Health inspection·August 19, 2025

F689 483.25 (d)(2) Based on interview and record review, the facility failed to ensure one of three residents sampled for falls with injury was provided with the necessary care to prevent an avoidable fall with injury (Resident 1) when the facility failed to: 1. Take Resident 1 to the bathroom on 3/9/25, after her family member (FM) told staff that she needed to go. Subsequently, Resident 1 got up on her own to use the bathroom and fell. This failure to toilet Resident 1 resulted in Resident 1 falling and sustaining a broken right ankle, foot and toes which caused her severe pain, a transfer to the hospital, and delayed her discharge back home by 6 weeks. 2.Ensure Resident 1 was assigned a Certified Nursing Assistant (CNA) to take care of her on the PM shift (2:30 pm to 11 pm), on 3/9/25. This failure resulted in Resident 1 having no CNA assigned to her care and help her to the bathroom and Resident 1 fell and sustained a broken ankle, foot and toes. 3.Review and revise Resident 1's care plan with new interventions to prevent further falls and injuries on 3/6/25. This failure resulted in Resident 1 having another fall three days later. Findings: 1.The facility's policy titled, "Falls and Fall Risk, Managing" revised March 2018, was reviewed and indicated, 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. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. A review of Resident 1's admission record indicated Resident 1 was admitted on 1/14/25 to nursing unit three (rooms 300-317), with diagnoses which included surgery to the right hip from a broken hip (due to a fall at home), dementia (a loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), Alzheimer's (a progressive disease that destroys memory and other important mental functions), osteoporosis (bones are weak and brittle), muscle weakness, and diabetes (high sugar in the blood). A review of Resident 1's January 2025 Physician's Orders indicated: a An order, dated 1/30/25, indicated Resident 1 did not have capacity to understand choices, to make health care decisions and/or participate in a treatment plan. Resident 1's Family Member (FM) was Resident 1's decision maker. b An order, dated 1/15/25, for Norco (narcotic pain pill) tablet 5-325 mg (milligram a unit of measurement), give one tablet by mouth every four hours as needed (PRN) for pain level 4-6 (moderate pain) and a Norco tablet 10-325 mg, give one tablet by mouth every four hours as needed for pain level 7-10 (severe pain). A review of Resident 1's Admission Minimum Data Set (MDS, a complete clinical assessment), dated 1/17/25, section C- Cognitive Patterns (determines residents' attention, orientation, and ability to register and recall information) indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment used to evaluate memory and decision making skills on a scale of 0 to 15, with 0 being highly impaired and 15 being no impairment), and Resident 1 scored 0, which indicated Resident 1's cognition was severely impaired. Section GG- Functional Abilities and Goals indicated Resident 1 required maximal assistance (Staff does mostof the work) from staff for bed mobility (to turn and reposition in bed), transferring from chair to bed and bed to chair, and was dependent (staff does all of the work) on staff for toileting (going to the bathroom). Section H- Bladder and Bowel indicated Resident 1 had occasional urinary incontinence (some loss of bladder control) episodes and was always continent (had full control) of her bowels. A review of Resident 1's Admission Fall Risk Assessment, dated 1/14/25, indicated that Resident 1 was at high risk for falls with a score of 22 based on Resident 1's cognition, previous history of falls, bowel and bladder continence (control), and medications she was taking. A review of Resident 1's care plans was conducted and indicated the following: a Musculoskeletal Care Plan, dated 1/14/25, included interventions to "Anticipate and meet needs...respond promptly to all requests for assistance." b High Risk for Fall Care Plan, revised 2/11/25, included interventions to anticipate and meet needs, keep within supervised view as much as possible, keep bed in low position with brakes locked, keep call light within reach. c. Bladder Incontinence Care Plan, dated 1/14/25, included interventions to offer toileting on rounds (an every two hour check done by the CNAs), upon request, and as needed. During a phone interview with FM on 6/10/25 at 9:44 am, FM stated, "Right before I left [the facility] that day [3/9/25] at about 6:15 pm, I told the nurse [Licensed Nurse A] that [Resident 1] was laying down to go to sleep but you will have to get her up and take her to the bathroom or she would try to go to the bathroom by herself." [LN A] responded okay." FM stated that around 6:50 pm, (40 minutes later), that same evening (3/9/25), FM received a call from the facility that Resident 1 had fallen trying to go to the bathroom. FM stated that 6:30 pm was Resident 1's usual time to go to the bathroom and get ready for bed. A review of Resident 1's Bladder Continence documentation dated 3/9/25, was conducted and indicated that Resident 1 was last taken to the bathroom at 4:27 pm, over 2 hours before she fell. A review of Resident 1's progress notes titled, "Alert Charting" dated 3/10/25 at 3:46 am, indicated LN B documented on 3/9/25 at 6:45 pm, that LN B found Resident 1 in her room between the bed and her room door, lying on her left side sitting halfway up with her hands holding her up on the floor, and indicated it appeared as though she (Resident 1) was trying to walk to the restroom. LN B documented, "[Resident 1's] lateral [outside] ankle was swollen and tender to touch. This nurse called MD [Medical Doctor] he ordered x-ray [to right ankle] to be done in the facility, Asper-creme [a cream that provides relief to joint pain and helps to reduce swelling] to be applied topically [on the skin of Resident 1's right ankle], ace bandage wrap [a stretchy bandage to help reduce swelling], ice [to right ankle], and a foot cradle [a frame that goes on the foot of the bed to lift sheets and blankets off of the and feet] to keep the blankets off the [right] foot since there is so much swelling and discoloration." A review of Resident 1's progress notes titled, "Nurse's Notes" dated 3/10/25 at 1:27 pm, LN A documented that Resident 1's right ankle was swollen, purple, and wrapped in an ace wrap. Resident 1 had an X-ray taken on 3/10/25 at 10:00 am, in the facility. Resident 1's FM was concerned and did not want to wait for X-ray results. Resident 1's FM insisted that Resident 1 be sent to the hospital. EMS (Emergency Medical Services 911) was called at 11:20 am and arrived to the facility at 11:35 am. Resident 1 then left by ambulance at 11:45 am, to go to the hospital. Resident 1 returned to the facility after her evaluation in the emergency department at the hospital. A review of Resident 1's Emergency Department (ED) provider notes on 3/10/25 at 12:00 pm, documented by the Emergency Department Physician (EDP), indicated, "examination of the right foot and ankle does show tenderness and swelling both to the dorsal [top] and lateral [outer side] of foot as well as the right ankle." Resident 1's ED X-ray results of her right ankle." Resident 1's ED X-ray results of her right ankle indicated Resident 1 had a broken ankle, a broken pinky toe, a broken big toe, and a broken bone on the top of her right foot. Resident 1 received Norco 5-325 mg 1 tablet at 1:34 pm, in the ED. EDP wrote new orders for Resident 1's right foot to be immobilized (not able to be moved) and to see orthopedics (Physician that specializes in bones). Resident 1 was then taken back to the facility. Resident 1's March 2025's Medication Administration Record (MAR) was reviewed for Resident 1's documented pain complaints and pain levels (0 - 10, 0 was no pain and 10 was extreme, severe pain). The following was documented on Resident 1's MAR: a. On 3/9/25 at 7:17 pm, LN B recorded Resident 1's pain level as a 6 (moderate) and administered one Norco 10-325 mg tablet. b. On 3/9/25 at 11:30 pm, Licensed Nurse B recorded Resident 1's pain level as 7 (severe pain) and administered one Norco 10-325 mg tablet. c. On 3/10/25 at 3:30 am, Licensed Nurse B recorded Resident 1's pain level as 5 (moderate pain), but did not administer any pain medication. d. On 3/10/25 at 8:00 am, Licensed Nurse A recorded Resident 1's pain level as 5 (moderate pain), but did not administer any pain medication. e. On 3/10/25 at 9:00 am, Licensed Nurse A recorded Resident 1's pain level as 5 (moderate pain), but did not administer any pain medication. f. On 3/10/25 at 5:05 pm, Licensed Nurse A recorded Resident 1's pain level as 8 (severe pain) and administered one Norco 5-325 mg tablet. A review of Resident 1's Social Service Note dated 3/17/25 at 10:32 am, Social Service (SS) documented Resident 1 was scheduled to discharge home on 3/12/25 with her FM, but due to Resident 1's recent falls that occurred on 3/6/25 where Resident 1 sustained a hematoma (large bump) on her forehead, then on 3/9/25 where Resident 1 sustained a fracture to the right ankle, foot and toes, Resident 1 was now not able to stand on her right foot. SS documented that Resident 1 required a Hoyer lift (a mechanical lift that transfers a resident without the resident touching the ground), and Resident 1 was not able to go home and required extended physical therapy. During a concurrent interview and record review on 7/8/25 at 1:41 pm, the Director of Rehab (DOR) stated that Resident 1 was preparing to discharge home on 3/12/25, but then Resident 1 had a fall on 3/9/25 and subsequently became dependent on staff for transfers and had to stay longer at the facility due to a broken right ankle. DOR indicated Resident 1 discharged home on 4/24/25, six weeks after she had initially planned to go home. During an interview on 7/8/25 at 2:23 pm, LN A stated that on 3/9/25 at around 6:20 pm, FM told her that she (FM) was leaving and to have a CNA take Resident 1 to the bathroom. LN A indicated Resident 1 required help to go to the bathroom, was confused, and was always getting out of bed without help. LN A said she asked CNA E to take Resident 1 to the bathroom. LN A stated she also asked LN B (the oncoming nurse) to get a CNA to take Resident 1 to the bathroom. LN A stated, "I was worried that she [Resident 1] might get out of bed. I should have checked on her, but I thought the CNA was going to help her." During a phone interview on 7/9/25 at 10:39 am, LN B indicated on the night of 3/9/25 around 6:45 pm, Resident 1 was found on the floor in her room. LN B indicated Resident 1 had fallen right after LN B had started her night shift (6:30 pm to 7 am) and she remembered Resident 1 being in a lot of pain after the fall. LN B stated that Resident 1 had dementia and when she sat up on the side of the bed, that meant she needed to go to the bathroom or was hungry. LN B stated that 6:30 pm was Resident 1's normal time to go to the bathroom and since Resident 1 had dementia, she was unable to always answer accurately to whether she needed to use the bathroom. LN B stated LN A had not reported to her that Resident 1 needed to go to the bathroom. During a phone interview on 7/10/25 at 2:33 pm, CNA H stated she worked on 3/9/25 from 6:30 pm to 11:00 pm, on nursing unit three and was never asked to take Resident 1 to the bathroom and confirmed she never took Resident 1 to the bathroom. During a phone interview on 7/10/25 at 3:10 pm, CNA G stated that on 3/9/25 from 2:30 pm through 7:00 pm, she was assigned to float (a CNA that was not assigned to specific rooms or residents but helps where help was needed) on unit three. CNA G stated she was never asked to take Resident 1 to the bathroom on 3/9/25, however around 6:35 pm, she had walked by Resident 1's room and saw Resident 1 sitting on the edge of her bed. CNA G stated she asked Resident 1 if she needed to use the bathroom and Resident 1 responded "no." CNA G then assisted Resident 1 to lie back down and had not taken her to the bathroom. CNA G stated she then left Resident 1's room and within minutes she heard "help me, help me" and saw Resident 1 on the floor in her room. During a phone interview on 7/10/25 at 3:15 pm, CNA E confirmed she was assigned to care for Resident 1 on 3/9/25 from 2:30 pm to 11:00 pm, but never took care of her, and has not taken care of Resident 1 since February 2025, because Resident 1's FM requested her to no longer care for Resident 1. CNA E stated LN A never asked her to take Resident 1 to the bathroom. 2. Nursing Staff Assignment and Sign-In Sheet, dated 3/9/25, for PM shift 2:30 pm to 11 pm, on nursing unit three (rooms 300-317), was reviewed and indicated that CNA E was scheduled to work 2:30 pm to 11 pm, and assigned to Resident 1's room, CNA G was scheduled to work from 2:30 pm to 7 pm, CNA H was scheduled to work 6:30 pm to 11 pm, CNA J was scheduled to work from 2:30 pm to 7 pm, and CNA K was scheduled to work from 2:30 pm to 11 pm, were all assigned to nursing unit three. During a phone interview on 7/10/25 at 2:33 pm, CNA H stated she worked on 3/9/25 from 6:30 pm to 11:00 pm, on nursing unit three and confirmed she was not assigned to Resident 1. During a phone interview on 7/10/25 at 3:10 pm, CNA G stated that on 3/9/25, she was assigned as a float on unit three from 2:30 pm to 7 pm and confirmed she was not assigned to care for Resident 1. During a phone interview on 7/10/25 at 3:15 pm, CNA E confirmed she was assigned to care for Resident 1 on 3/9/25 from 2:30 pm to 11:00 pm and had not taken care of her. CNA E explained that she was not allowed to care for Resident 1 because since February 2025, Resident 1's FM did not want her to take care of Resident 1. The surveyor asked CNA E if this had been communicated to a nurse or another CNA and if CNA E knew who ended up taking care of Resident 1. CNA E replied that it was not her job to find someone to replace her, it was the nurse's job. CNA E stated she never cared for Resident 1 on 3/9/25 and does not know who did. 3. The facility's policy titled, "Assessing Falls and their Causes" dated March 2018, was reviewed and indicated, "Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident. When a resident falls, the following information should be recorded in the resident's medical record: 6. Appropriate interventions taken to prevent future falls." A review of Resident 1's progress notes titled, "Change in Condition" (CIC) dated 3/6/25, LN D indicated Resident 1 had a fall on 3/6/25 at 3:32 pm, documentation included "[LN D] found res [Resident 1] sitting on floor to right side of bed. Res [Resident 1] sitting on her buttocks on floor mat. Res wearing socks, no incontinence at time of fall, brief [adult diaper] was dry. Bed below knee height. Hematoma [bump or "goose egg"] to top of head measuring approx. [approximately] 3 cm [centimeters, 2.5 centimeters equal about one inch] X [by] 3.2 cm." Resident 1's nursing progress note documentation from 3/6/25 through 3/9/25 was reviewed and indicated that there was no nursing documentation which identified possible or likely causes of Resident 1's fall on 3/6/25, as the facility's policy indicated there should have been. A review of Resident 1's Fall Care Plan, created on 3/6/25, indicated that no revisions or new interventions had been made after Resident 1's fall with injury on 3/6/25. A concurrent interview and record review was conducted with the Assistant Director of Nursing (ADON) on 7/8/25 at 3:19 pm. Resident 1's CIC note from 3/6/25, nursing documentation notes from 3/6/25 through 3/9/25, and Fall Care Plan dated 3/6/25, were reviewed with the ADON. The ADON confirmed Resident 1 had a fall and hit her head on 3/6/25, and there was no CIC nursing documentation or revisions to her Fall Care plan, and there