review of a Falls and Fall Risk Managing policy revised March 2018 indicated: Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation Fall Risk Factors: 2. Resident conditions that may contribute to the risk of falls include: a. fever; b. infection; c. delirium and other cognitive impairment; pain; d. lower extremity weakness; e. poor grip strength; f. medication side effects; g. orthostatic hypotension; h. functional impairments; i. visual deficits; and j. incontinence. 3. Medical factors that contribute to the risk of falls include: a. arthritis; b. heart failure; c. anemia; d. neurological disorders; and balance and gait disorders; etc. Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling The Administrator and DON H were notified of the Immediate Jeopardy on 04/23/25 at 04:44 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 following Plan of Removal was submitted by the facility and accepted on 04/23/25 at 8:30 p.m. All items listed will be completed by 5:00 PM on 4/24/25 with continued follow-up for scheduled staff. 1. Administrator/DON initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. 2. The corporate MDS Nurse and the facility MDS Nurse initiated a review of all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. This action started on 4/23/25. 3. Administrator/DON initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. 4. The Administrator and DON all licensed nursing staff on fall policy procedure and interventions post fall. This action started on 4/23/25. 5. MDS Nurse and DON will ensure new admissions have appropriate care plans placed for risk assessments. All licensed nursing staff will in-serviced on implementing interventions for new admissions. This action started on 4/23/2025. 6. Administrator and DON were in-serviced on 4/24/2025 by Regional Director of Clinical Services on all the policy mentioned above, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. Regional/corporate staff will follow-up on each fall/incident in question and direct with appropriate interventions. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was made aware of the Immediate Jeopardy 04/23/25 at 5:15 p.m. and has been involved in developing the Plan of Removal. These conversations are considered part of the QA process. A QAPI meeting was held on 04/23/25 with attendance of Administrator, Director of Nursing, MDS Coordinator, Regional Director of Clinical Services, and Chief Operating Officer. This plan was initially implemented 04/23/25 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 04/24/25 by 5:00 p.m. with continuation of oncoming staff and follow-up. Monitoring: Record review and interviews of completed: * Record review of the In-Services indicated the Administrator and DON H were in-serviced on 4/24/2025 by Regional Director of Clinical Services on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, and to notify regional/corporate staff of ALL falls/incidents care plans and are to notify regional/corporate staff of any discrepancies. * Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse reviewed all care plans for current accident/interventions in place to ensure it's on the care plan and a viable intervention. Completed on 04/24/25. * Record review of a resident list indicated the Corporate Nurse, DON H, and the MDS Nurse initiated an update on all fall risk assessments that they are accurate, interventions are in place and care plan coincides. Completed on 04/24/25. * Record review of an In-Service signature sheet indicated the Administrator/DON H initiated an in-service regarding policy and procedure for initiation of care plans for falls for licensed staff on 4/23/25. A post-test will be performed with staff over information in-serviced on by administration, and a score of 100% must be achieved. If less than 100%, staff will be reeducated and retest until 100% is achieved. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. * Record review of an In-Service signature sheet indicated the Administrator and DON H initiated an in-service for all licensed nursing staff on fall policy procedure and interventions post fall. On 04/24/25 at 01:20 p.m. 13 licensed staff employed were in-serviced. One licensed staff on FMLA was left to in-service. During an interview on 04/24/25 at 08:20 a.m., DON H said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of all falls/incidents care plans, and to notify regional/corporate staff of any discrepancies. During an interview on 04/24/25 at 08:25 a.m., the Administrator said he had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, initiation of care plans for falls, to notify regional/corporate staff of ALL falls/incidents care plans, and to notify regional/corporate staff of any discrepancies. During an interview on 04/24/25 at 08:35 a.m., the MDS Nurse said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 08:45 a.m., the ADON said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 09:15 a.m., RN A said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 09:25 a.m., LVN B said she worked the 6a to 6p shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 10:03 a.m., LVN C said she worked the 6p to 6a shift. She said she had in-services on 04/23/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 10:06 a.m., LVN D said she worked PRN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 12:02 p.m., LVN E said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 12:49 p.m., RN F said she was the weekend RN. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. During an interview on 04/24/25 at 01:08 p.m., LVN G said she worked the 6p to 6a shift. She said she had in-services on 04/24/25 on Fall Risk Assessments, residents triggering for high risk for falls on assessment interventions were to be implemented, the Fall Policy and Procedure and interventions post fall, and initiation of care plans for falls. The Administrator and Regional Director of Operations were informed the Immediate Jeopardy was removed on 04/24/25 at 02:50 p.m. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrected system that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #1) Resident #1 was assessed as requiring assistance of 2 staff members for bed mobility and total assistance of 1 for bathing. Resident #1 was assisted by one staff member for a bed bath, fell out of the bed, and sustained two brain bleeds. An Immediate Jeopardy was identified on [DATE] at 11:40 a.m. While the Immediate Jeopardy was removed on [DATE] at 04:14 p.m., the facility remained out of compliance at the scope and severity of actual harm and a scope of isolated. The facility was continuing to complete in-service training and monitoring the effectiveness of the Plan of Removal. This failure could place residents who required assistance with bed mobility and bathing at risk for falls, injuries, and hospitalization. Findings included: Record review of the face sheet dated [DATE] indicated Resident #1 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (complete loss of the ability to move some or all of the body) and hemiparesis (partial weakness) following cerebral infarction affecting right dominant side, traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain from a brain injury), and traumatic subdural hemorrhage (blood between the brain and its outermost covering from an injury). Record review of the MDS dated [DATE] indicated Resident #1 had severely impaired cognition, required extensive 2-person assistance of physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), required total assistance of 1 staff member for bathing, and had no falls since admission. Record review of the care plan dated [DATE] indicated Resident #1 required extensive assistance for bed mobility, required total dependency from staff for bathing, and was at high risk for falls. The care plan did not address how many staff were needed for bathing and bed mobility. Record review of a Fall Risk assessment dated [DATE] indicated Resident #1 was at high risk for falls and he had no falls in the last 3 months. Record review of an Incident Report dated [DATE] indicated CNA A was giving Resident #1 a bed bath, she touched a sore place on his right buttocks causing him to flinch and move about the bed. Resident #1 rolled off the bed onto the floor face down, lying on his right shoulder. Resident #1 had a large hematoma (blood pooling) to his left forehead, swelling to his right shoulder (the shoulder was tender to touch), and an abrasion to his right knee. He was not able to give account of fall. Record review of a written and signed statement dated [DATE] by CNA A indicated she was giving Resident #1 a bed bath. She wrote while I was cleaning his butt I noticed a sore and I put cream on his butt, he gripped his butt cheeks and jumped. I had one hand holding his hip but when he jumped I tried to grab him, but he fell off the bed. Record review of nursing notes with: * Entry dated [DATE] at 01:00 p.m. indicated while CNA A was giving Resident #1 a bed bath, she touched a sore place on his right buttocks causing him to flinch and move about the bed. Resident #1 rolled off the bed onto the floor face down and lying on right shoulder. Resident #1 had a large hematoma (blood pooling) to left forehead, swelling to right shoulder, the shoulder was tender to touch, and an abrasion to right knee. An ice pack was applied to left forehead and 911 called for transportation to the local hospital emergency room for evaluation and treatment. * Entry dated [DATE] 01:30 p.m. indicated Resident #1 was transported to the local hospital emergency room with 2 EMTs. * Entry dated [DATE] 06:00 p.m. indicated the local hospital contacted the facility and informed them Resident #1 was being transferred to a higher level of care hospital due to subarachnoid and subdural bleeding. The hospital indicated there was no fracture to the right shoulder. Record review of a hospital Neurosurgical Consultation report dated [DATE] indicated Resident #1 was brought to the emergency department after a fall from the bed during care. He underwent a CT (special x-ray equipment to help assess head injuries) of the head at the local hospital and was found to have a small subdural hematoma as well as subarachnoid hemorrhage. He was transferred to another hospital for higher level of care. Neurosurgery was consulted for further evaluation recommendations. At this time, no acute neurosurgical intervention was recommended. Recommendations due to the head injuries included for him to have systolic blood pressure (measures the pressure in the arteries when the heart beats) less than 130, the head of the bed was to be kept greater than 30 degrees, and he was started on Keppra (anti-seizure medication) 500mg twice daily for seizure prophylaxis for 7 days. During an interview on [DATE] at 09:25 a.m. the ADM said Resident #1 was being provided a bed bath by CNA A and the resident fell out of bed hitting his head. He said the resident was sent to the hospital due to hitting his head and was found to have bleeding, so he called in a report to the state office of a fall with an injury. He said the resident should have had 2 staff with the bed bath. During an observation on [DATE] at 11:20 a.m. Resident #1 was in his bed. He was clean, neat, and had no odors. He was not able to answer questions appropriately. An attempt was made to contact CNA A on [DATE] at 11:58 a.m. and she was not available for interview at time of the investigation. During an interview on [DATE] at 12:46 p.m. the DON said Resident #1 was being provided a bed bath by CNA A. She said the CNA turned him to his side to clean his buttock and apply barrier cream. She said he jerked and fell off the bed. She said he was a 2-person assist with bed mobility and there should have been 2 staff for his bed bath to prevent him from falling off the bed. She said the residents' information on what type of care they needed was in the [NAME] in the Point of Care system accessed by the CNAs. She said she expected all residents requiring 2-person assist with bed mobility to have 2 staff to provide a bed bath. She said now they had put in place for all persons with bed baths to be 2-person assist. During an interview on [DATE] at 10:16 a.m. the DON said she could not recall if the facility had a QAPI meeting to review the incident of Resident #1 falling out of the bed. She said all staff were in-serviced on the care plans and [NAME]. She did not provide a copy of all staffs' signature and related training for review. The ADM was notified on [DATE] at 11:40 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The Immediate Jeopardy template was provided to the ADM. The facility's Plan of Removal was accepted on [DATE] at 01:00 p.m. PLAN OF REMOVAL read: The following is a plan of removal, which has been immediately implemented at the facility to remedy the Immediate Jeopardy which was imposed on [DATE]. 1. Resident #1 was assessed after the incident, Resident was treated for injuries. MD and family made aware of the incident the day it occurred, [DATE]. 2. Resident #1 was assessed for level of assistance during ADLs. 2 persons when turning in bed Resident #1's care plan was changed to 2 person bathing by Director of Nursing on [DATE]. She assessed him and also ordered assist rail to right side to assist resident to turn. Assist rails were installed on [DATE] by maintenance supervisor. 3. All residents in the facility were assessed by the DON and ADON to determine the level of assistance needed during care. Residents were all assessed by [DATE] by DON and ADON and again 5/6-7/23. All care plans and [NAME] will be updated by MDS nurse and corporate MDS nurse by [DATE] to reflect the level of care needed. 4. The DON and ADON will in-service all nursing staff on following the care plans and/or [NAME] and providing care with the appropriate level of assistance by [DATE]. Specifically noted on this in-service was one- or two-person care, for bed baths, bed mobility, and bathing and the difference between them and where to find the information. We must assist all residents in the safest manner possible. The shower list will also specifically say if the resident requires a two-person bed bath or for bed mobility as well, these will be the same. Transfer will only be listed on the [NAME]. For new residents always ask a charge nurse or use two people until the residents' abilities are assessed. A picture of the PCC was attached to in-service to show staff where to find the [NAME] tab. The levels of assistance will be available to find on PCC and at nurse's station. If staff not in-serviced by [DATE] they will be in-serviced prior to working shift. [NAME] and care plans updated by MDS nurse and corporate MDS nurse by [DATE]. All residents have the potential to be affected by this alleged deficient practice. The Medical Director was initially made aware of the Immediate Jeopardy, and has been involved in the development of the plan to remove. To monitor for compliance the Administrator and/or designee will check 3 residents care per week to ensure the proper level of assistance is being provided. The monitored residents will always be different than the prior week's residents. Any negative findings will be remedied with further training or disciplinary actions. This plan was initially implemented [DATE] and will be monitored through completion by corporate and regional staff. Monitoring: Observations, interviews, and record reviews were conducted on [DATE] from 2:15 p.m. through 4:14 p.m. and included 2 alert residents, 4 LVNs, and 9 CNAs, 2 medication aides (who work all shifts), the ADON, and the DON. Staff were able to identify residents' the care plans, the [NAME] system and how to find level of resident care, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required level of staff assistance for ADLs. Staff were able to demonstrate the use of the [NAME] system for resident care needs. [NAME] for 10 residents were reviewed to ensure they matched with the resident's level of assistance required. Care plans matched the [NAME]. Facility audit for all residents indicated no issues or concerns and all care plans matched level of care in the [NAME]. Nursing staff were in-serviced on [DATE] and [DATE] where to find a resident's level of assistance in the [NAME]. Nursing staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. The [NAME] showed that Resident #1 was a 2-person assist. During an interview on [DATE] at 2:56 p.m., the DON said the audit of all residents' care plans and [NAME] revealed no issues or concerns. She said all residents' charts were reviewed and the care plans and [NAME] were corrected. She said all care plans reflected what the residents' current care needs. She said there will be no changes made to resident care needs without IDT discussion. All residents who required 2-person bed mobility also required 2-person assist for bed baths. A facility record audit dated [DATE] indicated all 55 residents' [NAME] and care plans were reviewed and updated. No residents indicated they were afraid during care or had complaints of their care. On [DATE] at 4:14 p.m., the Administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.