Failure to Prevent Accidents and Complete Required Assessments
Summary
The facility failed to provide necessary care and services to prevent accidents for three residents. One resident left the facility unsupervised after dinner without informing staff and was pulled by another resident on an electric chair. While passing over a gate frame, the resident's chair tilted, causing her to fall and land on her right shoulder. Although there were no head or skin injuries and vital signs were normal, the resident was transferred to an acute care hospital. The care plan for this resident included interventions such as educating her on the importance of informing staff before leaving the facility and explaining the risks of not doing so. However, there was no documented evidence that this education or explanation of risks was provided. Additionally, the resident's smoking assessment was not completed upon readmission, as verified by staff review. Two other residents experienced falls and were placed on care plans that required post-fall neurological checks for 72 hours. One resident was found sitting on the floor with no injuries, and the other was found lying on the floor after attempting to reach for a diaper, also with no injuries. Despite care plan interventions specifying neuro checks, medical record reviews for both residents failed to show any documented evidence that these assessments were completed following their falls. Staff interviews confirmed that neuro checks should have been performed and documented, but no such documentation was found. The Director of Nursing and other nursing staff verified the lack of documentation for both the education regarding leaving the facility and the required post-fall neuro checks. The facility's policies and procedures require comprehensive care planning, accurate assessments, and documentation of all relevant care and interventions, but these were not followed in the cases reviewed. These failures had the potential to negatively affect the health and well-being of the residents involved.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: For Resident 1, who was directly affected, corrective actions were taken immediately. On 8/1/25, the resident was re-educated by the DON and SS on the facility's out-on-pass policy, including the requirement to notify staff before leaving the premises. The charge nurse will monitor the signing in and out book. The resident was also informed of the potential dangers and/or risks associated with going out on pass, including the possibility of accident or injury. Specific safety concerns were addressed, such as nearby streets with vehicle traffic, and environmental hazards like uneven pavement, gravel, curbs, driveways, sidewalk cracks, steps, and stairs. This education was provided verbally and acknowledged in writing by the resident. A smoking assessment for Resident 1 was accurately completed by the LN per facility procedure, and all documentation was placed in the medical record on August 1, 2025. Residents 2 and 3 did not experience any harm as a result of the missed post-fall neuro checks. Both residents have since been discharged from the facility in accordance with their individual discharge plans. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, regarding their responsibility to initiate and document all resident education about the risks of leaving the facility without staff notification and monitoring the sign-in and out book. The RN Supervisor or designee reviews the resident signing in and out book daily for completeness and accuracy. To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to complete smoking assessments for all identified smokers at admission, re-admission, and quarterly. Medical Records verifies weekly that all residents identified as smokers have a current smoking assessment for completeness and accuracy. The DON and Medical Records director are responsible for ensuring these processes are maintained. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On August 1, 2025, the Medical Records audited residents who have an order for going out on pass. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on providing/documenting unsupervised leave risk education, including the monitoring of the sign-in and out book for completeness and accuracy. On August 1, 2025, the Medical Records identified and audited the residents who smoke. All smoking assessments were audited for completeness and accuracy. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on smoking assessment completion at admission, re-admission, and quarterly. On August 1, 2025, the Medical Records audited residents with similar risk factors and confirmed timely neuro checks for the other fall case. Licensed nurses were in-serviced by the DON on August 1, 3, and 5, 2025, on following care plans and completing neuro checks after falls. What measures will be put in place or what systemic changes will the facility make to ensure that the deficient practice does not recur: To prevent recurrence, Licensed Nurses were in-serviced by the DON on August 1, 3, 5, 2025, to initiate post-fall neuro checks in accordance with the facility's policy. The RN supervisor or designee now reviews all changes of condition daily to ensure neuro checks are initiated and documented. The DON and Medical Records Director are responsible for ensuring these processes are maintained. How the facility plans to monitor its performance to make sure that solutions are sustained: The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. To ensure sustained compliance, the Medical Records conducts daily audits of the residents with an out-on-pass orders. The RN Supervisor or designee will monitor the completeness and accuracy of the signing-in and out book. Any omissions are reported immediately to the DON for corrective action and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the out-of-the-facility education and monitoring of the sign-in and out book for completeness and accuracy. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records completes a weekly review of smoking safety assessments for all identified smokers, ensuring they are complete, accurate, current, and incorporated into the care plan. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews the smoking assessments for completeness, accuracy, currency, and incorporation into the care plan. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. To ensure sustained compliance, the Medical Records conducts daily audits of all new falls to verify neuro checks and resident education are documented. Any omissions are reported immediately to the DON for corrective actions and follow-up re-education. The DON compiles monthly audit results, tracks trends, and presents them to the QAPI Committee for review, discussion, and recommendations. The Interdisciplinary Team reviews care plan compliance quarterly to confirm interventions for falls. Monitoring will continue for at least three consecutive months (Aug-Sep-Oct) of sustained compliance before any change in audit frequency is considered. Compliance will be submitted to the QA committee monthly (Aug-Sep-Oct) or until substantial compliance is maintained. The Administrator will ensure compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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