The facility identified a census of 37 residents. The sample included 12 residents with three reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure adequate supervision resulting in preventable falls for Resident (R) 29. This deficient practice resulted in a pelvic fracture for R29 and created the risk for pain and impaired mobility. The facility additionally failed to safely secure hazardous materials, cleaning chemicals, and supplemental oxygen cylinders from eight cognitively impaired ambulatory mobile residents. This placed the residents at risk for preventable accidents and injuries. Findings Including: - The Medical Diagnosis section within R29's Electronic Medical Records (EMR) included diagnoses of a right femur (large leg bone) fracture (broken bone), left femur fracture upon admission, muscle weakness, cognitive-communication deficit, repeated falls, and dementia (a progressive mental disorder characterized by failing memory, confusion). R29's Quarterly Minimum Data Set (MDS) completed 04/21/24 noted a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognition. The MDS indicated she had lower extremity functional limitations and used a wheelchair for mobility. The MDS indicated she required supervision or touch assistance for bed mobility and transfers. The MDS noted she required substantial to maximal assistance with bathing, dressing, and toileting. The MDS indicated she was dependent on staff assistance during ambulation but used a wheelchair for mobility. The MDs indicated she had multiple falls since her prior assessment including one with a major injury. R29's Significant Change MDS completed 05/20/24 noted a BIMS score of 11 indicating mild cognitive impairment. The MDS indicated she had lower extremity functional limitations and used a wheelchair for mobility. The MDS indicated she required substantial to maximal assistance with bathing, toileting dressing, personal hygiene, and bed mobility and was dependent on staff for mobility in her wheelchair. The MDS indicated she had multiple falls since her prior assessment including one with a major injury. The MDS indicated she was dependent on staff assistance during ambulation but used a wheelchair for mobility. R29's Functional Abilities Care Area Assessment (CAA) completed 05/23/24 indicated she had a significant decline since her last MDS after a fall that resulted in a right pubis rami (pelvis) fracture. The CAA indicated she was unable to ambulate and required a wheelchair for mobility. The CAA indicated she could propel herself for short distances but required staff assistance to get around the facility. The CAA indicated she required substantial to maximal assistance with lower body dressing, bed mobility, standing, transfers, and bathing. R29's Fall CAA completed 05/23/24 indicated she had multiple falls since her admission. The CAA noted she had a major injury fall on 05/02/24 that resulted in a pelvic fracture. The CAA indicated she was a high fall risk due to her cognitive decline, medications, and medical diagnoses. R29's Care Plan initiated 10/21/23 indicated she was at risk for falls and injuries related to her weakness and impulsive nature. The plan instructed staff to ensure she wore non-skid socks (10/21/23), ensure her call light was within reach (10/26/23), provide frequent room checks (10/29/23), encourage her to use common areas for supervision (10/29/23), and not to leave her unattended (01/20/24). The plan revealed that R29 had 21 unwitnessed falls since her admission. R29's EMR under Progress Notes revealed she was admitted to the facility following surgery for a left hip fracture and an open reduction internal fixation procedure (ORIF- a surgical procedure to fix broken bones). A Fall Investigation report indicated R29 had an unwitnessed fall on 12/29/23. The report indicated R29 attempted to get out of her recliner unassisted. The report indicated she was moved to a closer room for better supervision. The report also indicated staff were educated to bring R29 out to the common area for better supervision and interaction with other residents. R29's EMR under Progress Note revealed on 01/20/24 R29 was found on the floor in the television common area by staff. The note revealed R29 sat on her bottom with her legs out in front of her. The note revealed R29 reported that she slid out of her wheelchair attempting to pick up her pencil. A Fall Investigation report for R29's unwitnessed fall on 01/20/24 revealed staff were educated not to leave her unattended and to ensure she was seated at a table to prevent items from dropping. The report indicated she was assessed and had no injuries from the fall. A Fall Investigation report for R29 indicated a second unwitnessed fall occurred on 02/25/24. The report revealed R29 attempted to get out of her recliner without assistance and fell. The report indicated a medication review was completed and staff were educated not to leave R29 unattended. R29's EMR under Progress Note revealed on 02/25/24 staff were called to the television common area by R29. The note indicated R29 knelt to pick up an object off the floor and couldn't get back up. The note indicated the nurse briefly left the area before the fall. A Fall Investigation report for R29's unwitnessed fall on 02/25/24 revealed R29 was in the television common area and knelt on the floor to pick up an object but was unable to get up. The report indicated no injuries occurred from the incident. The report indicated staff were educated not to leave her unattended. R29's EMR under Progress Note on 05/02/24 revealed staff found her on the floor in the television common area. The note indicated she was found on her right side. The note indicated she complained of right hip pain upon moving or standing. The note indicated a stat x-ray for her right femur and pelvis was ordered. R29's EMR under Physician Progress Note on 05/03/24 indicated her x-ray showed no fractures were found but a computed tomography scan (CT scan - a test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) would be ordered if persistent pain continued. R29's EMR under Progress Notes on 05/09/24 revealed a CT scan was completed due to persistent right hip pain. The CT scan revealed multiple pelvic fractures that occurred within her lower pelvic bone. On 07/30/24 at 12:50 PM, Staff pushed R29 in her wheelchair from the common television area to her room without foot pedals. R29's wore rubber-soled shoes. Her feet slid on the floor several times while being pushed. On 07/31/24 at 11:01 PM, R29 sat in her wheelchair in the television common area watching television. R29 was fidgeting with her shirt as she sat in front of the television room. Staff were not present in the day room or hallway to monitor R29. On 07/31/24 at 08:30 AM Certified Nurses Aid (CNA) (M) stated every resident's wheelchair should have foot pedals attached while being pushed. She stated the resident feet should never be allowed to drag during transport. She stated R29 was a high fall risk and required frequent reminders and redirections to wait for staff help. She stated higher fall-risk residents can be encouraged to use the television rooms and activities to prevent falls. She stated staff should monitor the residents while in the television room. On 07/31/24 at 08:15 AM Licensed Nurse (LN) H stated staff were expected to review the care plan and fall interventions for higher-risk residents. She stated staff were expected to provide frequent room checks and ask the residents to attend scheduled activities to provide supervision. She stated R29 had falls related to her impulsive behaviors and not knowing her limits when trying to transfer or stand. On 07/31/24 at 11:43 AM Administrative Nurse D stated the facility had attempted numerous interventions to reduce the number of falls for R29. She stated R29 was impulsive and would often attempt to stand or move herself without staff assistance. She stated staff were expected to offer activities and encourage her to use the common areas. She stated staff were expected to anticipate her needs and provide frequent checks while in her room. She stated R29 was supposed to be supervised while out in the common areas. She stated staff should never attempt to push the residents in their wheelchairs without foot pedals. The facility's Quality of Care policy (undated) indicates each resident will receive adequate supervision and assistance to prevent accidents. The policy indicated staff will ensure the environment remains free of potential hazards and each resident will be comprehensively assessed to identify potential risks related to falls and accidents. The policy indicated the facility will ensure the correct usage of assistance devices to allow safe treatment and care. The facility failed to ensure adequate supervision to prevent falls for R29. This deficient practice resulted in a pelvic fracture for R29. The staff further failed to use foot pedals when propelling the resident in the wheelchair placing the resident at risk for accidents. - On 07/29/24 at 07:26 AM, the unlocked soiled utility room on the 1900 hall revealed a bottle of Clean Power Profesco cleaning spray under the sink. The label said the spray caused skin irritation and serious eye damage and was directed to keep out of reach of children. On 07/29/24 at 07:34 AM, the isolation cart outside of R192's room had a container of Micro-Kill bleach wipes on the railing above it. The directions are directed to keep out of reach of children. On 07/29/24 at 07:56 AM, observation revealed five free-standing pressurized oxygen cylinders placed outside the oxygen storage rack in R191's room. On 07/29/24 at 07:56 AM, Licensed Nurse (LN) J stated the oxygen cylinders did not belong in R191's room and she did not know why they were there. LN J confirmed oxygen tanks should never be free-standing and should always be secured in a rack or other appropriate device. On 07/31/24 at 10:20 AM, Licensed Nurse (LN) G stated the facility locked up hazardous chemicals and stored oxygen cylinders in a locked room in the 1800 hall. On 07/31/24 at 11:43 AM, Administrative Nurse D stated the facility locked up hazardous chemicals and sanitation wipes. She stated the facility stored oxygen cylinders in the locked oxygen room in racks. Administrative Nurse D stated she heard hospice brought oxygen tanks in and placed them directly in the resident rooms, but the facility planned to address that. The facility's Storage Rooms policy, not dated, directed the facility to store cleaning supplies and chemicals in areas separate from food storage rooms and stored as instructed on the labels of such products. The facility's Oxygen Storage policy, dated November 2017, directed the facility to store oxygen cylinders in a dry, well-ventilated designated area. The facility stored empty oxygen cylinders separate from the full cylinders. The facility failed to store pressurized oxygen cylinders and hazardous chemicals securely and safely. This deficient practice had the risk of accidents and injuries to affected residents.