**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure proper transfer techniques to prevent falls and injuries for one of 7 residents (R2) reviewed for supervision to prevent falls in the sample of 7. This failure resulted in an Immediate Jeopardy when V8, Certified Nurse's Aide (CNA) transferred R2 incorrectly causing R2 to sustain bilateral femur (thigh) fractures and expiring on 04/14/24. This past non-compliance occurred from 04/11/24 to 04/12/24. The Immediate Jeopardy began on 4/11/24, when V8 attempted to transfer R2 by herself, and R2 falling and sustaining bilateral femur fractures. On 4/17/24, at 2:17 PM, V1, Administrator, V25, Regional Corporation Nurse and V26, Director of Clinical Operations were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed, and the deficient practice was corrected, on 4/12/24, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R2's Electronic Medical Record, EMR, undated documents R2 was admitted to the facility on [DATE]. R2's EMR, dated 05/29/19, documents R2 has a diagnosis of Alzheimer's Disease, unspecified. R2's EMR, dated 02/17/21, documents a diagnosis of chronic pain syndrome. R2's EMR, dated 10/01/22, documents a diagnosis of Vascular Dementia, unspecified severity, with agitation. R2's Care Plan dated 04/13/21 documents ADL (Activities of Daily Living): (R2) has an ADL Self Care Performance Deficit r/t (related to) limited mobility from her past left hip fracture, weakness and confusion. Alert, oriented to self. Incontinent of B&B (bowel and bladder). Able to feed self. Utilizes wheelchair for mobility. Hesitant in new environments and does not do well with too many options. Requires extensive assist and encouragement to complete most tasks. Has a stuffed, interactive cat that she often has nearby as a companion. R2's Care Plan Intervention, dated 03/10/22 documents TRANSFER: sit to stand using 2 assist. R2's Minimum Data Set, MDS, dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 99, which means the resident had severe cognitive impairment. The MDS documents that the resident required substantial/maximal assistance for roll left and right, sit to lying, and lying to sitting on side of bed. The MDS documents that the resident was dependent for sit to stand, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. R2's Health Status Note dated 04/11/24 at 11:39 PM documents The resident was being transferred into the room by aide and the resident's weight shifted toward the aide making the aide fall backward the resident came down forward and once this nurse immediately arrived at the room it was observed that the resident down on one knee and the aide holding her up best, she could. Resident was immediately assessed for injuries. there was no open area to the knees, this nurse attempted ROM (Range of Motion) and upon review the left femur seems to have a deformity. The right thigh had some swelling and at this time the aide and nurse was not clear if this was normal muscular tight swelling or from the fall. So, EMS (Emergency Medical Services), MD (Medical Director) and family notified once EMS arrived and was given report was informed of all concerns of bilateral knees and femurs. Pt (patient) vitals were stable. pt did not hit her head and was sent to (local hospital). R2's Health Status Note dated 04/12/24 at 12:24 PM documents Resident admitted to (local hospital) due to BLE (bilateral lower extremities) fractures. R2's Radiology Report dated 04/12/24 documents Acute significantly displaced and comminuted fracture of the mid left femur. Acute significantly fracture of the mid right femur. R2's Health Status Note dated 04/12/24 at 1:43 PM documents Clarification note per Nurses note incident occurred at 21:00. Facility's Lift Transfer Past Non-Compliance form, dated 04/12/24 documents under problem On 4-11-24 patient (R2) was transferred with 1 person assist but care plan was for sit to stand using 2 assist. On 04/16/24 at 2:09 PM, V8, CNA (Certified Nursing Aide) stated that she was putting R2 in her bed and R2 fell on her. She stated that she yelled for help because R2 was on top of her, and she could not move. She stated that she noticed R2's leg was deformed. She stated that she told the nurse that something was not right with R2's leg. She stated that R2 is normally a 2 assist, but she has been working with her for months. She (V8) stated she has been transferring R2 by herself for a while. She stated that R2's legs are contracted, and she always has her legs crossed. She (V8) stated that lifted her (R2) with a gait belt and put her (V8's) leg between R2's legs. She (V8) stated that she stumbled and R2 fell on top of her. She (V8) stated that the unit was not short staffed. She (V8) stated that R2 fell between 9:00 PM and 9:30 PM. She (V8) stated that it took a long time for the ambulance to get there. She (V8) stated that the ambulance arrived around 10:30 PM. She (V8) stated that the nurse ordered x-rays instead of calling an ambulance. On 04/16/24 at 2:27 PM, V9, Licensed Practical Nurse, LPN, stated that she was sitting at the nurses' station. V9 stated that she heard yelling down the hall. She (V9) stated she ran to see R2 with one knee on the floor kneeling and V8 holding R2 up with R2's back against the dresser. She (V9) stated that she was able to assist R2 into her wheelchair. She (V9) stated that she assessed R2 and noticed a bulging area on her right thigh. She (V9) stated that she ordered a STAT x-ray. She stated that she had another aide come look at R2's legs and that aide stated that her legs did not look that way before. She (V9) stated that instead of waiting on (mobile x-ray company), she called the ambulance. She (V9) stated that the hospital could get an x-ray quicker and that R2 had already been given her norco (pain medication) at 8:00 PM, so the ER (Emergency Room) could give her more pain meds. She (V9) stated that she did not see a gait belt or a sit to stand. She stated that V8 never asked her or the other CNA on the unit for help to transfer R2. On 04/17//24 at 12:47 PM, V21, ER Physician, stated that the resident (R2) had very severe osteopenia and never would have survived surgery. He (V21) stated that he is unsure if the fractures contributed to her death, but it did not help. On 04/17/24 at 2:08 PM, V19, Medical Director stated that in his professional opinion the bilateral femur fractures contributed to R2's death. Facility's Fall Prevention Policy (S.A.F.E.) dated 02/2021 documents The S.A.F.E. program promotes Safety, Assessment, Fall prevention and Education of both staff and residents. The Immediate Jeopardy and deficiency practice that began on 4/11/24 was corrected/removed on 4/12/24 after the facility took the following actions to correct the noncompliance prior to the start of current survey: 1. DON (V2) or Designee (V14) to provide 100% of nursing staff were educated on 2 person transfers with all lifts following the patient [NAME] prior to their next assigned shift. Done 04/12/24. 2. DON or Designee will provide education to direct care staff on correct procedures for following the [NAME] prior to allowing staff to work their next assigned shift. Done 04/12/24. 3. Staff will not be allowed to work and will be taken off the schedule until all education is completed. 4. Education will continue until all nursing staff have been educated, staff will not be allowed to return to work until the education has been provided. 5. All new nursing staff and agency will have the same information reviewed with them at the time of orientation. 6. AD HOC QAPI meeting was immediately held with the medical director on 04/12/24. 7. The DON or Designee will complete 5 lift educations a week for 8 weeks. 8. Any deficient practices will be corrected immediately. Patterns or trends will be reported to QA committee for further recommendations and follow-up. 9. All resident's transfer status' reassessed and reviewed by V3, Assistant Director of Nursing, ADON on 04/12/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain residents' highest practicable physical well-being by assessing and providing timely care and treatment of fractures for 1 of 3 residents (R22) reviewed for quality of care in the sample of 43. This failure resulted in R22 not receiving timely care and treatment for three days after a fall. When R22 was sent to the hospital for treatment, it was identified that he had bilateral femur fractures and a dislocated knee. The Immediate Jeopardy began on 11/23/23 when R22 had a syncope episode during a transfer by V14, Certified Nurse's Aide (CNA) with a sit-to stand lift. The facility did not conduct an assessment after this incident to ensure the safest mode of transfer for R22. Again on 11/24/23, R22 had another syncope episode while being transferred with a sit to stand lift. On 11/26/23, after having pain throughout the day, R22 was sent to the hospital. R22's sustained severely displaced fracture of the right proximal femur shaft, a severely comminuted distal left femoral fracture with displacement with likely disruption of the knee joint. On 12/1/23, at 12:50 PM, V3, Director of Nursing (DON) and V28, Licensed Practical Nurse/Travel Nurse Manager was notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 12/2/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R22's Face Sheet, undated, documents R22 has the following diagnoses: Rheumatoid Arthritis, Weakness, Bilateral Osteoarthritis of the Knees and Abnormalities of Gait and Mobility. R22's Minimum Data Set (MDS), dated [DATE], documents R22 is cognitively intact and is dependent with transfers. R22's Care Plan, dated 8/17/23, documents R22 is at risk for falls. R22's Care Plan does not address that R22 has episodes of syncope. R22's Progress Note, dated 9/13/2023 at 2:00 PM, the CNA (Certified Nurse's Assistant) was assisting resident in bed, staff states resident's legs gave out, so she slowly lowered him to the floor. Upon assessment no injuries noted and Power of Attorney at bedside. Resident helped up and laid down in bed. Vital signs 130/66 (blood pressure), 88 (pulse), 18 (respirations), 98.3 (temperature) and 97% (oxygen saturation) on 2 liters. Will continue to monitor. R22's Progress Note, dated 11/23/23 at 8:30 PM, documents Returned to facility per (Outside Company) transport. Taken to room (Room #). CNAs times/x2 to assist to bed per sit to stand. Was unable to raise bed. Resident passed out. Lowered to floor. There was no documentation in R22's medical record that after R22 had a syncope episode on 11/23/23, the facility reassessed R22 for the safest mode of transfer due to syncope. There was no documentation that staff conducted a full assessment to ensure that R22 had not sustained any injuries after this incident. R22's Progress Note, dated 11/24/23 at 9:31 PM, documents Resident had a syncope episode tonight while being transferred in sit to stand. When aide lifted the resident, the resident became unconscious and started to snore. Episode last for 20 secs (seconds). Resident now in bed and is still drowsy. R22's Progress Note, dated 11/26/23 at 5:08 AM, documents R22 was given pain medication during the night for pain. R22's legs were edematous, and the left knee area was bruised from the fall. R22 had difficulty moving his left leg. There is no documentation that the Physician was notified of R22's change in condition. R22's Progress Note, dated 11/26/23 at 10:15 PM, documents R22 was complaining of pain to his buttocks and back throughout the day with several needs for pain medication. V15, Nurse Practitioner, called the facility and an update on R22's condition, increased edema and bruising to the knee. R22's Progress Note, dated 11/26/23 at 10:37 PM, documents upon assessment of R22's left leg, it has had a significant change with increased swelling, abnormal coloring, and increased pain. Physician exchange notified, awaiting response. R22's Progress Note, dated 11/26/23 at 10:51 PM, documents the nurse spoke with the on-call Physician and a new order was obtained to send to the local ER (Emergency Room) for evaluation and treatment. R22's Progress Note, dated 11/27/23 at 4:37 AM, documents R22 was admitted to the hospital with a diagnosis of Low Hemoglobin, A Dislocated Left Knee and Bilateral Femur Fractures. R22's ER notes, dated 11/27/23, document R22 was brought into the ER for bilateral knee pain, swelling and deformity after a fall at his nursing facility 2-3 days ago. Patient states he fell at the nursing home and the pain became worse today. R22's right femur x-ray showed a severely displaced fracture of the right proximal femur shaft. R22's left femur x-ray showed a severely comminuted distal femoral fracture with displacement. R22's left knee x-ray showed a severely comminuted and displaced distal femoral fracture with likely disruption of the knee joint. Discussed patient history, exam, and other pertinent info with orthopedic surgeon. He advises sending patient to an orthopedic trauma specialist at an outside hospital. Patient has been accepted and will be transferred to the outside hospital for further treatment. On 11/30/23 at 9:10 AM V12, CNA, stated she had worked 6 AM - 2:30 PM on 11/23/23 and R22 was okay. V12 came back in and worked the night shift on 11/23/23 from 11:00 PM - 6:00 AM, R22 had his call light on, so she went into his room, and he told her that he did not faint, he was dropped by staff. V12 stated R22 was complaining of a lot of pain and didn't want to be touched. V12 stated she is not sure if he had any injuries because he was hurting and wouldn't let her touch him. V12 stated R22 needed some pain medication, so she let the nurse know. On 11/30/23 at 9:50 AM, V14, CNA, stated R22 had been passing out in the sit to stand mechanical lift off and on since admission. V14 stated on 11/23/23, unsure of exact time, she and V16, RN, were getting R22 ready for bed and was going to lay him down. V14 stated R22 was in the sit to stand mechanical lift and passed out so she had to spring to get the other CNA to ease R22 to the floor. V14 stated V16, RN, asked R22 if he was hurt, R22 stated yes, and he needed some pain medication. V14 stated she did not see V16, RN, do any other assessments on R22 and he was placed in the bed using a full mechanical lift. V14 stated she did not see any visible injuries to R22. V14 stated if R22 had injuries, he should have been sent out. On 11/30/23 at 10:22 AM V15, Nurse Practitioner, stated she was sent a message through (communication application) on 11/23/23 that R22 had a syncopal episode in the sit to stand. V15 stated she had discontinued R22's Midodrine a couple of weeks earlier, so she gave orders to restart that. V15 stated she called the facility on Sunday, 11/26/23, during the day, to check in with all the units. V15 stated she talked to the nurse on duty for R22 and reminded her that R22 had been restarted on his Midodrine and the nurse did not report anything to her about R22's fall, any injuries or pain. V15 stated she got a text message that night from the on-call Physician stating R22 was sent to the hospital with his bone protruding. V15 sated they should have notified her or the Physician with any changes. On 11/30/23 at 11:20 AM V21, R22's Daughter, stated V17, R22's Wife notified her (V21) that R22 had fainted and was lowered to the ground and R22 immediately got on the phone and told her (V21) that they dropped him. On 11/30/23 11:20 AM V22, R22's Son, stated that the facility called V17, R22's Wife, on her cell phone and she was told that R22 fainted and was lowered to the floor but R22 said he was dropped. V22 stated R22 laid in his bed from Thursday night (11/23/23) until Monday morning (11/27/23). V22 stated the nurse on duty, unsure of name, communicated with V17 several times on 11/26/23 and R22 needed to be sent to the hospital. V22 stated R22 had bilateral fractured femurs with significant displacement and the bone was protruding from the skin. V22 stated R22 was kept at the local hospital for a couple of hours and was then sent to an outside hospital due to the extent of his injuries and they were worried that the femoral artery was damaged. V22 stated he was admitted to the outside hospital, has had significant blood loss, and required two surgeries with the orthopedic and vascular doctor and remains in ICU at the hospital. On 12/05/23 at 9:28 AM, V3, Director of Nursing, stated she would expect staff to identify changes in condition and provide the necessary care and treatment needed. The Significant Condition Change & Notification policy, dated 11/2019, documents the purpose of the policy is to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as: an accident or incident, with or without injury, that has the potential for needed medical practitioner intervention, a significant change in the resident's physical, mental or psychosocial status, a need to significantly alter treatment and transfer of the resident from the facility. Charting will include an assessment of the resident's current status as it relates to the change in condition. The Immediate Jeopardy that began on 11/23/23 was removed on 12/2/23 when the facility took the following actions: Section 1 1. On 12-1-23, The V1, Administrator and V3, DON were educated to ensure all residents must be assessed and provide timely care and treatment by V4, Regional Nurse Consultant, to ensure the safety of the facility's residents. 2. On 12-1-23, The facility has assessed all residents for change in condition. These initial assessments were done by the Nurse Management Team. The Nursing management team consist of V3, DON, V26, MDS Coordinator, V40, Care Plan Coordinator, V8 and V9, Infection Control Nurses and V18, Wound Care Nurse on 12-1-23. From the facility's assessment done by the Nursing Management Team, those resident change in condition have been addressed. The Nurse must assess the resident after a change in condition and notify the MD and RR immediately and inform the V3, DON/Designee of the occurrence. In Clinical meeting the occurrence will be discuss in depth. The following residents' changes in conditions that occurred on 12-2 and 12-3 are reviewed by the IDT Team on 12-4-23. R20, R52, R33 and R75 to ensure that Proper documentation, SBAR (Situation, Background, Assessment, and Recommendation), Nurses notes, Medical Doctor/MD, and RR (resident representative) notification were done, and treatment was carried out by the nurse immediately. 3. On 12-1-23, The facility will ensure that all residents are assessed for change in condition timely and the residents' care plan will be updated accordingly. Any change in condition, the nurse must assess the resident immediately, notify the MD and RR and inform the V3, DON/Designee of the occurrence. Change in condition that occurred on 12-2 and 12-3 are reviewed by the IDT Team (V3, DON, V26, MDS Coordinator, V40, Care Plan Coordinator, V8 and V9, Infection Control Nurses, and V18, Wound Care Nurse) on 12-4-23. R20, R52, R33 and R75 to ensure that Proper documentation, SBAR, Nurses notes, MD and RR notification were done, and treatment was carried out by the nurse immediately. The nursing management team (V3, DON, V26, MDS Coordinator, V40, Care Plan, V8 and V9, Infection Control Nurses and V18, wound Care nurse) will monitor the resident in the facility for possible residents' changes in condition to ensure that the nursing staff identify and provide timely treatment for the resident. Weekly to ensure compliance. 4.On 12-1-23, The facility will ensure that all residents are assessed for change in condition timely. 5. On 12-1-23, An ADHOC meeting with V42, Medical Director was held, and the identified issues were discussed. During this time the following policies for Falls, Transfers and Mechanical Lifts and identifying change in condition and notifying the MD of those changes were reviewed. At this time, it was determined that the facility would allege compliance as of 12-1-23 with the safety of all residents. Section 2 Other residents have the potential to be affected by the alleged deficient practice. Section 3 Systemic Changes to Ensure Compliance All nursing staff will be in-serviced on the following: The IDT Team and the ADHOC committee reviewed the policies and procedures to ensure current practices are being followed. This review occurred on 12-1-23. The policy for change in condition was reviewed. At this time, it was determined the facility would allege compliance with as of 12-2-23. License nursing staff was in-serviced on assessing and providing care and treatment and to provide timely documentation. The nurse must assess and document their assessment after each fall/lowering of the residents or change in conditions. This assessment must be communicated to the physician. This in-service was performed on 12-1-23 and 12-2-23 by V3, DON/Designee. Certified Nursing staff was in-serviced to communicate any changes in the resident status (i.e., falls or changes in condition) to all nursing immediately and through on and off shift report. This assessment must be communicated to the physician. This in-service was performed on 12-1-23 and 12-2-23 by V3, DON/Designee. Section 4 V3, DON/Designee will review residents' progress notes 4 x week to ensure that residents' assessments, care, and treatments are performed in a timely manner and documented in a timely manner. Any noted issues will be immediately addressed and reviewed in the QAPI process. The abatement plan was validated on 12/5/23. R20, R341, R33 and R75 were reviewed for changes in condition. The following staff were interviewed for validation that the in-servicing had been completed: V28, LPN/Travel Nurse Manager; V2, Assistant Administrator; V4, Regional Nurse; V3, DON; V30, CNA; V11, LPN; V12, CNA; V31, LPN; V27, LPN; V32, CNA; V19, CNA; V33, CNA; V34, LPN; V13, CNA; V34, LPN; V35, CNA; V36, LPN; V37, CNA, and V38, CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on interview and record review, the facility failed to assess for and provide safe transfer techniques to prevent falls/injury for 1 of 14 residents (R22) reviewed for safe transfer techniques to prevent injury/falls in the sample of 43. This failure resulted in an Immediate Jeopardy when the facility failed to reassess R22 for the safest mode of transfer after having syncope episodes while being transferred with a sit-to stand lift. R22 sustained severely displaced fracture of the right proximal femur shaft, severely comminuted distal left femoral fracture with displacement of the knee joint. R22 has had two surgeries, a blood transfusion and remains in the Intensive Care Unit (ICU). The Immediate Jeopardy began on 11/23/23 when R22 had a syncope episode during a transfer by V14, Certified Nurse's Aide (CNA) with a sit-to stand lift. The facility did not conduct an assessment after this incident to ensure the safest mode of transfer for R22. Again on 11/24/23, R22 had another syncope episode while being transferred with a sit to stand lift. On 11/26/23, after having pain throughout the day, R22 was sent to the hospital. R22's sustained severely displaced fracture of the right proximal femur shaft, a severely comminuted distal left femoral fracture with displacement with likely disruption of the knee joint. On 12/1/23, at 12:50 PM, V3, Director of Nursing (DON) and V28, Licensed Practical Nurse/Travel Nurse Manager was notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 12/2/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: 1. R22's Face Sheet, undated, documents R22 has the following diagnoses: Rheumatoid Arthritis, Weakness, Bilateral Osteoarthritis of the Knees and Abnormalities of Gait and Mobility. R22's Minimum Data Set (MDS), dated [DATE], documents R22 is cognitively intact and is dependent with transfers. The MDS does not indicate that R22 utilizes a mechanical lift. R22's Care Plan, dated 8/17/23, documents R22 is at risk for falls and requires an assistance of one staff with transfers. R22's Care Plan does not indicate that R22 utilizes a mechanical lift. R22's Care Plan did not document R22 had any syncope episodes. R22's Progress Note, dated 9/13/2023 at 2:00 PM, the CNA (Certified Nurse's Assistant) was assisting resident in bed, staff states resident's legs gave out, so she slowly lowered him to the floor. Upon assessment no injuries noted and Power of Attorney at bedside. Resident helped up and laid down in bed. Vital signs 130/66 (blood pressure), 88 (pulse), 18 (respirations), 98.3 (temperature) and 97% (oxygen saturation) on 2 liters. Will continue to monitor. There was no documentation in R22's medical record that the facility reassessed R22's for safe transfer techniques after he was lowered to the floor on 9/13/23. R22's Progress Note, dated 11/23/23 at 8:30 PM, documents Returned to facility per (Outside Company) transport. Taken to room (Room #). CNAs x2 to assist to bed per sit to stand. Was unable to raise bed. Resident passed out. Lowered to floor. There was no documentation in R22's medical record that after R22 had a syncope episode on 11/23/23, the facility reassessed R22 for the safest mode of transfer due to syncope. R22's Progress Note, dated 11/24/23 at 9:31 PM, documents Resident had a syncope episode tonight while being transferred in sit to stand. When aide lifted the resident, the resident became unconscious and started to snore. Episode last for 20 secs (seconds). Resident now in bed and is still drowsy. R22's Progress Note, dated 11/26/23 at 5:08 AM, documents R22 was given pain medication during the night for pain. The Note documented R22's legs were edematous, and the left knee area was bruised from the fall and R22 had difficulty moving his left leg. There is no documentation that the Physician was notified of R22's change in condition. R22's Progress Note, dated 11/26/23 at 10:15 PM, documents R22 was complaining of pain to his buttocks and back throughout the day with several needs for pain medication. V15, Nurse Practitioner, called the facility and an update on R22's condition, increased edema and bruising to the knee. R22's Progress Note, dated 11/26/23 at 10:37 PM, documents upon assessment of R22's left leg, it has had a significant change with increased swelling, abnormal coloring, and increased pain. Physician exchange notified, awaiting response. R22's Progress Note, dated 11/26/23 at 10:51 PM, documents the nurse spoke with the on-call Physician and a new order was obtained to send to the local ER (Emergency Room) for evaluation and treatment. R22's Progress Note, dated 11/27/23 at 4:37 AM, documents R22 was admitted to the hospital with a diagnosis of Low Hemoglobin, a Dislocated Left Knee and Bilateral Femur Fractures. R22's ER notes, dated 11/27/23, document R22 was brought into the ER for bilateral knee pain, swelling and deformity after a fall at his nursing facility 2-3 days ago. Patient states he fell at the nursing home and the pain became worse today. R22's right femur x-ray showed a severely displaced fracture of the right proximal femur shaft. R22's left femur x-ray showed a severely comminuted distal femoral fracture with displacement. R22's left knee x-ray showed a severely comminuted and displaced distal femoral fracture with likely disruption of the knee joint. Discussed patient history, exam, and other pertinent info with orthopedic surgeon. He advises sending patient to an orthopedic trauma specialist at an outside hospital. Patient has been accepted and will be transferred to the outside hospital for further treatment. The Facility Investigation regarding R22's fractures, undated, documents the following: Interview with V14 conducted on 11/27/23 documents the resident was back from his family visit and took resident to his room to place him bed. She called out from the room for assistance because the resident went limp and passed out in the Sit to Stand Lift. The Interview documented V14, V16, RN (Registered Nurse) and V27, LPN (Licensed Practical Nurse) assisted and lowered R22 to the floor. The Interview documented a full mechanical lift was obtained and R22 was placed in the bed. Interview with V27, Agency LPN, conducted on 11/27/23, documents V27 came to the floor to talk with V16, and heard V14 call for help from R22's room. The Interview documented V27 immediately ran into the room and saw R22 hanging in the sit to stand lift in a fetal position. The Interview documented they immediately lowered R22 to the floor. Interview with V16, RN, conducted on 11/27/23, documents V14was putting R22 to bed and he went limp in the sit to stand lift, he R22 was very heavy so they lowered him to the floor. Interview with V25, LPN, conducted on 11/27/23, documents V25 stated that in report from the midnight nurse on 11/26/23, that the resident legs were swollen, and he was in pain. At 1:00 PM, V25 observed the left leg with bruising and swelling notified. V15, Nurse Practitioner (NP) called for an update on R22. At 10:22 PM, R22 wanted more over the counter (OTC) pain medication and V25 went into the room to assess R22. V15 was called because R22 had pain in his back and buttocks. V25 received order to transfer to the ER (Emergency Room) for evaluation and treatment, Summary: Interview with staff and the CNA (V14). This CNA was suspended pending investigation related to the transfer. We cannot substantiate that the incident that occurred on 11/23/23 was the primary causative factor. (R22) has a history of chronic steroid use and has received injections prior to his nursing home admission. Being on prednisone for long period of time may predispose the resident to osteopenia which makes him prone to fractures. With the weight of (R22) and the transfer from the bed to the sit to stand, (R22) became limp. V14's Employee Suspension Form, dated 11/27/23, documents the following: Offense being investigated - Improper operation of community equipment that resulted in harm of team member, resident, or visitor; Date of alleged offense and a brief narrative of the events that led to the suspension: 11/23/23 - Improper transfer of resident using (sit to stand) lift by herself. On 11/30/23 at 9:10 AM V12, CNA, stated she had worked 6 AM - 2:30 PM on 11/23/23 and R22 was okay. V12 came back in and worked the night shift on 11/23/23 from 11:00 PM - 6:00 AM, R22 had his call light on, so she went into his room, and he told her that he did not faint, he was dropped by staff. V12 stated R22 was complaining of a lot of pain and didn't want to be touched. V12 stated she is not sure if he had any injuries because he was hurting and wouldn't let her touch him. V12 stated R22 needed some pain medication, so she let the nurse know. On 11/30/23 at 9:50 AM, V14, CNA, stated R22 had been passing out in the sit to stand mechanical lift off and on since admission. V14 stated on 11/23/23, unsure of exact time, she and V16, RN, were getting R22 ready for bed and was going to lay him down. V14 stated R22 was in the sit to stand mechanical lift and passed out so she had to spring to get the other CNA to ease R22 to the floor. V14 stated V16, RN, asked R22 if he was hurt, R22 stated yes, and he needed some pain medication. Stated she did not see V16, RN, do any other assessments on R22 and he was placed in the bed using a full mechanical lift. V14 stated she did not see any visible injuries to R22. V14 stated if R22 had injuries, he should have been sent out. V14 stated because R22 was passing out in the sit to stand, she wasn't sure why he wasn't made to use the full mechanical lift. V14 stated when they were transferring R22 on 11/24/23, he felt lightheaded, and they had to slide the full mechanical lift pad under him and use that lift. On 11/30/23 at 10:22 AM V15, Nurse Practitioner, stated she was sent a message through (communication application) on 11/23/23 that R22 had a syncopal episode in the sit to stand. V15 stated she had discontinued R22's Midodrine a couple of weeks earlier, so she gave orders to restart that. V15 stated she called the facility on Sunday, 11/26/23, during the day, to check in with all the units. V15 stated she talked to the nurse on duty for R22 and reminded her that R22 had been restarted on his Midodrine and the nurse did not report anything to her about R22's fall, any injuries or pain. V15 stated she got a text message that night from the on-call Physician stating R22 was sent to the hospital with his bone protruding. V15 sated they should have notified her or the Physician with any changes. On 11/30/23 at 11:20 AM V21, R22's Daughter, stated V17, R22's Wife notified her (V21) that R22 had fainted and was lowered to the ground and R22 immediately got on the phone and told her (V21) that they dropped him. On 11/30/23 at 11:20 AM V22, R22's Son, stated that the facility called V17, R22's Wife, on her cell phone and she was told that R22 fainted and was lowered to the floor but R22 said he was dropped. V22 stated R22 laid in his bed from Thursday night (11/23/23) until Monday morning (11/27/23). V22 stated the nurse on duty, unsure of name, communicated with V17 several times on 11/26/23 and R22 needed to be sent to the hospital. V22 stated R22 had bilateral fractured femurs with significant displacement and the bone was protruding from the skin. V22 stated R22 was kept at the local hospital for a couple of hours and was then sent to an outside hospital due to the extent of his injuries and they were worried that the femoral artery was damaged. V22 stated he was admitted to the outside hospital, has had significant blood loss, and required two surgeries with the orthopedic and vascular doctor and remains in ICU at the hospital. V22 stated on 11/23/23, R22 was with the family celebrating Thanksgiving and around 8:20 PM, R22 was taken back to the facility by an outside transportation company. V22 stated R22 had been back at the facility for a very short time before he had fallen. V22 stated R22 is adamant that he was dropped. V22 stated R22 had no ambulatory capacity and was unable to walk. V22 stated he is not sure why the facility was using the sit to stand lift if he couldn't stand. V22 stated R22 told him V14, CNA, was frustrated because the bed was not working. On 11/30/23 at 11:42 PM, V23, Certified Occupational Therapy Assistant (COTA) stated, We saw (R22) in October and at that time we evaluated him and for transfers we recommended a sit to stand. (R22) was able to stand at the parallel bars and was weight bearing. If a resident was hooked up properly to the sit to stand, they should not have been able to fall out of it. On 12/1/23 at 9:20 AM V23, LPN, stated she worked on 11/26/23 and sent R22 to the hospital. V23 stated when she came in for her shift, she was told by the night shift nurse that R22 needed his compression socks put on, but she couldn't get them on because his legs were so swollen. V23 stated the night nurse told her that R22 was lowered to the floor 3 days prior but was not on fall precautions because it wasn't a fall. V23 stated she assumed that he was being assessed for the bruising and edema and now they were just monitoring it. V23 stated early in her shift she went in to assess R22's legs and there was some edema and bruising noted. V23 stated R22 was complaining of pain in his back and butt and was given pain medication throughout the day. V23 stated she had just given R22 pain medication around 9:00 PM and R22 was asking for it again, this concerned V23, so she went and assessed R22 again and he was complaining of left leg pain. R22's left leg was so much worse about three times the size it was that morning and the left knee had a big knot that looked like it was protruding. V23 stated it was not there at the beginning of her shift. V23 stated it had been a few hours since she had seen it. V23 stated she called the physician on call and received new orders to send R22 to the hospital. V23 stated she did not notify the physician earlier in the shift because his condition hadn't changed until that night. The Immediate Jeopardy that began on 11/23/23 was removed on 12/2/23 when the facility took the following actions to remove the Immediacy: 1. On 12-1-23, The V1, Administrator, and V3, DON, were educated on the Fall Risk and Transfer Status and Safety when utilizing mechanical lifts and updating the care plan by the Regional Nurse, V4, to ensure the safety of the facility's residents. 2. The facility performed a whole house audit to ensure transfers status of all residents. This audit was performed by the Nursing Management Team consist of V3, V26, MDS Coordinator, V40, Care Plan Coordinator, V8 and V9, Infection Control Coordinators, and V18, Wound Care Nurse on 12-1-23. When there is a concern with the mode of transfer, the nurse along with the IDT team will reassess transfer status. This reassessment will occur with changes in conditions, quarterly and as needed. When a transfer poorly goes the nursing staff will notify the MD, POA and V3, V3/Designee of the occurrence. The nursing staff will consult the MD on the new mode of transfer. V3/Designee will notify the Therapy Dept to perform a screen. The IDT Team will update the new mode of transfer on the care plan and any changes will be communicated to the nursing staff from the V3/Designee immediately. The IDT Team consist of V3, DON, V1, Administrator, V2, Asst Administrator, V40, Care Plan Coordinator, V26, MDS Coordinator, V18, Wound Care Nurse, V8/V9, Infection Control Nurse, V41, Social Service Therapy. 3. On 12-1-23, The facility has assessed all residents fall risk. This audit was performed by the Nursing Management Team on 12-1-23. When there is a concern with the mode of transfer, the nurses along with the IDT Team will perform a reassessment if a change in condition occurs, quarterly or as needed. When a transfer poorly goes the nursing staff will notify the MD, POA and V3/Designee of the occurrence. The nursing staff will consult the MD on the new mode of transfer. V3/Designee will notify the Therapy Dept to perform a screen. The IDT Team will update the new mode of transfer on the care plan and any changes will be communicated to the nursing staff from the V3/Designee immediately. 4. On 12-1-23, The facility will ensure safety is utilized with the use of mechanical lifts through observational returned demonstrations and the residents' care plan have been updated accordingly. Nursing staff performed return demonstrations on 1-person, 2-person, sit to stand and Hoyer lift transfers on 12-1-23 and 12-2-23. These demonstrations were observed by the Nursing Management Team. These return demonstrations will be conducted Quarterly and as needed by the Nursing Management Team. I am concerned that in Section 4 they noted that they will be done 3 x weekly for 8 weeks. 5. On 12-1-23, The IDT Team and the ADHOC meeting with the V42, Medical Director was held, and the identified issues were discussed. During this time the following policies for Falls, Transfers and Mechanical Lifts were reviewed. At this time, it was determined that the facility would allege compliance as of 12-2-23 with the safety of all residents. Section 2 Other residents have the potential to be affected by the alleged deficient practice. Section 3 Systemic Changes to Ensure Compliance The IDT Team and the ADHOC committee reviewed the policies and procedures related to the use of the mechanical lift to ensure current practices are followed. This review occurred on 12-1-23. All nursing staff will be in-serviced on the following: Nursing staff (Licensed Nurses and Certified Nursing staff) was in-service by the V3/Designee on transferring the resident appropriately based on the resident mode of transfer. When there is a concern with the mode of transfer, the nurses along with the IDT Team will be performing a reassessment if a change in condition occurs immediately, quarterly, and as needed. This service in-service was performed by the V3/Designee on 12-1-23. Nursing staff was in-serviced by the V3/Designee on using the appropriate equipment to maintain safety of all residents. This will be communicated to all nursing staff through on and off shift report. This in-service was performed by the V3/Designee on 12-1-23. Section 4 V3, DON/Designee, will do observational audits 3x a week for 8 weeks to ensure that the resident mode of transfer is correct and appropriate transfer methods are being done to prevent falls. Any noted issues will be immediately addressed and reviewed in the QAPI process. The abatement plan was validated on 12/5/23. R20, R341, R33 and R75 were reviewed for falls, transfer status, fall risk and care plans with no concerns. The following staff were interviewed for validation that the in-servicing had been completed: V28, LPN/Travel Nurse Manager; V2, Assistant Administrator; V4, Regional Nurse; V3, DON; V30, CNA; V11, LPN; V12, CNA; V31, LPN; V27, LPN; V32, CNA; V19, CNA; V33, CNA; V34, LPN; V13, CNA; V34, LPN; V35, CNA; V36, LPN; V37, CNA, and V38, CNA. B. Based on interview and record review, the facility failed to ensure residents at risk for elopement were being adequately supervised in 1 of 2 residents (R74) reviewed for supervision to prevent elopement in the sample of 43. Findings include: R74's Face Sheet, undated, documents R74 has the following diagnoses: Alzheimer's disease, Cognitive Communication Deficit and Senile Degeneration of the Brain. R74's Minimum Data Set (MDS), dated [DATE], documents R74 has moderate cognitive impairment, is independent with ambulation and wanders daily. R74's Care Plan, dated 3/9/23, documents R22 is at risk for elopement/wandering due to a history of attempts to leave the facility unattended, impaired safety awareness and wanders aimlessly. R74's Elopement Assessment, dated 5/12/23, documents R74 is at risk for elopement. R74's Progress Note dated, 8/25/23 at 4:13 PM, documents the following: Resident is wandering from 3 South to 3 north trying to get on the elevator. Resident went through the emergency door on 3 north and went down the stairs. This writer was unable to redirect resident. He then went through the emergency door on 1 north. This writer was able to redirect him back inside. Resident is sitting in the dining area watching TV at this time. Will continue to monitor 9/2/2023 18:01 Resident has removed his wander guard. Resident continues to leave all and try to get on the elevator. Also going to 3 North try to go out the exit door. Resident becomes combative when you try too re-direct him. Will continue to monitor. R74's Progress Note, dated 9/5/23 at 10:33 AM, documents the following: Resident continues wandering and exit seeking behaviors. Requires redirection from entering peers' rooms. Easily redirected at this time. Wander guard not in place. Nurse Manager informed this writer that resident had removed his wander guard. R74's Progress Note, dated 9/10/23 at 12:20 PM, documents the following: CNA reported to this nurse resident had gone with activity assistant at approximately 10:30 AM to church. This nurse was then notified at approximately 12:00 PM that resident had not returned back from church. Building was searched thoroughly for resident's whereabouts. On call nurse was notified of not being able to locate resident at that time immediately. On call nurse stated administrator had been notified with proper procedures being conducted. R74's Progress Note, dated 9/10/23 at 4:00 PM, documents the following: Resident returned to facility at 3:45 PM, all assessments including Skin, Elopement, Neuros, fall, Pain, and SBAR being conducted per protocol. Resident denies any pain or discomfort. No injuries noted, skin intact per usual with dark purple bruising to upper extremities and reddened knees. 15-minute checks initiated. Resident pleasant and cooperative with care. The Facility Investigation documents the following: Final report 9/10/23 - On 9/10/23 at approximately 12:00 PM a family member reported to staff that they had seen R74 walking down the street. Staff members went out searching. Police department was notified. Next of kin and physician were notified. R74 was found at approximately 3:30 PM. R74 was found still on the property on the west edge. R74 stated he was trying to go to the bank and that he knew they were searching for him, but he was trying to hide R74 was assessed and found to have no injuries. R74 had been in the chapel for church services. Staff were assisting residents back to their respective neighborhoods when R74 left by crossing over the building to the independent living side and exiting the building. R74 walked down the sidewalk west on F Street then turned right, toward Catawba Avenue. R74 was found sitting off the right side of the road. R74 had his wander guard on when he returned, and it was functioning. Chronological events per V10, Activity Aide: 9/10/23 at 10:45 AM, church started and V10 went to get residents for church. R74 walked with her to the chapel; 11:15 AM, church was over and V10 took another resident to their room, R74 was sitting in the chapel talking to other residents; 11:23 AM, V10 returned to the chapel, noticed R74 was gone, V10 checked the bathroom next to the chapel and didn't see him, so she checked 2 north and 2 south and did not see him; 11:50 AM, V10 went to kitchen and asked if they saw R74; 11:55 AM, V10 went to 3 south and 3 north and asked if they saw him or not or if he was in his room; 12:00 PM, V10 checked 1 south and 1 north and did not see him; 12:05 PM, V10 went to front desk and walked around the building and didn't see him so then she walked to the police station and looked inside and did not see R74. On 11/30/23 at 9:10 AM, V12, CNA, stated R74 wanders and tries to escape all the time. V12 stated he is not allowed off of the unit by himself. On 11/30/23 at 10:22 AM, V15, Nurse Practitioner, NP, stated R74 is at risk for elopement and has no safety awareness. On 12/05/23 at 9:28 AM, V3, Director of Nursing, DON, stated she would expect staff to assess residents after a fall and provide the necessary care and treatment, and provide adequate supervision/monitoring for residents at risk for elopement. The Elopement Policy, dated 5/2023, documents it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. C. Based on interview and record review the facility failed to assess for causative factors related to residents' falls and implement progressive interventions based upon this assessment for 5 of 11 residents (R39, R45, R52, and R69) reviewed for falls in the sample of 43. Findings include: 1. R39's Face Sheet, undated, documents R39 has the following diagnoses: Repeated Falls, Trans-Ischemic Attack (TIA), Alzheimer's Disease and Vascular Dementia. R39's Minimum Data Set, MDS, dated [DATE], documents R39 is severely cognitively impaired and has a history of falls. R39's Fall Risk Assessment, dated 10/17/23, documents R39 is at high risk for falls. R39 did not have a Care Plan addressing his fall risk or interventions to prevent falls. R39's Progress Note, dated 9/14/23 at 5:09 PM, documents R39 was observed on the floor by the bed. Vital signs were within normal limits (WNL). When asked what happened, R39 stated he was trying to get into bed. Denies hitting his heads. Neuro checks started due to fall being unwitnessed. Family and MD made aware. There was no documentation in R39's progress note that a new intervention was implemented to prevent further falls. R39's Progress Note, dated 10/12/23 at 12:55 AM, documents the evening CNA reported to the nurse that during her last round R39's arm was bleeding from a fall he had earlier on the evening shift around 6:00 PM or 6:30 PM. When nurse went to check on the resident, two skin tears with bruising were noted to the right arm side by side just above the elbow. Both areas were cleansed with wound cleanser. Resident stated he was not having any pain at this time. POA and MD notified of findings. Will continue to monitor. There was no documentation in R39's record of the fall that allegedly occurred on the evening shift, the root cause of the fall was identified or that a new intervention was implemented to prevent further falls. 2. R52's Physician Order Sheets (POS) dated November 2023 documents diagnoses of Multiple Sclerosis, Myocardial Infarction, Hypertension, Pressure Ulcer of Sacral Region, Pressure Ulcer of Right Heel, Pressure Ulcer of Sacral Area, Pressure Ulcer of Right Buttock, Right Heel, Need for Assistance with Personal Care, Pressure Ulcer of Left Heel. R52's Fall Risk assessment dated [DATE] at 1:58 PM, document R52 was High Risk for falls. R52's Nurse's Notes dated 9/12/2023 at 1:42 PM, Resident was yelling and was found lying on his back was on the floor and lower half on bed. This nurse assessed resident with no injuries noted. Resident complained lower abdominal pain, will not let this nurse palpate. Resident is more confused today than normal. R52's Care Plan dated 9/12/2023 intervention for R52's fall was documented as Resident sent to ED (Emergency Department) for evaluation of fall. No other intervention for R52's fall for 9/12/2023 was documented. R52's Follow up Report documents, Resident sustained fall on 9/12/2023. No injuries noted. Observed on floor in room. Root cause of fall may be attributed to the following diagnostic weakness, muscle wasting and atrophy, multiple sclerosis. Immediate intervention-send to ED, Emergency Department for evaluation. Care Plan updated and followed. 3. R69's Face sheet dated 5/13/2023 document diagnoses of wedge Compression Fracture of Second Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing, Alzheimer Disease with Early Onset, Unspecified Dementia, Unspecified Severity, with Psychotic Disturbances, Alzheimer Disease And Anxiety. R69's Care Plan documents, R69's daughter is her POA (Power of Attorney) for healthcare and is assisting with decision making related to (R69's) memory deficits. The resident has impaired cognitive function/dementia or impaired thought process. R69's Minimum Data Set (MDS) dated [DATE] document R69 was severely impaired for cognition for activities of daily living. R69's Behavior Note dated 5/1/2023 at 12:07 AM, Note Text: resident still up after midnight, wandering the hall, reaching over the nurses' desk, very confused, staff attempted several times to get resident to go to bed, resident refusing and continuing to wander. R69's Nurse's Notes dated 5/1/2023 at 152 AM, Note Text: resident still up wandering the hall, attempting to go into other residents' rooms, resident is not able to be redirected at this time. R69's Nurse's Notes dated 5/1/2023 at 10:25 PM, Note Text: Resident was in another resident room trying to get into the floor on right side. Hematoma to mid/right side forehead. (Right forehead). Unwitnessed. R69's Fall Report dated 5/1/2023 documents, Resident was in roommates room trying to get into recliner and fell onto floor on right side, moves all extremities WNL (within normal limits) upon assessment hematoma noted to middle/right side of forehead. This nurse and CNA helped resident back to her bed. Intervention: Care Plan documented Staff to ensure resident is ready for bed and in bed before shift change. This intervention did not address that R69 has a history of wandering throughout the night and does not wish to go to bed. On 12/1/2023 at 10:28 AM, V26, Care Plan Licensed Practical Nurse (LPN)/MDS Coordinator stated, Our former Care Plan person is no longer here. We reviewed all falls as a team, and I would expect appropriate interventions to be added to all Care Plans. I am not sure what happened but hopefully now that we have new staff members, we can address those things properly and make sure all interventions moving forward are carried over. 4. R45's Electronic Health Record dated 11/10/21 documents R45 had diagnoses of Alzheimer's Disease. R45's Electronic Health Record dated 3/14/23 also documents R45 has a diagnosis of Vascular Dementia. R45's Fall Risk Data Collection dated 9/29/23 documents R45 is low risk for falls. R45's Fall Risk Data collection dated 11/11/23 documents R45 is high risk for falls. R45's Minimum Data Set (MDS) dated [DATE] documents R45 is severely cognitively impaired. R45's Care Plan, dated 10/6/23, documents R45 will be free of injury through the next review date. R45's interventions are ensuring proper visual aides are available to support (R45) participation in activities. Ensure R45's glasses are clean and in good working condition. R45's Fall Investigation dated 1/24/23 documents resident was on the floor laying on her back by the bathroom door a small bump and bruise on the back of her head. R45's Care Plan was not revised with a progressive intervention to prevent her from potential future falls after she fell on 1/24/23. R45's Fall investigation dated 3/2/23 documents (R45) found by CNA (Certified Nursing Assistant) sitting on floor next to the toilet in her room Resident said that she was trying to get back into her wheelchair. R45's Care Plan was revised on 3/3/23 with initiation of intervention on 3/2/23 and documented Increase frequency of checks on reside while she is in her room. R45's Care Plan was updated on 3/6/23 with another intervention anti-roll backs on wheelchair. R45's Fall Investigation dated 3/17/23 documents resident fell trying to transfer herself to the recliner. R45's Care Pl[TRUNCATED]