Health inspection·November 3, 2025

T22 DIV5 CH3 ART3-72311(a)(2) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. T22 DIV5 CH3 ART5-72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. T22 DIV5 CH3 ART5-72521(a) Administrative Policies and Procedures (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. T22 DIV5 CH3 ART5-72521(b) Administrative Policies and Procedures (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. T22 DIV5 CH3 ART5-72521(c)(1)(A)(B) Administrative Policies and Procedures (c) Each facility shall establish at least the following: (1) Personnel policies and procedures which shall include: (A) Written job descriptions detailing qualifications, duties and limitations of each classification of employee available to all personnel. (B) Employee orientation to facility, job, patient population, policies, procedures and staff. This Requirement is not met as evidenced by: On 10/02/2025 at 10:19 AM, an unannounced visit was conducted at the facility to investigate complaints and a facility reported incident regarding: Patient 1 falling from the bed and landing face down on the floor. This resulted in Patient 1’s death. The facility failed to ensure staff followed patient’s plan of care, patient plan of care were written to ensure patient goals and facility objectives were achieved, and failed to ensure employee orientation to policies and procedures including but not limited to 1. Leaving a patient in a bed at the high position unattended 2. Staff was not trained on low-air loss mattress use or fall safety These violations resulted in Patient 1 falling from the bed and landing face down on the floor, which led to Patient 1’s death. FINDINGS: Record review of Patient 1’s Clinical Admission Record indicated, Patient 1 was admitted to the facility on 10/15/24. Diagnoses included: quadriplegia (paralysis from the neck down, affecting both arms and legs, usually due to a spinal cord injury), a personal history of physical injury and trauma, and dementia (a progressive decline in mental abilities). At the time of the incident, Patient 1 was in room 39 bed A. During an observation on 10/2/2025 at 2:05PM in room 39, there were three beds (39A, 39B and 39C). Bed A was the first bed near the door, bed with side table beside it. Both guard rails were down. The restroom is at the far end of the room, in front of bed C. During a telephone interview conducted on 10/2/2025 at 2:32 PM, Certified Nurse Assistant (CNA) 1, CNA1 stated, “I was providing incontinent (being unable to control the release of urine from the bladder or feces from the bowels) care, and when I was about to finish the task, Patient 1 had another bowel movement. I left Patient 1 alone in a high bed position, with the bed rails down on both sides. While I was in the restroom, I heard a loud thud. I rushed out and saw Patient 1 face down on the floor. I called for help. I thought he was safe—I didn’t think he would fall. I had left him lying on his side.” During an interview on 10/2/2025 at 1:46PM with Nurse Supervisor (NS), NS stated, the incident happened on 9/20/2025 at around 9:45PM. The evening shift CNA 1 was providing incontinent care to Patient 1. CNA 1 went to the bathroom to get additional supplies. CNA 1 left Patient 1 on a side lying position. I asked what happened, CNA 1 told me that he failed to put the patient in supine (Lying flat on your back) position.  Patient 1 has a low air mattress (a special air mattress that inflates and deflates its air compartment in a repeating pattern). When asked where the mattress was, NS stated they had removed it.   "During a phone interview on 10/2/2025 at 2:20 PM with Registered Nurse (RN) 1, RN 1 stated: 'I was at the nurses’ station when I suddenly heard a loud thud. I heard someone repeatedly saying, "I’m so sorry," and then I realized it was coming from room 39A. I went into room 39 and saw Patient1 lying on the floor beside the bed. CNA 1’s right hand was supporting Patient 1’s head and left arm was supporting the body." Review   of facility document titled “Employee Safety Responsibilities: General dated 8/28/2025, Employee Safety Responsibilities indicated, “…#4. Falls: When any individual falls, no one should help him/her to get up until a nurse has checked for injuries…” During a concurrent interview and record review on 10/02/2025 at 1:28PM, with DSD (Director of Staff Development), CNA 1’s employee file was reviewed. CNA 1’s employee file indicated no low air loss mattress or fall safety training. Review of employee file for CNA 1 titled Annual Clinical Care Training Checklist, Certified Nursing Assistant dated 8/28/2025, Annual Clinical Care Training Checklist indicated, “#3 Care of resident…c. Peri-care…with employee initial…evaluator initial…date 8/28/2025. There was no competency validation or skills check description and rationale. Review of Patient 1’s Order summary report dated 10/16/2024, Order summary report indicated, may use of low air loss mattress to prevent skin breakdown. Review of Patient 1’s Nurses Progress note dated 9/20/2025 at 10:49PM, the nurse progress note indicated, “Heard License Nurse (LN) overhead page calling writer to go to the 3rd floor, upon arriving saw patient on the floor face down on his right side CNA 1, behind patient supporting his torso and head. Repositioned patient on his back. Upon assessment, bump on right forehead 4cm x 4cm reddish discoloration, linear cut on right eyelid 4cm, skin tear on right cheek 1 cm, abrasion on right elbow 1 centimeter (cm, small unit used to measure length) , abrasion right thigh 1 cm, and skin tear on right thigh 1 cm. Transferred patient back to bed, first aid provided… Emergency services 911 contacted for urgent transfer. MD (Medical doctor) informed…” Review of Patient 1's Minimum Data Set (MDS, a standardized, comprehensive assessment tool) Section C (Cognitive Patterns, how your brain thinks, learns, remembers, and understands things.) dated 7/12/2025, the MDS indicated, BIMS (Brief Interview for Mental Status which evaluates cognition, the ability to remember and think clearly) score of 4, which indicated had severe cognitive impairment (significant challenges with memory, orientation, and recall). Review of Patient 1’s MDS section GG (Functional Abilities) at 0115 (Functional Limitation in Range of Motion) dated 7/12/2025, MDS indicated Patient 1 showed both upper and lower extremities had impairment on both sides.  The MDS also indicated Patient 1 was dependent on two or more staff is required for the patient for toileting hygiene and roll left and right; the ability to roll from lying on back to left and right side and return to lying on back on bed.  Review of Patient 1’s Care Plan Report, initiated on 10/16/24, care plan report indicated, Patient 1 is “At risk for falls and injury related to: Cognitive Impairment, Spinal cord injury C5-C7.( Bones in your neck support your head, protect your spinal cord, and control movement and feeling in your upper body) ” The goal is for Patient 1’s risk factors to be managed to minimize falls and injury. The intervention includes keeping Patient 1’s bed in a low position. Review of Patient 1’s records titled "Fall Risk Evaluation", dated 9/20/2025, the fall risk evaluation indicated, “Gait was impaired, " ... at high risk of fall with a score of 51, where Fall scoring: High risk 45 – and higher. Review of Patient 1’s History and Physical (H&P) from the General Acute Care Hospital (GACH) Intensive Care Unit (ICU), dated 9/21/25 at 5:13 AM, the H&P indicated, “Patient 1 living at a nursing home fell off his bed and hit his head, found to have a right subdural hematoma (a buildup of blood on the right surface of the brain) and extensive subarachnoid hemorrhage (a medical emergency where a significant amount of bleeding occurs in the space surrounding the brain)… .” Review of Patient 1’s Death Summary (DS) from the GACH, dated 9/21/25 at 12:39 PM, The Death summary indicated Patient 1 died on 9/21/25 at 10:57 AM. The DS also indicated, Patient 1’s preliminary cause of death was Traumatic brain injury (TBI). Review of the facility's 5 Day Summary of Investigation, dated 9/28/25, indicated “On 9/20/2025 at about 9:40 PM, Patient 1 experienced a fall incident, when Patient 1 rolled from their (sic) bed onto the floor. Patient 1 sustained injuries and was transferred to the hospital via 911. On 9/24/2025 facility received the hospital report that Patient1 expired on 9/21/25 with a diagnosis of Traumatic Brain Injury…Based on medical record review and staff interviews, the facility determined Patient's positioning in the bed and use of a low-air-loss mattress were contributing factors…” Review of the facility's (Policy & Procedure) P&P titled "Falls Management Program", revised on 1/2019, The P&P indicated " .. To provide residents with hazard free environment, adequate supervision and reduce risk factors leading to falls and injury. It is the policy of this facility to provide residents with a safe environment which is free from accident hazards as possible. The facility will provide residents with adequate supervision and assistive device to prevent accidents…” In violation of the above cited standards, the facility failed to ensure staff followed patient’s plan of care, patient plan of care were written to ensure patient goals and facility objectives were achieved, and failed to ensure employee orientation to policies and procedures including but not limited to 1. Leaving vulnerable patient in a bed at the high position unattended. 2. Staff was not trained on low-air loss mattress use or fall safety. These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a substantial factor in the death of a patient.