**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00143902 Based on interview and record review the facility failed to ensure a timely assessment for a change in condition in 1 (Resident #100) of 1 resident reviewed for timely assessment for a change in condition resulting in the delay of communication with a provider, delay of transfer to acute care setting for evaluation and a delay of treatment. Findings include: Resident #100 Review of an admission Record revealed Resident #100 had pertinent diagnoses which included: rhabdomyolysis (muscle breakdown that causes toxins to leak into the bloodstream), abnormalities of gait (walking) and mobility, and acidosis (blood becomes too acidic due to problems related to kidneys or lungs). Review of a Minimum Data Set (MDS) assessment for Resident #100, with a reference date of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #100 was cognitively intact. In a telephone interview on [DATE] at 3:49 PM., Family Member (FM) S reported that he had visited Resident #100 on the Friday before she was sent to the hospital, and Resident #100 was as good as she had been. FM S reported that Resident #100 was sent to the acute care hospital (Name Omitted) by the facility on the Monday after the visit. FM S reported that Resident #100 was sent to the local emergency room (Name Omitted) and was then transferred to a larger hospital (Name Omitted) in another town for further evaluation and treatment. FM S reported he received a call from the acute care hospital (Name Omitted) and the caller told him that he needed to get there pretty quickly, that Resident #100 had declined, and her condition was grave. FM S reported that Resident #100 died at the acute care hospital (Name Omitted) on Monday, [DATE]. Review of Progress Note/Alert Note for Resident #100 dated [DATE] at 22:49 PM., authored by Contract Nurse (CN) D revealed . Resident left arm observed swollen, red, and warm to touch, DR (doctor) called unable to contact, voice mail left, note put into Dr's book. Review of Progress Note/Alert Note for Resident #100 dated [DATE] at 5:04 AM., authored by CN D revealed .upon transferring resident to restroom resident stated she felt dizzy, resident was transferred back to bed, bp (blood pressure) was obtained 63/38 called MD (doctor), per dr order push fluids, lay head flat, and raise legs, recheck bp, 52/33, 69/37, 70/41. Resident showing no signs of distress, no signs of hypotension (low blood pressure). Resident stated laying back in bed she felt better. Resident stated she cannot consume large amounts of water due to a previous surgery, writer explained to resident the urgency of drinking water to help raise her bp. Resident in bed, comfortable .will continue to monitor bp throughout the day. Review of Progress Note/Interdisciplinary Documentation for Resident #100 dated [DATE] at 9:43 AM., revealed .complains of not feeling well, color is pallor, left hand is swollen, elevated on a pillow. Noted left hand open area clean with a small amount of drainage, left hand and arm almost up to the elbow is very warm to touch and red, skin turgus (turgor- skin's ability to change shape and return to normal) return is very slow. (Name Omitted) doctor was notified, left message about pts (patients) condition. Waiting for return call . Review of Progress Note/Interdisciplinary Documentation for Resident #100 dated [DATE] at 9:45 AM., revealed .pt had 4 large episodes of diarrea (diarrhea) with a foul smell, blood pressures times 5 within 30 min period runs 60/40 p85 (pulse) . Review of Progress Note/Interdisciplinary Documentation for Resident #100 dated [DATE] at 12:35 PM., revealed . Orders received from Dr. to send Resident #100 to the hospital for further evaluation of decreased B.P., weakness and fatigue and redness and warmth to the left arm. In an interview on [DATE] at 4:10 PM., Nurse Practitioner (NP) R reported that the nurses know to contact her directly if they are unable to reach an on-call provider. NP R reported that the nurses should not let the patient suffer, there needs to be some action to resolve the situation. In an interview on [DATE] at 4:22 PM., Licensed Practical Nurse (LPN) C reported when a call was placed to the on-call provider after hours, that call was answered by the call service. The call service would take note of the resident specific information, and then the call service would transfer the nurse call to the provider to speak to them. In an interview on [DATE] at 4:33 PM., Registered Nurse (RN) G reported that non-urgent resident situations are placed into the doctor's book. RN G reported that the provider looks at the doctor's book and follows up with requests when they are in the building. RN G reported that non-urgent things like a fall without injury or a resident request to see the doctor are things to put in the doctor's book. RN G reported that a decreased blood pressure or signs of an infection were not something that should go in the doctor book, for those situations the doctor should be called. In an interview on [DATE] at 4:33 PM., Infection Preventionist (IP) F reported that if the on-call provider did not call back within 5 minutes, the nurse should call back. The nurse practitioner was here every day during the week, and you could call her 24 hours a day 7 days a week. There was an on call answering service to use during non-business hours. IP F reported that she did not recall any staff having difficulties getting ahold of a provider after hours. In an interview on [DATE] at 9:37 AM., NP Q reported that the expectation was that if the on-call provider did not respond within 15 minutes, the nurse needed to call back. NP Q stated that if the symptoms were manageable with the resources available, then do that, if not send them to the hospital. NP Q stated If their vitals are crashing then they need to be sent out. NP Q reported that she would not question a resident transfer to the emergency room in an urgent situation. NP Q reported that she would expect that she or the on-call provider were notified of the resident transfer. In an interview on [DATE] at 10:04 AM., Clinical Care Coordinator (CCC) I reported that she did not recall what happened with Resident #100 before she was sent to the hospital. CCC I accessed Resident #100's online hospital record and reported that she was admitted to the ICU (Intensive Care Unit) for septic shock, cellulitis of the left upper arm and a UTI (urinary tract infection). In an interview on [DATE] at 11:35 AM., CCC I provided this surveyor a handwritten timeline related to Resident #100's condition prior to transfer to acute care hospital (Name Omitted). CCC I reported that from the first documented sign and symptom of infection were noted in Resident #100's left arm on [DATE] at 22:49 to the documented order to transfer to the emergency room on [DATE] at 12:35 PM., was too long for the resident to wait for physician order to transfer. In an interview on [DATE] at 1:19 PM., IP F reported that Resident #100's blood pressure reading was critical, and she should have been sent out. IP F reported that the nurse would call the on-call provider through the answering service, if they didn't call back, then the nurse should call again. IP F reported that if there still was no response from the on-call provider the nurse should have called the on-call manager for guidance. In a telephone interview on [DATE] at 2:38 PM., Call Center Coordinator (CCC) W reported that the on-call answering service does not have the option for a nurse calling in to leave a voice mail message (this is in contrast to CN D's written note). CCC W reported that the operator asks the nurse calling specific questions related to the patient such as name, date of birth , and reason for the call. The operator would then put the nurse calling on hold and would then call the provider on call. If the provider answered the phone the nurse's call was transferred to the provider. If there was no answer by the provider, the operator should instruct the nurse if they had not received a call back within 15 minutes to call again. CCC W reported that the operator would continue to reach out to the on-call provider every 15 minutes. If contact was not made with the on-call provider, the operator had instructions to continue to reach out to a provider every 15 minutes until someone was reached. CCC W reported that calls related to nursing home residents were considered priority calls. In a telephone interview on [DATE] at 3:28 PM., Director of Nursing (DON) B reported that she remembered Resident #100 going to the hospital. DON B reported that she went to look at Resident #100, remembered her arm was swollen, and the nurse had gotten an order to transfer her to the hospital for treatment. DON B reported that her expectations for contacting the on-call provider was to call and speak to them. DON B reported that if the nurse had to leave a voice mail for the on-call provider her expectation was that the nurse would call back until they spoke with an on-call provider. DON B reported that if the nurse could not get ahold of the on-call provider, the nurse should call her, she was available 24 hours a day, 7 days a week. This surveyor while on the phone with DON B read the progress note entries for Resident #100 from the dates of [DATE] and [DATE] and DON B reported that her expectations were that the nurse should have continued to try to contact the on-call provider regarding Resident #100's condition. DON B reported that nurse definitely should have called back to the on-call provider after the repeated blood pressure readings were low and Resident #100 should have been sent out to the hospital long before she was sent. DON B reported that Resident #100's blood pressure readings were low enough to be emergent and the nurse should have sent he to the hospital when her blood pressure readings did not improve. In a telephone interview on [DATE] at 3:57 PM., Certified Nurse Assistant (CNA) N reported that she recalled on the day Resident #100 was sent to the hospital from the facility, Resident #100 looked very pale, and she was very nauseous. CNA N stated I remember the nurse telling me Resident #100 was being sent to the hospital. I remember I checked her vitals and got her ready for the hospital, Resident #100 had loose stools (diarrhea), her blood pressure was very low, and her heart rate was high. In a telephone interview on [DATE] at 4:18 PM., CN D reported that she worked with Resident #100 on the night shift before she was transferred to the hospital. CN D reported that she made a note in the doctor book that Resident #100's arm was swollen. CN D reported that Resident #100's blood pressure was low, and she contacted the on-call provider. CN D reported that on-call provider gave her orders to push fluids, lay her head flat, and elevate her legs. CN D reported that she felt that Resident #100 needed to go to the hospital, and that her blood pressure was too low. This surveyor asked CN D if she called any nursing managers, or Resident #100's family, or the on-call provider again and CN D stated I don't remember calling anyone else, but I spoke to the other nurses, and no one said to do anything else. CN D stated, I learned after that night, you can call the family and ask would they want their family member sent to the hospital. CN D stated I don't know if I should have called back again and again to try to convince the on-call to send her (Resident #100) to the hospital, but I just monitored her all night. Review of ED Provider Note dated [DATE] revealed . diagnosis septic shock, urinary tract infection without hematuria (blood in the urine), Cellulitis of the left upper extremity, lactic acidosis, elevated liver function tests, AKI (acute kidney injury), Sepsis with multi-organ dysfunction . Review of H&P Notes dated [DATE] at 19:55 PM., revealed .speak with patient's family who stated they saw her on Friday (7/28) and that at that time she was able to ambulate and that her left arm had the healing wound but that it was not erythematous. They stated that she typically has some swelling in that forearm (midway) and hand that worsens with ambulating when she lets it hang down . Review of Critical Care History and Physical Exam dated [DATE] at 10:16 PM., revealed . 65 yo (year old) F (female) presented to (Name Omitted) ED (emergency department) 7/31 for generalized weakness, diarrhea, and abdominal pain. Hx (history of) L (left) forearm pressure ulcer now appearing cellulitic for the past several days. She was hypotensive on arrival, received 3L (liters) of IVF (intravenous fluids) .for septic shock. Urinalysis without a clean sample, nitrite positive however not convincing for infection, only other current source is LUE (left upper extremity) cellulitis . Review of ED to hosp-admission . dated [DATE] at 11:17 AM., revealed .patient's vitals are significant for severe hypotension of 63/39 .patient is significantly ill appearing pale .pulses are weak though 1+ .immediate concern for septic shock related to infection, likely cellulitis of the left upper extremity . patient leaving with EMS, vitals currently stable . Review of Physician Discharge as deceased Summary dated [DATE] at 6:17 AM., .admitted [DATE] .reason for admission septic shock .not long after ICU arrival pt lost pulses, PEA (pulseless electrical activity, a type of cardiac arrest that occurs when the heart stops beating due to weak electrical activity) arrest . ROSC (return of spontaneous circulation) was achieved after 10 minutes .discussed care with family member who requested that patient be made a DNR (do not resuscitate) .was noted to be in asystole again at 0611 when TOD (time of death) was called, patient without any heart tones auscultated, no central pulses .

This citation pertains to Intake MI00144494 Based on interview and record review the facility failed to prevent the worsening of a pressure ulcer in 1 (Resident #101) of 2 residents reviewed for pressure ulcers resulting in Resident #101 being sent to the hospital for evaluation and/or treatment. Findings include: Resident #101 Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: pressure ulcer of the sacral region stage 4, osteomyelitis of the vertebra, sacral and sacrococcygeal region (infection of the vertebra bone in the sacral region), and functional quadriplegia (the complete inability to move). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 4/11/24 revealed a Brief Interview for Mental Status (BIMS) score of 13/15 which indicated Resident #101 was cognitively intact. Review of Wound Measurement 2.2 for Resident #101 dated 4/11/24 15:32 PM., revealed .sacral wound measures 13.9 X 14.6 X 4.2 stage IV present on admission .wet to dry dressing removed and wound vac placed as per hospital orders . Review of Office Visit (Name Omitted) for Resident #101 dated 4/19/24 revealed .Physical exam .wound length 10.6 cm (lying on left side), wound width 11 cm, wound depth 4.2cm .Negative Pressure Wound Therapy (wound vac, machine to apply constant pressure to a wound to promote healing) sacrum mid wound vac placement date 4/19/24 .cycle is continuous, target pressure is 150mm/HG . no signs of infection .Negative dressing pressure machine to sacral wound: cleanse with saline .apply adaptic to exposed bone, apply santyl (nickel thickness) to wound bed and NPWT (negative pressure wound therapy) at 150 mm/HG, change 3 x (times) a week and as needed . Review of Wound Measurements 2.2 for Resident #101 dated 4/19/24 14:49 PM., revealed .sacrum to coccyx wound-measuring 10.6 X 11X 4.2 .Large amount of tan serosanguineous (tan in color) drainage noted . Review of Wound Measurements 2.2 for Resident #101 dated 4/29/24 13:50 PM., revealed . sacrum to coccyx wound - measuring 13.6 X 14.2 X 3 . large amounts of tan serosanguineous drainage noted . Review of Wound Measurements 2.2 for Resident #101 dated 5/3/24 14:56 PM., revealed .new area observed to L (left) buttock during skin check. Area measured 2 X 4.8 X 0.1, areas is superficial, no drainage . Review of Physician Orders for Resident #101 dated 5/8/24 revealed .sacrum-cleanse with normal saline pack Dakins soaked kerlix wound, cover with ABD (abdominal) and secure with tape and change daily and PRN (as needed) . dated 5/9/24 .wound consult and possible surgical consult for pt (patient) bilateral lower extremities. Pt. has swelling on both feet and blisters under great toes . Review of Office Visit (Name Omitted) for Resident #101 dated 5/10/24 revealed .Left ischial (area of the buttock that covers the pelvic bone) wound, Stage 4 Sacral ulcer, malodor (foul odor), Left plantar (bottom of the foot) blister, Right heel pressure ulcer, Blister to right D1-D5 (base of the toes on the right foot) Erythema (redness) to the base of the right great toe . Patient with worsening sacral wound with known osteomyelitis. She is c/o (complaint of) nausea, fever, chills, and sweats. I feel it is prudent to ensure patient is not becoming septic (systemic infection of the blood). Updated the ER and we will send her by non-emergent EMS (emergency medical services). Review of Physician Orders for Resident #102 revealed .5/10/24: VO/TO (voice order/telephone order) transfer to ED (emergency department) for evaluation and treatment ordered on 5/13/24 . In an interview on 7/3/24 at 8:29 AM., Certified Nurse Assistant (CNA) J reported that Resident #101 had a wound on her buttock with a wound vac. CNA J reported that the wound vac was making the wound worse because the wound vac would dislodge from the wound. CNA J reported that Resident #101 was not able to reposition herself in bed or in the wheelchair, and she could wash her face, but not much else. CNA J reported that Resident #101 was dependent for all her cares. CNA J reported that Resident #101 did not like to get out of bed and when she was in her wheelchair she didn't like to go back to bed. CNA J did not indicate where this would be documented in the medical chart. In an interview on 7/3/24 at 8:43 AM., Licensed Practical Nurse (LPN) K reported that Resident #101 had a large wound on her buttock and had a wound vac. LPN K reported that the wound vac was making her wound worse. LPN K reported that Resident #101 did not like to be turned or repositioned in bed or in her wheelchair because it hurt her to move. LPN K reported that Resident #101's lack of turning and repositioning could contribute to the wound deteriorating, and continuing to have pressure on an existing wound would continue to cause the wound to get worse. LPN J did not indicate why this was not documented in the medical chart In an interview on 7/3/24 at 9:37 AM., Nurse Practitioner (NP) Q reported that Resident #101 had a wound on her sacral region, with a wound vac, that did get worse while she was in the facility. NP Q reported that she was unaware if Resident #101 allowed staff to provide care and position her. In an interview on 7/3/24 at 10:04 AM., Clinical Care Coordinator (CCC) I reported that Resident #101 was admitted with a stage 4 sacral wound and the wound vac was applied when she admitted to the facility. CCC I reported that Resident #101's wound was getting worse. CCC I reported that Resident #101 did not like to be positioned off her wound. CCC I reported that Resident #101 would tell staff no when staff asked to reposition her off her wound area. CCC I reported that Resident #101 was not being turned or repositioned as frequently as she should have been. CCC I reported that Resident #101's wound did deteriorate while she was in the facility and that she was developing other wounds where the wound vac drape was positioned. Review of Care plan for Resident #101 initiated 4/12/24 revealed focus .potential risk for impaired skin integrity related to stated IV pressure wound to sacrum .will show improvement of impaired skin integrity as evidence by no s/s (signs and symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity .Interventions .assist with re-positioning with use of draw sheet as needed .bridge heels in bed if indicated .measure open areas on admission and weekly, PRN (as needed), pressure reducing cushion to wheel chair .pressure reducing mattress . Review of Care Plan for Resident #101 revealed no noted care plan interventions related to turning scheduled, repositioning schedule, wound vac use, or resident's choices or preferences related to mobility, repositioning, and/or turning. No noted care plan intervention related to resident refusal to be turned or repositioned in bed or wheelchair. No noted care plan related to the use of a wound vac. In a telephone interview on 7/3/24 at 1:50 PM., Registered Nurse (RN) G reported that Resident #101 didn't like to be moved or repositioned, it hurt her. RN G reported that she educated Resident #101 on the benefits of moving and repositioning off her wound. When asked by this surveyor if RN G documented Resident #101 preference to not be repositioned, RN G replied I do not recall documenting refusal of care. In an interview on 7/3/24 at 1:59 PM., CCC I reported that Resident #101 didn't like to be positioned on her sides, she didn't like to be moved, it hurt her. CCC I reported that Resident #101 preferred to be on her back when in bed and/or sitting in her wheelchair. This surveyor asked CCC I if the staff documented that Resident #101 was refusing to be repositioned in bed or in her wheelchair. CCC I reported she would find out where the refusal of care was documented. In an interview on 7/3/24 at 3:00 PM Nursing Home Administrator (NHA) A and CCC I were in NHA's office, and both were unable to provide any documentation that Resident #101 refused to be repositioned by staff in her bed and/or in her wheelchair. NHA A and CCC I were unable to provide a care plan for Resident #101 that had resident specific interventions related to positioning in bed and wheelchair.

This citation pertains to intake numbers MI00143061 and MI00143279. Based on interview and record review the facility failed to ensure that staff followed care planned interventions and professional standards of care for 2 residents (Resident #1 & #3) out of 5 residents reviewed for accidents and hazards, resulting in major injuries (fractures) after avoidable falls. Findings: Resident #1 (R1) Review of an admission record reflected R1 admitted to the facility with the following pertinent diagnoses: muscle weakness, abnormalities of gait and mobility, erosive osteoarthritis, difficulty walking and a need for assistance with personal care. Review of a Care Plan initiated on 12/13/2021 reflected R1 had Altered functional mobility and ADL's (Activities of Daily Living) related to her diagnoses. The care plan specified that R1 was to ambulate with therapy only (intervention initiated 6/19/23 and resolved on 2/26/24). FALL RISK MANAGEMENT interventions included in the ADL care plan indicated R1 was to have one person assistance with transfers. The care plan also indicated Resident (R1) chooses to walk with walker or push wheelchair on occasion even with reminding her that she needs assistance in facility with walking. Review of a Care Plan initiated on 12/14/21 reflected R1 was at risk for falls or injury related to impaired mobility. The goal of the care plan was to provide individualized interventions to attain the resident's (R1's) highest practicable well-being in keeping with their preferences and assessment for independence. Interventions to meet the goal included instructions for staff to refer to the ADL care plan for fall risk interventions. Review of a Witnessed Fall incident report dated 2/19/24 reflected Registered Nurse (RN) J was called to the room by Certified Nurse Aide (CNA) after R1 had fallen. The Resident Description reflected Resident stated that she was walking to her wheelchair, and she fell as she was turning around and fall forward on her right side. Resident stated, 'I hit my head and my hip hurts'. Review of a Facility Reported Incident (FRI) dated 2/19/24 reflected (R1) had a fall that resulted in fracture. (R1) had to use the restroom and was being assisted by (CNA T). As (CNA T) was assisting (R1) back to her bed from the bathroom, she attempted to lock the wheelchair which resulted in her letting go of (R1's) hand, and (R1) then lost her balance and fell to the floor. The investigation report revealed CNA T admitted she did not review R1's care plan prior to providing assistance to R1, did not use a walker, and did not use a gait belt. R1 was diagnosed with a right femur fracture that required surgical intervention to repair. During an interview on 3/14/24 at 7:25 a.m., R1 confirmed the details of the fall that resulted in her broken leg on 2/19/24. R1 said CNA T did not use a gait belt during the transfers and said she did not have her walker with her during the trip to the bathroom on 2/19/24. Resident #3 (R3) Review of an admission Record revealed R3 admitted to the facility with pertinent diagnoses that included: bipolar disorder, morbid (severe) obesity and dementia. Review of a Witnessed Fall incident report dated 3/1/24 reflected R3 sustained a fall from her bed when CNA K was changing R3 in the bed, rolled to her side away from her. R3 rolled off the bed and onto the floor. Investigation details included with the incident report reflected the following: Upon interview (CNA K) she stated that (R3) was in the bed and she was providing peri care. (CNA K) stated that the last time she rolled her to pull her pants up, the (R1) off the bed (sic), she tried to grab her by the back of her pants, but she (R1) kept going and landed onto the floor and onto her knees. The facility received notification from a hospital at 12:35 p.m. that R3 suffered an acute moderately displaced comminuted fracture of the distal femur (a broken leg). She (R3) also suffered a mild irregularity along the medial epicondyles may reflect acute mildly displaced fracture of the left elbow. During an interview on 3/14/24 at 2:10 p.m., the Director of Nursing (DON) reported that she was the first person to respond to CNA K's request for help after R3 rolled off the bed on 3/1/24. According to the DON, after R3 was stabilized and sent to the hospital, she interviewed CNA K who said that she rolled R3 away from her while providing peri care in the bed. When asked, the DON did not report any concerns with the technique CNA K used to care for R3 while rolling her in the bed. During an interview on 3/14/24 at 2:20 PM, Regional Nurse Consultant (RNC) V said she knew the standard of care while providing bed mobility with the assist of one staff person was to roll a resident/patient toward the caregiver and never away from the caregiver. If resident care cannot be provided while rolling the person toward that caregiver, then a second person should assist, to prevent the person from falling from the bed. RNC V said the facility reported R3's fall that resulted in fractures to the State Agency (SA) because she knew the standard of care had not been followed. RNC V and the DON both reported that facility wide education to all staff regarding the standard of care pertaining to bed mobility with one person assistance had not been started.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00133951. Based on interview, and record review, the facility failed to implement fall interventions (utilize 2 staff for a 2 person transfer/assist with shower) for 1 of 3 residents (Resident #101) reviewed for accidents and hazards, resulting in a fall with a fracture of the left hip for Resident #101. Findings include: Review of an admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: history of stroke affecting left side. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 11/28/22, revealed a Brief Interview for Mental Status (BIMS) score of 11/15 which indicated Resident #101 was cognitively intact. In an interview on 1/31/23 at Resident #101 reported she was getting a shower last month with Certified Nurse Aide (CNA) P. Resident #101 reported she was sitting in a shower chair, and had leaned forward to dry her hair, and all of a sudden the chair must of tipped forward and she started to fall forward. Resident #101 reported (CNA P) tried to prevent the fall, but it all happened so fast. Resident #101 reported (CNA P) immediately called for help, other staff and nurses came, assessed her and got her up. Resident #101 reported it was just an accident, (CNA P) did not do anything to hurt, or harm her. Resident #101 reported she broke her hip, but is now doing well, and can bear weight on it as tolerated. Review of a Facility Reported Incident (FRI) investigation dated 12/12/2022 revealed: Investigation: Statements from staff: Licensed Practical Nurse (LPN) M Staff Interview: (LPN M) Upon interview with (LPN M), she stated that on 12/11/22 she (LPN M) heard (CNA P) yelling for help from the shower room. (LPN M) stated that she ran down the hall to the shower room and when she entered, she observed (Resident #101) on the floor of the shower room, and she was halfway still in the shower chair, the top half of her body, and the bottom half on the floor, with the shower sling still underneath her. (CNA P) stated to (LPN M) that (Resident #101) fell forward and she (CNA P) couldn't catch her. (LPN M) stated that as she had entered another CNA (CNA L), heard (CNA P) calling for help as well, and ran to the shower room to see what was needed. (LPN M) stated that she and (CNA L) pulled the shower chair from underneath (Resident #101) as it was half tipped over and (Resident #101) was hanging off it and assisted (Resident #101) to a lying position on the floor so that she could assess her. (LPN M) stated that she assessed (Resident #101) extremities. (Resident #101) complained of left knee pain upon assessment and back pain. (LPN M) instructed (CNA L) to support (Resident #101) left knee at that time for comfort. No bruising or swelling noted to the knee. (LPN M) performed ROM to the left leg, and (Resident #101) complained of pain, but only to the knee. (LPN M) stated that (Resident #101) has chronic pain to this knee per her baseline, and no signs or symptoms of fracture or dislocation were observed to her knee. She (LPN M) stated that (Resident #101) did complain of a headache, as she stated that she hit her head on the wall when she fell. (LPN M) initiated neuro checks at that time .(Resident #101) had no complaints of pain or discomfort to any other area at that time, but (LPN M) assessed her back and did observe some bruising beginning to form on her back and wrapping to her left hip (Resident #101) stated that her headache had subsided and had no further c/o knee pain. Head to toe assessment performed and there were no signs or symptoms of fracture or dislocation observed at the time of assessment (Resident #101) has chronic residual pain to her left side secondary to CVA. She (Resident #101) takes routine pain meds and receives gel (pain medication lotion/gel) topically to her left leg and knee, which are the areas she (Resident #101) has the most pain. Noted purple discoloration to left hip/buttocks. Slight swelling observed, though (Resident #101) has swelling and pain to her left side which is chronic and her baseline. (CNA P) was with resident when fall occurred and stated that (Resident #101) hit her head on the shower wall when she fell. (Resident #101) required assist x3 including mechanical lift to get up from ground and into her wheelchair Staff interview (Certified Nurse Aide-CNA P) Upon interview with (CNA P) on 12/14 she (CNA P) stated that while in the shower room, she (CNA P) had washed (Resident #101) body and washed her (Resident #101) hair as well. (CNA P) stated that she was pulling the shower chair towards her (CNA P) to get (Resident #101s) hair dried, and she (CNA P) does not know exactly what caused the chair to tilt forward, but it did, and she (CNA P) believes that the loop from the shower sling got in front of the wheel, causing the chair to tip forward, but (Resident #101) fell forward halfway out of the chair and onto the floor. (CNA P) stated that she tried to stop or lower (Resident #101) to the floor as best as she (CNA P) could to keep her (Resident #101) from falling. When asked how (Resident #101) transfers, (CNA P) stated that she (Resident #101) is a two-person mechanical lift for transfers. (CNA P) stated that (Resident #101) is a 2 person for showers as well, though she (CNA P) performed her (Resident #101) shower by herself (CNA P) . Staff Interview (CNA L) Stated she (CNA L) heard (CNA P) yelling for help and she (CNA L) immediately responded and went into the shower room. She (CNA L) observed (Resident #101) halfway on the shower chair and half on the floor. She (CNA L) stated that she (CNA L) then assisted the charge nurse (LPN M) with lying (Resident #101) on the floor and the nurse assessed her and then she (CNA L) assisted with getting the sling beneath (Resident #101) and transferring her from the floor into her (Resident #101) wheelchair and then into bed Conclusion: Despite the facility preference of having two staff members present for bathing (through staff interviews several staff members were available to assist), (CNA P) chose to bath (Resident #101) independently which resulted in a fall from the shower chair with fracture. The facility can validate the care plan was not followed and there was no willful intent to abuse or neglect the resident (Resident #101). The resident (Resident #101) does not allege abuse and states the event was an accident . In an interview on 2/1/23 at 3:15 PM., Nursing Home Administrator (NHA) A reported the incident that happened on 12/12/2022 that resulted in a fall with a fracture for (Resident #101) was due to (CNA P) not following (Resident #101's) care plan and using 2 staff to shower (Resident #101). NHA A reported a throughout investigated was completed and reported to the State Agency. NHA A reported the facility immediately held in-services, and training for all staff on the importance of following resident care plans, and making sure to ask for help when needed. NHA A reported audits, training and updating care plans is an ongoing Quality Assessment and Assurance (QAA) Quality Assurance and Performance Improvement (QAPI) discussion and plan to reduce falls, falls with injury and following the person centered resident Care Plans. The facility was granted a Past Noncompliance as they had corrected the noncompliance prior to survey entry and sustained compliance thereafter.