Failure to Honor Guardian Restrictions on Unsupervised Leave of Absence
Summary
Surveyors identified a deficiency in which the facility failed to follow a resident’s legal guardian’s request to prohibit unsupervised Leaves of Absence (LOAs). The resident had been admitted with bipolar disorder, current manic episode with psychotic features, anxiety disorder, and schizoaffective disorder. An Annual MDS showed the resident was cognitively intact with a BIMS score of 15. The resident’s care plan documented risk for injury related to elopement, dissatisfaction with guardian placement, intent to leave the facility, and schizophrenia, with interventions including updating boundaries, mental status, and guardian guidance/consent, and noting that the guardian sometimes gave permission for the resident to sign herself out. Amended Letters of Guardianship from probate court showed the resident was deemed incompetent and had a legal guardian over person only. Record review showed that over a several‑month period the resident signed herself out and went on unsupervised LOAs 159 times. The resident’s guardian reported she had repeatedly asked the DON and Administrator for months not to allow the resident to leave unsupervised because of the resident’s schizophrenia and non‑adherence with medications, and stated she had personally seen the resident downtown at a bus stop punching people and at a bread store. The Regional Director of Clinical Operations confirmed the facility allowed the resident to leave unsupervised on a daily basis because she had a BIMS of 15 and “has rights,” despite knowing the guardian did not want the resident to go on LOAs. The Administrator and DON also confirmed they allowed the resident to leave unsupervised daily, citing resident rights and the resident’s intact cognition, even though the guardian had informed the facility not to let the resident leave.
Penalty
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A resident with Huntington’s disease, dementia, and known fall risk fell from a low bed onto a floor mat after shaking, and staff did not respond until alerted by a surveyor. The resident was assisted back to bed with a two-person assist, but no immediate assessment or VS were obtained, and there was no same-day nursing documentation of the fall. An LPN stated that staff typically did not complete fall assessments or obtain VS when a resident was found on a floor mat or observed getting out of bed, and facility leadership confirmed this practice, despite a written falls protocol requiring assessment and documentation of all falls, including VS, injury and neuro assessment, pain evaluation, and timely identification of causes and contributing factors.
The facility failed to provide adequate supervision and ensure safe use of assistive devices during care and transfers, resulting in accidents for two residents. One resident with morbid obesity, chronic respiratory failure, and complete dependence for bed mobility and ADLs was provided incontinent care by a single CNA, despite requiring two-person assistance for transfers; during care, the resident rolled, grabbed the bed rail, and fell from the bed to the floor, later being found to have a painful right-leg contusion. Another resident with post-stroke hemiplegia, multiple comorbidities, and dependence on staff for ADLs and transfers was being moved from wheelchair to bed with a mechanical lift when she slid from the lift pad to the floor because the pad was not fully positioned under her buttocks and could not be adequately adjusted by staff.
The facility failed to complete thorough fall investigations and post-fall monitoring for two residents at risk for falls due to deconditioning and multiple comorbidities. In one case, a cognitively intact resident with vascular disease, diabetes, CHF, and foot ulcers was found on the floor after sliding from a recliner; the incident report lacked documentation of environmental, situational, and physiological factors, neurological checks for the unwitnessed fall were not initiated, required 72-hour monitoring was missed on night shifts, and the fall risk assessment was not updated until several days later. In another case, a cognitively intact, wheelchair-dependent resident with dementia, DVT, and general weakness was found on the floor with the wheelchair tipped over after an unwitnessed fall, and the neurological check section on the post-fall form was crossed off with no monitoring documented, despite facility expectations and policy requiring such assessments after unwitnessed falls.
A resident with dementia, severe cognitive impairment, a history of multiple prior falls, and documented need for substantial assistance and 24-hour supervision with ADLs and toileting was left unattended on the toilet by a CNA who left the room to obtain linens and an adult brief. Despite care plan and fall risk assessments indicating the resident required one to two staff for transfers, ambulation, and toileting, and was unsteady and only able to stabilize with assistance, the CNA exited the bathroom and bedroom. While unsupervised, the resident got off the toilet and was attempting to leave the bathroom when she fell backwards, striking her back and head on the sink. An LPN responding to the incident found the resident on the bathroom floor with a back bruise and a goose egg on her head, and hospital evaluation later confirmed multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, all associated with this fall. Facility documentation and interviews confirmed that the resident was known to frequently get up without assistance and was generally not left alone on the toilet, but on this occasion the established supervision and assistance requirements were not followed, leading to the fall and injuries.
A resident with recent right hip surgery, poor standing balance, and an inability to pivot was evaluated by PT, who recommended use of a Sara Steady or sit‑to‑stand lift for all transfers. This recommendation was not converted into orders or added to the care plan, and there was no written communication process to ensure nursing staff were aware of the change. Despite the resident’s increased dependence for transfers, two CNAs later performed a manual two‑person transfer from wheelchair to recliner using an under‑arm lifting technique without a gait belt. During the transfer, the resident’s feet slid, she became "dead weight," and staff bore her weight under her arms, hearing a loud pop from the right shoulder. The resident developed pain and limited ROM, and subsequent imaging showed an acute angulated fracture of the humeral neck. The DON and therapy staff confirmed that a mechanical stand‑assist device and gait belt should have been used and that the facility had no transfer policy, leading to the unsafe transfer and resulting injury.
A resident with dementia, Alzheimer’s disease, and multiple comorbidities was identified as high risk for falls and care planned for safety, including non-skid footwear and supervision in common areas, yet experienced multiple falls resulting in serious injuries over time. The facility repeatedly failed to provide or document comprehensive fall investigations, did not substantiate its claim that orthostatic hypotension caused one fall, and did not demonstrate that key interventions such as proper footwear and ordered safety checks were in place at the time of several falls. The resident fell in her room, while on C. diff isolation, near the nurses’ station, and in the secured unit dining room, sustaining an L3 compression fracture, head laceration requiring staples, a right hip fracture, and later multiple rib and wrist fractures and facial laceration. Staff interviews revealed gaps in supervision, incomplete communication about the resident’s restlessness and agitation, and lack of clear determination of fall causes, while the facility withheld fall investigations as QAPI and could not show that fall risks and behaviors were adequately assessed and addressed.
Failure to Assess and Document Resident Fall per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to timely assess and document a fall for a resident identified as being at risk for falls. The resident, admitted with diagnoses including Huntington’s disease, hypothyroidism, constipation, and dementia, had a care plan identifying fall risk related to increased need for assistance with bed mobility and transfers, Huntington’s disease, overactive bladder, and a history of falls. Interventions included use of a low bed, floor mat, bolsters, dycem to the wheelchair, nonskid footwear, and supervision with staff remaining with the resident in the bathroom. During observation, the resident began to shake and fell out of bed onto a floor mat, landing on her back, while the bed was in the low position. Staff did not immediately respond until alerted by the surveyor, and two staff members then used a two-person assist to return the resident to bed. Following the fall, the resident was not immediately assessed on the floor or after being returned to bed, and vital signs were not obtained at that time. An LPN later stated that the resident had increased shaking over the past week, confirmed that a two-person assist was used to return the resident to bed, and acknowledged that no vital signs had been taken immediately after the fall and still had not been completed at the time of the interview. The LPN also stated that staff typically did not complete a fall assessment if the resident was found on the floor mat next to the bed. Review of the nurse’s notes showed no documentation of the fall on the day it occurred, and a later note documented the resident as found lying next to the bed with no injury noted and normal range of motion, with the resident denying pain. The Administrator and Regional Nurse reported that the resident frequently got out of bed and this was considered a behavior, and that staff would not complete a fall assessment or obtain vital signs if they observed the resident getting out of bed or found on the fall mat, even if the fall was unwitnessed. This practice was inconsistent with the facility’s Falls - Clinical Protocol policy, which required assessment and documentation of all falls, including vital signs, injury assessment, neurological status, pain, changes in condition, identification of possible causes within 24 hours, documentation of contributing factors, and monitoring and follow-up.
Inadequate Supervision and Improper Use of Assistive Devices During Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and ensure the safe use of assistive devices during care and transfers, resulting in accidents for two residents. One resident with chronic respiratory failure, ventilator dependence, heart failure, morbid obesity (weight 557.8 pounds), bilateral lower-extremity range-of-motion limitations, and complete dependence for bed mobility and ADLs was identified as at risk for falls and skin integrity issues. Her care plan included protective and preventative skin care and monitoring during daily care, and the MDS documented she was dependent on staff for bed mobility and always incontinent of bowel and bladder. Despite this, the facility’s staff and regional nurse continued to assert that only one staff member was required for ADL care, even though the resident required a two-person assist with a mechanical lift for transfers and was completely dependent for bed mobility. On the date of the incident, a single CNA provided incontinent care to this resident in bed. During care, the resident rolled onto her side toward the door, grabbed the bed rail, attempted to reposition her legs, and continued rolling until she fell from the bed to the floor. The CNA’s witness statement indicated she was on one side of the bed, saw the resident roll and fall, then moved to the other side to check on her before leaving the room to get assistance. The resident was later documented as having severe pain in the right leg, with hospital evaluation revealing tenderness and a contusion of the right lower extremity, though no fracture was found. The investigation and interviews confirmed that the resident’s size, dependence for bed mobility, and need for two-person assistance for transfers were not translated into a requirement for two-person assistance during bed mobility and incontinent care. The second resident involved had a history of hemiplegia and hemiparesis following a stroke, hypertension, dysphagia, dysarthria, acute and chronic respiratory failure, heart failure, and type II diabetes mellitus. Her care plans identified her as a fall risk and documented dependence on staff for ADLs and transfers, with interventions including use of a mechanical lift for chair-to-bed and bed-to-chair transfers. During a two-staff transfer from wheelchair to bed using a mechanical lift, the resident slid from the lift pad to the floor. Staff statements and the facility’s fall/skin incident report documented that the mechanical lift pad was not positioned fully under the resident’s buttocks, and staff attempted to adjust it but were unsuccessful, resulting in the resident slipping out of the pad. This event demonstrated improper pad placement and unsafe use of the mechanical lift during the transfer.
Incomplete Fall Investigations and Missed Post-Fall Neurological Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and thorough fall investigations and post-fall monitoring for two residents. One resident with diagnoses including peripheral vascular disease, diabetes with foot ulcers, CHF, hypertension, and a non-pressure chronic ulcer of the right heel and midfoot was cognitively intact and care planned for fall risk due to deconditioning, with interventions such as anticipating needs, ensuring call light and appropriate footwear, and following fall protocol. After this resident was found sitting on the floor in front of a recliner, having reportedly slid from the chair and denying injury, the incident report for the fall was left incomplete, with no documentation in the sections for predisposing environmental, situational, or physiological factors, and only vital signs, a brief statement of findings, and notifications recorded. For this same resident, the Post Fall Monitoring Form showed that the section for initiation of neurological checks following the unwitnessed fall was crossed off, and there was no documentation of immediate neurological monitoring. The required 72-hour post-fall monitoring, to be completed every eight hours for six shifts, was not done on the midnight shifts on two specified dates. Additionally, the resident’s fall risk assessment, which facility policy required to be completed after any fall, was not updated until eight days after the fall. Interviews with the DON and Regional Clinical Nurse confirmed that neurological checks should have been implemented for this unwitnessed fall, that the incident report was not fully completed, that post-fall assessments were missed on specified shifts, and that the fall risk assessment should have been completed immediately after the fall. A second resident, with diagnoses including difficulty in walking, DVT of the right lower leg, dementia, general weakness, diabetes, and wheelchair dependence, was also cognitively intact and care planned for falls due to deconditioning, with interventions such as Dycem to the chair, appropriate footwear, call light in reach, items within reach, and a custom wheelchair. This resident experienced an unwitnessed fall in which the resident was found sitting upright on the floor, leaning against the bed with shoes on, and the wheelchair tipped over on its side. The Post Fall Monitoring Form again showed the neurological check section crossed off with no documentation of immediate neurological monitoring. Interviews with the Administrator confirmed that the facility’s expectation was to initiate neurological checks for any unwitnessed fall, that this resident’s fall was unwitnessed, and that neurological checks were not completed despite this expectation. Facility policies on falls and fall prevention required assessment after any fall, monitoring for 72 hours, and detailed documentation and review, which were not followed in these cases.
Unsupervised Toileting of High-Risk Resident Resulting in Serious Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance with toileting for a resident with a known high risk of falls, resulting in a serious fall and injuries. The resident had dementia, a history of falls, periprosthetic fracture around an internal prosthetic of the left hip joint, a fracture of the neck of the left femur, age-related macular degeneration, and osteoarthritis. Her care plan, initiated and revised prior to the incident, identified her as at risk for falls due to dementia, decreased mobility, increased weakness, unsteady gait, and a history of multiple prior falls when attempting to stand, transfer, or ambulate without assistance. The care plan and fall risk evaluation documented that she required assistance from one to two staff for all transfers, ambulation, and toileting, had severely impaired cognition, and needed substantial or maximal assistance with toileting hygiene and transfers, as well as 24-hour supervision and assistance during ADLs and transfers. In the months preceding the incident, the resident experienced multiple falls, including events on 10/12/25, 10/29/25, 11/07/25, 12/02/25, and 12/25/25, each occurring when she attempted to stand, transfer, or ambulate without assistance. A fall risk evaluation dated 12/25/25 further documented that she was cognitively impaired, unable or unwilling to follow directions, and displayed behaviors such as restlessness, wandering, resisting care, and altered safety awareness. She was unsteady and only able to stabilize with assistance when moving from seated to standing, walking, moving on and off the toilet, and transferring between surfaces. Occupational therapy records indicated she required maximum assistance of one staff member for transfers from various surfaces and multimodal cues to increase ADL performance, reinforcing that she required continuous supervision and assistance during ADLs and transfers. On 03/21/26, despite these documented risks and needs, the resident was left unattended on the toilet by a CNA who was unfamiliar with her and her fall risks. According to the progress note and fall investigation, the CNA placed the resident on the toilet and then left the bathroom and bedroom to obtain new bedding and an adult brief from the hallway linen closet. While the CNA was away, the resident got herself off the toilet. When the CNA returned, she observed the resident coming out of the bathroom door and saw her fall backwards, striking her back and head on the sink. Initial documentation and the fall questionnaire indicated the CNA found the resident standing and that the resident became startled and fell back, with no mention that the CNA assisted her to the floor. The LPN who responded to the incident found the resident on the bathroom floor with a bruise on her back and a goose egg on the back of her head and documented that the CNA reported seeing the resident fall and being unable to reach her in time to assist. Subsequent hospital evaluation documented multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, which were associated with this fall. The facility’s own investigation noted that the resident had been left alone in the bathroom and added an intervention for staff to remain in the bathroom until the resident finished toileting, underscoring that the lack of supervision during toileting led to the fall and resulting injuries. Additional interviews supported that residents with similar cognitive impairment and toileting needs were generally not left alone on the toilet and required frequent checks, with staff often remaining in or just outside the bathroom to monitor them. The LPN confirmed that this resident was known to frequently get up without assistance and, for that reason, was not typically left alone on the toilet. The administrator acknowledged that staff from other buildings, who were unfamiliar with residents and their risks and were unlikely to review care plans, were being used at the time of the incident. The facility’s fall management policy required ongoing review of care plans and use of fall risk evaluations to identify individualized fall risk factors, but in this case, the CNA did not follow the resident’s established need for continuous supervision and assistance during toileting, directly leading to the unsupervised toileting event and subsequent fall. The hospital records following the incident documented that the resident presented after a mechanical fall with chest wall pain and visible bruising to the left side. Imaging and physician notes identified left-sided rib fractures (seventh through eleventh ribs), a small left hemopneumothorax, an acute left T9 transverse process fracture, and hematomas of the left chest wall, retroperitoneum, and right iliacus muscle. The records stated it was unknown whether osteopenia or osteoporosis contributed to the fractures and did not characterize the fractures as pathological. The physician noted that the resident was at high risk of falls and had been sent to the emergency room after this fall, confirming that the injuries were associated with the incident in which she was left unattended while toileting. The facility’s documentation of the event, including the fall investigation and questionnaires, consistently indicated that the resident was left alone in the bathroom despite her documented need for assistance and supervision with toileting and transfers. The lack of a contemporaneous witness statement from the CNA and the later, typed statement created over a month after the fall introduced discrepancies about whether the CNA partially assisted the resident to the floor. However, the LPN’s account and initial documentation emphasized that the CNA reported seeing the resident fall and being unable to reach her in time, and that the resident struck her head and back on the sink. These facts, combined with the resident’s known fall risk profile and care plan requirements, form the basis of the deficiency for failing to ensure adequate supervision and assistance to prevent accidents during toileting. The facility’s fall management policy, revised 10/24/25, required that care plans be reviewed throughout treatment to ensure resident-specific fall reduction interventions were incorporated and that fall risk evaluations be completed on admission, after significant changes, quarterly, and as necessary. The resident’s care plan and evaluations had already identified her need for assistance and supervision with toileting and transfers, yet on the day of the incident, these interventions were not followed when the CNA left her unattended on the toilet. This failure to adhere to the resident’s individualized fall prevention measures and to provide adequate supervision in the bathroom directly preceded the resident’s unsupervised attempt to ambulate, her fall, and the serious injuries documented in the hospital records.
Improper Manual Transfer Without Implementing PT Recommendations Leads to Humerus Fracture
Penalty
Summary
The facility failed to ensure a resident was transferred safely in accordance with physical therapy recommendations and safe transfer practices, resulting in an arm fracture. The resident had a history of significant orthopedic issues, including a surgically repaired right femur neck fracture and a prior nondisplaced fracture of the right humerus, along with diagnoses such as heart failure, kidney disease, and hyperlipidemia. Following a fall at home on Easter that caused a right hip fracture requiring surgical repair, the resident was readmitted with orders for weight bearing as tolerated to the right lower extremity and with hospital instructions that included no pivoting, no bending the hip beyond 90 degrees, and avoiding low chairs. A physical therapy evaluation on 04/10/26 documented that the resident had poor standing balance, was unable to pivot, and recommended use of a Sara Steady or sit‑to‑stand lift for transfers. However, this recommendation was not converted into physician orders or incorporated into the resident’s care plan, and there was no written communication process between therapy and nursing to ensure implementation of new transfer recommendations. At the time of the incident, the resident’s functional status had declined compared to earlier assessments. The discharge‑return anticipated MDS showed that the resident was now dependent on staff for sit‑to‑stand, bed/chair transfers, toilet transfers, and tub/shower transfers, and the walking section was skipped, indicating increased dependence. Despite this, the active transfer order in the chart had been updated only later to “transfer with two assistance and sit to stand,” and staff continued to perform manual transfers. On 04/12/26, two CNAs attempted to transfer the resident from a wheelchair to a recliner using an under‑arm lifting technique, with one CNA on each side hooking their arms under the resident’s arms. No gait belt was used during this transfer, and the CNAs reported that there was no gait belt available in the room. The resident, who was known by staff to have a history of not bending her legs or assisting with pushing up during transfers, began to slide, panicked, and became “dead weight,” causing staff to bear her full weight under her arms. During this improper manual transfer, both CNAs reported hearing a loud crack or pop from the resident’s right shoulder area, and one CNA felt the shoulder move up as if it dislocated. The resident immediately experienced pain, numbness, and limited range of motion in the right upper extremity. Initial x‑ray of the right shoulder showed no acute fracture or dislocation, but the resident continued to have pain and limited range of motion, and subsequent imaging of the right humerus and surrounding structures the next day revealed an acute mildly angulated fracture of the humeral neck. The DON and therapy staff later confirmed that the resident should have been transferred with a Sara Steady or sit‑to‑stand mechanical lift per the PT’s 04/10/26 recommendation and that a gait belt should have been used for all transfers. The DON also confirmed that the facility had no transfer policy and that she was unaware of the PT’s recommendation until after the incident, as the facility relied on verbal communication in morning meetings and had no written process to ensure therapy recommendations were implemented. These actions and omissions led to the resident being transferred manually without a gait belt and contrary to therapy recommendations, resulting in the humeral fracture. The facility’s internal investigation documented that the root cause of the injury was an unsuccessful transfer when the resident began to slide and staff had to bear all of her weight under her arms. CNA interviews corroborated that they used the under‑arm technique instead of a gait belt and were unaware of the PT’s recommendation for a mechanical lift. The DON confirmed that staff on the date of the incident should have been using a stand‑assist mechanical lift and a gait belt for transfers, and that there was no facility policy on transfers at the time. The survey findings concluded that the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents, as evidenced by the improper transfer that caused the resident’s humeral fracture.
Failure to Investigate and Prevent Recurrent Falls in a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly assess and address the causes of repeated falls for a resident at high risk for falls, and to ensure that fall-prevention interventions were consistently implemented. The resident was admitted with Alzheimer’s disease, dementia, anxiety disorder, atrial fibrillation, and other comorbidities, and was care planned early on for safety concerns and fall risk, including use of non-skid footwear and encouragement to stay in common areas while awake. A falls risk assessment identified the resident as at higher risk for falls. Despite this, the facility did not complete or provide comprehensive fall investigations, did not document orthostatic blood pressure assessments when claiming orthostatic hypotension as a cause, and did not demonstrate that existing interventions such as non-skid footwear were in place at the time of multiple falls. On one occasion, the resident was found on the floor in her room after reporting she heard voices in the hall and went to check; the facility later stated the fall was related to orthostatic hypotension, but there was no evidence in the medical record that orthostatic blood pressures were obtained at the time of the fall. The resident was sent to the ER and diagnosed with a closed compression fracture of the L3 vertebra. Subsequent falls occurred when the resident was restless and trying to stand up alone, including while on C. diff isolation, and when she was observed on camera walking around her room, sitting on the arm of a recliner, and falling to the floor. In these instances, the record did not show that the facility verified whether non-skid footwear was in use, and interviews confirmed that at least one fall occurred when the resident had nothing on her feet. The facility’s comprehensive fall investigations and witness statements were withheld as QAPI, and no documentation was provided to show thorough investigation, confirmation that interventions were in place, or determination of root causes. Additional falls included an unwitnessed fall where the resident was found on the floor next to her rollator with a head laceration requiring staples, and another fall near the nursing station where she was found sitting on the floor in front of her wheelchair and later diagnosed with an intertrochanteric right femoral fracture. The facility reported that the resident was last seen 10–20 minutes before some of these falls, but did not provide evidence that ordered safety checks (such as every 15-minute checks during isolation) were actually completed. The final fall occurred in the secured unit dining area, where the resident was assisted to a padded wheelchair in a semi-reclined position and left in the dining room while the LPN passed medications and CNAs provided morning care to other residents. Within approximately 5–15 minutes, the resident was found on the floor with facial injury, multiple fractures, and extensive ecchymosis. Staff interviews indicated the resident had been restless and scooting in her chair the prior day, but this was not communicated in report, and the facility could not identify the cause of the fall. The death certificate later listed the manner of death as accident, with the underlying cause being sequelae of blunt impacts to the head, trunk, and left arm with fractures and soft tissue injuries due to falls.
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