**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #14) reviewed for accidents and supervision. 1. The facility failed to ensure 2-person assistance was used while providing Resident #14 a bed bath on 06/09/2024. This resulted in Resident #14 falling out of bed and fracturing her right distal tibia (right lower end of the leg). 2. The facility failed to ensure staff knew where to find resident information on the required level of assistance each resident needed. An Immediate Jeopardy (IJ) situation was identified on 12/11/2024 at 4:25 PM. While the IJ was removed on 12/12/2024 at 3:59 PM, the facility remained out of compliance at a scope of isolated with the potential for minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure could place residents at risk for falls, injuries and hospitalizations. Findings include: Record review of Resident #14's face sheet, dated 12/12/2024, indicated Resident #14 was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #14 had diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and rheumatoid arthritis (chronic disease that causes inflammation of the joints and pain and can also affect other body systems). Record review of Resident #14's quarterly MDS assessment dated [DATE], indicated Resident #14 was dependent on staff for toileting hygiene, showering/bathing self, and personal hygiene. Record review of Resident #14's Quarterly MDS Assessment, dated 10/25/2024, indicated Resident #14 usually understood others and was usually able to make herself understood. Resident #14 had a BIMS score of 8, which indicated her cognition was moderately impaired. Resident #14 was dependent on staff for toileting hygiene, showering/bathing self, and personal hygiene. Resident #14 required substantial to maximum assistance with rolling left and right. T Resident #14 was always incontinent. Record review of Resident #14's care plan, revised 11/06/2024, indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner related to weakness, immobility, poor balance, and forgetfulness. Resident #14 indicated she required for bed mobility maximum assistance of 2 staff, transfers total assistance of 2 staff using a lift, toileting maximum assistance of 2 staff, and bathing total assistance of 1. 2 staff for transfers in and out of the shower. Record review of Resident #14's progress note, dated 06/09/2024 at 11:48 AM, indicated, Called to resident room by aide resident sitting in floor beside bed. Aid [sic] was giving resident a bed bath and asked resident roll onto her left side. Resident rolled to [sic] fast and to [sic] far and slid out of bed aid [sic] was able to partially catch resident before her whole body hit the floor resident did not hit her head full assessment done no deformity or shortening noted Resident assisted back into bed resident has bruise to right ankle resident can move foot with no pain. MD, RP and Admin notified signed by LVN Z. Record review of Resident #14's progress note dated 06/09/24 at 9:25 PM and signed by LVN Z, indicated . received x-ray results resident has FX (fracture) of distal tibia called [telehealth] got order to send to ER. Record review of Resident #14's progress note dated 06/10/24 at 2:32 AM and signed by LVN FF, indicated . Resident returned from ER at approx. (approximately) 0030 (12:30 AM) hrs (hours) via ambulance. Splint to RLE (right lower extremity) to immobilize r/t (related to) fx to distal tibia . Record review of Resident #14's progress note dated 06/11/24 at 11:57 AM signed by RN B, indicated . Res (resident) back from ortho (orthopedic) apt. (appointment) with new cast to r/t lower leg circulation cont. (continues) . Record review of Resident #14's radiology (medical imaging) Patient Report for the right ankle, dated 06/09/2024, indicated, .Findings: there is a fracture of the distal tibia (fracture of the lower leg). Record review of Resident #14's Post Fall Evaluation, with an effective date of 06/09/2024, signed 07/18/2024 by the previous DON, indicated position at the time of the fall lying in bed, activity at the time of the fall was a bed bath, range of motion was limited per the resident's norm, the resident had no falls in the past 6 months, immediate intervention implemented to prevent further falls was education. The root cause or causes of the fall was bed positioning during bed bath. Intervention/system change was assist rails. Record review of an undated witness statement signed by CNA A indicated, On Sunday June 9, 2024 I, [CNA A], was working west hall when [Resident #14] got on her call light needing to be changed when I [CNA A] went to change [Resident #14] I notice [sic] she had BM all up and down her from head to toe. I told her would she like a shower to get all the BM off her she said no I [CNA A] than told [Resident #14] she needed and [sic] bed bath to remove all the BM. [Resident #14] wasn't happy but turned to the side saying she don't want anything done to her I [CNA A] told [Resident #14] I can't not [sic] leave her in that condition I [CNA A] turned my back to get everything I needed to clean [Resident #14] up when I notice [sic] she had throwed [sic] her legs off the side of the bed and started to go down on her knees I [CNA A] ran over to the other side to help her to the floor when ask [sic] [Resident #14] why did she throw her legs off the bed she look [sic] at me and cut [sic] her eyes. During an observation on 12/11/2024 at 12:41 PM, revealed Resident #14 had assist bars on both sides of the bed. During an interview on 12/09/2024 at 11:49 AM, Resident #14 said a CNA was changing her and the CNA let me fall. Resident #14 said the CNA was talking on her phone and the CNA turned her back to her. Resident #14 said she told the CNA I'm going to fall and she fell. Resident #14 said she broke her ankle, and this happened about 3-4 months ago and they got rid of her the same day she was a black girl. Resident #14 said she did not know the CNAs name. During an attempted phone interview on 12/11/24 at 12:14 PM, LVN Z did not answer the phone. During an attempted phone interview on 12/11/2024 at 12:17 PM, the previous DON did not answer the phone. During an interview on 12/11/2024 at 12:58 PM, CNA C said she worked on 06/09/2024, but was not the CNA who provided care to Resident #14. CNA C said she remembered the CNA who cared for Resident #14 the day of the fall, but she could not remember her name. CNA C said Resident #14 required 2-person assistance for bed baths and mobility. During an interview on 12/11/2024 at 1:59 PM, CNA E said Resident #14 required 2-person assistance for her bed baths and repositioning. CNA E said whenever it was hard to turn the residents, she would use 2 people to provide care. CNA E said she did not have her log in to the electronic system. CNA E said sometimes when they reported at the end of the shift the other CNAs reported to her the level of assistance the residents required with their ADLs. During an interview on 12/11/2024 at 2:01 PM, CNA F said Resident #14 required 2-person assistance for her bed baths. CNA F said Resident #14 required one person on one side and one person on the other because she was totally dependent for mobility. CNA F said if she did not know the level of assistance a resident required, she would ask the nurse. CNA F said she relied on the nurse to tell her. CNA F said the level of assistance required by a resident for ADLs should be in the computer. CNA F attempted to demonstrate where to locate the information but was unable to find it. During an interview on 12/11/2024 at 2:04 PM, RN B said she had been a nurse at the facility for 31 years, and Resident #14 had always required 2-person assistance with all her ADLs for safety because of the air bed she had. RN B said most of the time the CNAs could ask the nurses and they could tell them the type of assistance the residents required. RN B said the information might be in the computer where the CNAs documented that they used to have a binder with the level of assistance required for the residents ADLS at the nurses' station, but it was no longer there. RN B said she was not working on 06/09/2024 when Resident #14 fell. During an interview on 12/11/2024 at 2:08 PM, CNA C said she remembered it was CNA A who provided care to Resident #14 on 06/09/2024. CNA C said if she was not familiar with a resident, she would ask the nurse what type of assistance they required for their ADLs. CNA C said there used to be a book at the nurses' station with the information, but it was no longer there. CNA C said she did not know where in the electronic system she could find the information regarding the level of assistance a resident required with their ADLs. During an interview on 12/11/2024 at 2:13 PM, CNA G said she was PRN, and Resident #14 required 2-person total assistance for changing her. CNA G said she usually asked the other CNAs the level of assistance required by the residents. CNA G said she did not know if there was anywhere they could look, and they did not have time to look in the electronic system when they started their shift. CNA G said it was important to know the level of assistance a resident required for their ADLs so they knew what the residents needed, and they could properly care for them. During an interview on 12/11/2024 at 2:23 PM, the ADON said Resident #14 required 2-person assistance for her ADLs. The ADON said the staff could look in the [NAME] (electronic system they chart on) for the information regarding how much assistance the residents required for their ADLs. The ADON said the CNAs should be aware they could find the information in the [NAME]. The ADON said if the CNAs did not know where to find this information it was a safety issue. During an interview on 12/11/2024 at 2:26 PM, the DON said Resident #14 required 2-person assistance for ADLS which included bed mobility and bathing. The DON said the MDS Coordinator was responsible for ensuring the care plans were updated. The DON said she thought where the care plan indicated bathing total assistance of 1. 2 staff for transfers in and out of the shower it was saying 1-to-2-person assistance, but she had only known for Resident #14 to require 2-person assistance. The DON said the care plan should indicate 2-person assistance. The DON said she did not know what happened on 06/09/2024. The DON said the MDS Coordinator should have revised Resident #14's care plan after the fall. The DON said the CNAs should be checking the [NAME] for the level of assistance required, and they should have access to it. The DON said in the past she verbally provided the CNAs education regarding using the [NAME], but she had not done an official in-service. The DON said it was important for the staff to know the level of assistance a resident required for the resident's safety and to prevent injuries to themselves or to the residents. During an interview on 12/11/2024 at 3:24 PM, the Administrator said when Resident #14 had the fall on 06/09/2024, she had only been at the facility for four days, and she did not remember much about the incident. The Administrator said she remembered the CNA, the bed bath, and she thought Resident #14 was too close to the edge of the bed. The Administrator said she only remembered the CNA was in the room and was trying to change the bed and Resident #14 rolled off the bed. The Administrator said the CNA did not work there anymore, and she could not recall the CNAs name. During an attempted phone interview on 12/11/2024 at 3:40 PM, CNA A did not answer the phone. During an attempted phone interview on 12/12/2024 at 10:08 AM, CNA A did not answer the phone. Record review of the facility's Fall Management System, reviewed 02/19/2021, indicated It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs . The licensed nurse will assess and document the condition of the resident at least once per shift for at least 72 hours post fall. 4. Documentation in the nurse's notes and/or care plan will reflect interventions attempted . An Administrative nurse will ensure that the resident's plan of care is revised to reflect each fall and interventions that were implemented . interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable This was determined to be an Immediate Jeopardy (IJ) was identified on 12/11/2024 at 4:25 PM. The Administrator and the Corporate Nurse were notified. The Administrator was provided with the IJ template on 12/11/2024 at 4:39 PM. The following Plan of Removal submitted by the facility was accepted on 12/12/2024 at 1:41 PM: Issue Cited: Failure to use 2 staff transfer assistance while providing Resident #14 a bed bath. The Facility failed to ensure staff knew where to find resident information on the required assistance needed. 1. Immediate Action Taken: A. On 6/9/2024 Resident #14 was assessed by charge nurse, notification to physician and X-rays obtained after the fall. Resident #14 was monitored every shift. B. On 6/10/2024 the Nurse Assistance was suspended pending investigation where she was subsequently terminated due to failure to report back to work. C. On 6/10/2024 the DON/Designee completed an investigation into an incident involving Resident #14. D. On 6/10/2024 the DON provided in-service education to all staff on Abuse and neglect. This education was completed on 6/10/2024. E. On 6/14/2024 the DON/Designee in-service education with license nurses and Nurse aide on use of PCC [NAME] that determines type and amount of care residents required for all ADL's. This was completed on 6/15/2024. All clinical staff are provided with training and access upon hire. F. On 12/11/2024 DON/Therapy assessed all residents to determine the type and number of staff assistance required for ADL's and validated that all [NAME] have been updated. This was completed on 12/11/2024. F. On 12/11/2024 the DON/Designee provided in-service education with all license nurses and Nurse aide on use of PCC [NAME] that determines type and amount of care residents required for all ADL's. This was completed on 12/12/2024 at 6:30 am, and no licensed nurse or Nurse Aide will be allowed to work until this education has been provided. 2. Identification of Residents Affected or Likely to be Affected: On 6/14/2024 the DON/Designee reviewed all residents requiring 2 persons bed mobility and bathing to verify that care plan and C.N.A. [NAME] reflected the type of care residents require. 3. Actions to Prevent Occurrence/Recurrence: A. DON/Designee will review 24-hour nurse report daily in the morning meeting to validate that the care plan and [NAME] has been reviewed/revised for any resident that has a change in bed mobility or bed bath. B. The DON/Designee will review all Incident/Accidents daily in the morning meeting to validate those residents with falls that involved bed mobility or falls during bed baths, had the appropriate number of staff needed during the transfer. C. The Regional Nurse Consultant will provide oversight into this process weekly x 4 weeks. D. The facility will continue to provide training to all license nurse and Nurse Aides upon hire and as need on documentation procedures for the [NAME] system on PCC to identify type and amount of care a resident requires. On 12/11/2024 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to and reviewed plan to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 12/12/24 Monitoring of the POR included the following: During an interview on 12/12/2024 at 1:50 p.m., the DON and the Corporate Nurse said the In-service on ADL care was verbal and there was not any handouts or policy to review. The DON said she in-serviced on positioning a resident in bed during care, and in-serviced verbally on Finding the information on the amount of assistance each resident for bathing, and bed mobility required on the [NAME]. The DON said the staff not only verbalized understanding but also demonstrated understanding of the use of the [NAME]. The DON and Corporate nurse said the post incident/fall protocol policy was not an actual policy but an assessment in the computerized system required completion after a fall. During an interview on 12/12/2024 at 2:46 PM, the DON said she would review the 24-hour report daily in the morning meetings and verify that all the necessary assessments and updates were completed for any incidents that occurred the day before. During an interview on 12/12/2024 at 2:20 PM, the Medical Director said he had been contacted regarding the immediate jeopardy and plan of removal. During interviews conducted on 12/12/2024 between 2:29 PM and 3:57 PM, MA N, LVN O, CNA P, the ADON, CNA F, LVN K, CNA H, CNA Q, LVN R, CNA E, CNA G, the Treatment Nurse, MA D, MA S, CNA T, CNA U, CNA V, LVN W, MA X, and CNA Y were able to verbalize they were provided in-service education on the use of the [NAME] and where to find the type and amount of care residents required for all ADL's. Record review of Resident #14's progress notes indicated on 06/09/2024 she was assessed by the charge nurse; the physician was notified and an x-ray obtained. Resident #14's progress notes indicated she was monitored every shift from 6/9/2024-6/11/2024. Record review of a facility document titled, Associate Discplinary [sic] Memorandum, indicated CNA A was suspended pending investigation beginning on 06/10/24. After the investigation was completed, discharge was effective 06/13/24. The document indicated, During f/u (follow up) call for investigation employee quit on the spot w/ (with) no notice via phone-hung up on the Admin/DON signed by the Administrator and the previous DON on 06/13/2024. Record review completed of Resident #14's Witnessed Fall Incident Report, dated 06/09/2024 indicated, Nursing Description: called to residents room by aid [sic] resident sitting in the floor beside bed; Resident Description: I rolled out; Witnessed: Yes . Injuries observed at time of incident bruise right ankle (outer) .Other info rolled out of bed while getting bed bath . Record review of an In-Service Program Attendance Record with the topic Abuse and Neglect, dated 06/10/2024, indicated 23 staff signatures. Record review of an In-Service Program Attendance Record, dated 06/14/2024, with the topic Incontinent Care: Rotating and changing residents in a timely manner, completing showers as scheduled and upon request, know your residents and check for [NAME] changes, and taking your time and letting the resident know what is happening with their care indicated 14 staff signatures. Record review of the CNA job description indicated Essential job Duties and Responsibilities: Assists residents with activities of daily living including bathing, dressing, grooming, toileting, changing of bed linens, and positioning in and out of bed, chair, etc. Assists with resident recreation programs. Prepares residents for meals and snacks, assists residents in eating where needed and records food intake. Reads and follows daily care plans; performs assigned restorative and rehabilitative procedures; reports changes in resident condition to nurse in charge; documents care provision on resident record/flowsheets as required and reports accidents and incidents; and provides nursing functions as directed by supervisor. Record review completed of the [NAME] and care plans for 60 residents to verify they included the type and number of staff assistance required for ADLs and the [NAME] and care plans matched. The Administrator was notified the Immediate Jeopardy was removed on 12/12/2024 at 3:59 PM. The facility remained out of compliance at a severity level of no actual harm, with the potential for minimal harm that is not immediate jeopardy, a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.