HILDEBRAND CARE CENTER

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 10/16/2023 and 10/22/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A revisit survey was completed on 8/28/23 for all previous deficiencies cited on 7/6/23. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 8/28/23 for all previous deficiencies cited on 7/6/23. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO32928 was completed 7/5/23 to 7/6/23. Two deficiencies were cited.

Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#1) of three residents reviewed out of three sample residents. Resident #1 fell on 2/1/23 in the bathroom. He had increased pain, at the facility, for two days until 2/3/23, when an x-ray confirmed he had a fracture of the left hip. Two resident representatives were interviewed. Both representatives said Resident #1 had called them all night long on 2/1/23 and 2/2/23 complaining of being in pain and being unable to move his left leg. The representatives said they had requested the resident be sent to the emergency room (ER) on 2/2/23 for an x-ray of the left hip. However, the facility had an x-ray at the facility, without results until 2/3/23. Resident #1 was interviewed on 7/6/23. He said he had severe stabbing pain and had been unable to move his leg for two days after falling in the bathroom on 2/1/23. He said he was then sent to the ER, from the facility, after a couple days of being in pain and had surgery related to injuries from the fall. There was no additional documentation of facility staff monitoring the resident's condition for pain or evaluation of the resident's change of condition after the initial fall evaluation on 2/1/23, between 2/1/23 to 2/3/23. Resident #1 was given only one tablet of 325mg (milligrams) of acetaminophen (Tylenol) for pain three times as needed from 2/1/23 to 2/3/23 for an undocumented (unknown) pain level. On 2/2/23 and 2/3/23 the Tylenol was documented as not effective. There was no documentation of what was done for the resident when the one tablet of Tylenol was not effective. The resident had an order for Norco pain medication as needed on admission 8/23/22; however, the facility staff said it had never been ordered from the facility pharmacy and therefore was not available to administer for the resident's unresolved pain, during the 2/1/23 to 2/3/23 time period. The 2/3/23 emergency room assessment notes documented the resident was in pain with any motion and his leg was externally rotated and shortened. The resident had surgery to repair the fracture and returned to the facility on 2/6/23. Resident #1 continued to complain of daily pain and difficulty placing weight on the left leg during the survey period. Cross-reference S704 accident hazards for the facility's failure to implement effective fall interventions that caused a fall with major injury and subsequent falls after he returned to the facility. Findings include:I. Facility policy and procedureThe Pain Clinical Protocol, revised March 2018, was received from medical records (MR) on 7/5/23 at 5:50 p.m. The policy documented in pertinent part, "The nursing staff will assess each individual for pain whenever there is a significant change in condition. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level."II. Resident #1A. Resident statusResident #1, age 88, admitted on 8/23/22, and readmitted on 2/6/23. According to the July 2023 computerized physician orders (CPO) diagnosis included, history of left femur fracture and left hip pain, neuropathy (nerve pain), chronic low back pain and repeat falls. The 5/15/23 facility assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of nine out of 15. The resident required extensive one person assistance with bed mobility, dressing and personal hygiene; and required extensive two person assistance with transfers, and toileting. The assessment documented the resident reported his worst pain level on a 0 to 10 scale (with 10 being the worst pain on the scale); was 4 out of 10. The assessment further documented that the resident said he had almost constant pain that limited his daily activity. B. Resident and resident representative interviewsTwo of the resident's representatives were interviewed via telephone on 7/6/23 at 10:19 a.m. The first representative said the resident called her all night complaining of being in pain on 2/1/23. On 2/2/23 the representative called the facility and spoke to registered nurse (RN) #1. The representative requested the resident be sent to the hospital for an x-ray. The representative said the facility did not send Resident #1 to the hospital but had a mobile x-ray come out to the facility on 2/2/23. The representative said she had asked the nurses on the phone about pain medication and they said they were giving the resident pain medication. The representative later found out the resident had only received one Tylenol for his pain. The representative said there were no x-ray results on 2/2/23. She had called the facility multiple times requesting alternative treatment for the resident, as Resident #1 was in so much pain. The representative said Resident #1 called her all night again on 2/2/23 with complaints of pain to his left leg and inability to move the leg. The representative said she called the facility again 2/3/23, in the morning, to see if the x-ray results were available, and was told the results were not back yet. The representative said she received a call, a short time later that morning (2/3/23) from the facility, to notify her the resident had a hip fracture and was being sent to the hospital. A second resident representative joined the telephone interview with the first resident representative. The second resident representative said Resident #1 had also called her all night on 2/1/23 and 2/2/23 complaining of stabbing pain to his left leg. She said he told her his leg was out to the side and he could not move the leg. The second representative was getting ready in the morning to head to the facility on 2/3/23, while the first resident representative kept calling the facility. The second representative said that while on the way to the facility she received the information that the resident had a fracture of the left hip and was being sent to the hospital. The second representative said Resident #1 layed in bed for two days in pain, even after being asked by the first representative that the resident be sent to the hospital. The second representative said the facility only gave the resident Tylenol which was ineffective for pain from a fractured hip. The first representative said he continued to have a lot of pain to this day. Resident #1 was interviewed on 7/6/23 at 11:28 a.m. Resident #1 said he remembered when he fell and broke his hip. He said he had fallen in the bathroom. Resident #1 said he had a lot of pain for a few days and could not move his leg. He said anytime he tried to move it the pain was severe, but if he did not move it then it was not as bad. He said the nurses gave him Tylenol but that did not help much. He said the pain was a sharp pain and remembered he could not move his leg. He said the nurses had an x-ray done and then he went to the hospital for surgery. Resident #1 said he still had pain, and it was difficult to put any weight on his left leg. Resident #1 said the staff did not check with him throughout the day to offer assistance with toileting. He said he had to call them, and they were slow to answer the call light. C. Record reviewThe pain care plan, initiated 8/26/22, documented in pertinent part, potential for alteration in comfort related to chronic back low back pain, osteoarthritis, peripheral neuropathy, and history hip surgery which was added on 5/17/23. Interventions included:-Monitoring for side effects of Tylenol, dated 8/26/23. Monitoring for side effects of narcotic pain medications, dated 8/26/22. -Give medications as ordered, dated 8/26/22, and monitor for side effects, and effectiveness. -Notify the physician if therewere side effects or if medication were consistently ineffective. -Report to nurse vocal and non verbal indication of pain. Pain assessment quarterly and as indicated. It documented the resident's acceptable level of pain was "extreme." Use dementia face scale if needed. Try alternate methods of pain relief such as repositioning rest, stretching, ambulating, warmth, coolness, and distraction. On 2/1/23 at 4:51 p.m. the nursing progress notes documented the resident had taken himself to the bathroom, and fell pulling up his pants, obtaining a skin tear to the left wrist and abrasion to the low back. No other injuries noted (cross-reference S704). On 2/3/23 at 7:55 a.m. the nursing notes documented the resident's daughter called about the x-ray results. The nurse documented the facility had not received them yet. -There was no documentation in the medical record regarding why or when an x-ray had been ordered. There was no further assessment of the resident documented since the fall 2/1/23 at 4:51 p.m. On 2/2/23 at 8:29 a.m. the nursing notes documented the x-ray results were received and the physician was notified. Orders were received to transfer the resident to the hospital with a hip fracture. The hospital record dated 2/3/23, documented Resident #1 was admitted after a fall from a standing height. He was hypoxic (low oxygen levels) due to atelectasis (collapsed lung or section of lung) after "laying around for two to three days post fall." The left hip was x-rayed and confirmed an acute fracture. The resident had surgery to repair the left hip on 2/3/23. The February 2023 medication administration record (MAR) and treatment administration records (TAR) were reviewed. -There were no pain assessments documented for the resident. The MAR documented the resident was on routine acetaminophen (Tylenol) 325 mg one tablet three times per day. The MAR documented the resident had an order for as needed (PRN) Tylenol 325 mg every four hours as needed for pain, dated 10/25/22. The MAR documented the resident had an order for Hydrocodone-acetaminophen (Norco) 5-325 mg by mouth every six hours as needed for pain (scale 4-10), ordered 8/23/22. On 2/1/23 the resident did not receive any PRN Tylenol. On 2/2/23 at 12:33 a.m. the resident received as needed Tylenol for pain. It documented the Tylenol was effective.-There was no pain level documented. On 2/2/23 at 12:54 p.m. the resident received PRN Tylenol. The pain medication was documented as not effective. -No pain levels were documented and here was no follow up on the resident's pain. On 2/3/23 at 7:34 a.m., the resident received Tylenol and the pain medication was documented as not effective. -The was no pain level documented. The nursing notes documented at 7:55 a.m. the physician would be called about getting the resident's Norco (hydrocodone and acetaminophen 5-325 mg, opioid narcotic analgesic) refilled.-However, the resident was admitted to the facility with the order for Norco. The interviews (see below) revealed the facility had never sent the Norco order to the pharmacy and therefore it had never been filled or available for the resident. An Interview for Pain Assessment, dated 2/13/23, after the resident's hip fracture, was reviewed. The assessment documented the resident had a history of neuropathy, chronic low back pain and pain in the left hip due to a history of fracture. The pain assessment documented Resident #1 was on schedule pain medication and had received PRN pain medication. It documented he had received non-medication interventions. The interview documented the pain was occasional and made sleeping difficult. On a scale of 1 to 10, Resident #1 rated his pain at a 10 for the worst it had been. -There was no information on what exacerbated the pain or made it better. There was no information on what an acceptable level of pain was or pain goal. There was no description of the pain, characteristics of the pain or the location of the pain. There were no listed non-medication interventions listed on the pain assessment. -The May 2023 Interview for Pain Assessment was requested from the DON and not received by the end of the survey on 7/6/23. The facility assessment, dated 5/23/23, documented the resident had constant pain which affected his activities of daily living. Weekly nursing charting in the progress notes was reviewed for the last 90 days. There was a weekly summary twice in April 2023, once in May 2023 and four times in June 2023. -The weekly charting, when it was done weekly, did not contain documentation regarding pain. It did not document whether the resident had pain or not. The June and July 2023 medication administration records revealed the following:-Resident #1 received Tylenol 325mg (milligrams), by mouth, three times daily routinely, order date 2/6/23 for June and July 2023. -Resident #1 received gabapentin (antiseizure medication used for nerve pain) 600 mg three times per day routinely for neuropathy, order date 2/6/23, for June and July 2023. Additionally, the resident had as needed (PRN) orders started on 5/1/23 for Hydrocodone-acetaminophen (Norco) 5-325 mg by mouth every six hours as needed for pain (scale 4-10). Tylenol (acetaminophen) capsule 325 mg, one tablet by mouth every four hours as needed for pain. The June 2023 MAR documented Resident #1 received Norco 6/11/23, 6/15/23 two times, 6/23/23, 6/24/23 and 6/25/23 for pain of 8 out of 10. Pain included the lower extremities, lower back, and reddened buttocks. On 6/16/23, there was no Norco signed out as administered. However, on 6/16/23 at 11:46 p.m, the nurse documented that the Norco was documented as somewhat effective. However, there was no time documented for when it was given or what pain level. Resident #1 received PRN Tylenol for an undocumented pain level on 6/10/23 and 6/30/23. The MAR from 7/1/23 to 7/5/23, documented Resident #1 received Tylenol for pain of 4 out of 10 on 7/3/23. -However, the orders were to give Norco for pain levels of 4 to 10. On 6/12/23 at 12:14 p.m., the nursing progress notes documented the resident had pain to the buttocks on 6/12/23 at 12:14 p.m. The buttocks were documented as red, shiney and sore. -There were no pain levels and no PRN Tylenol or Norco given per the nursing notes and MAR. On 6/16/23 at 1:58 p.m., the nursing progress notes documented the resident complained of pain to his buttocks and coccyx. The area was documented as red and the resident requested to go to the hospital due to the pain. -There was no pain level documented and no PRN Tylenol or Norco documented as given. The nursing notes documented again at 6:22 p.m. that the resident complained of pain to the reddened buttocks. -It is unknown if Norco was given, or at what time and for what level of pain on 6/16/23 (see above). There was no pain level. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/5/23 at 2:07 p.m. RN #1 looked at his laptop and said there was no documentation about the resident's condition or pain level after the fall. He said there should have been. RN #1 said he had sent a text to the physician for an x-ray on 2/2/23 due to the resident being in pain. He could not remember the resident's pain level at that time or what prompted him to call for an x-ray. RN #1 said he should have documented the x-ray order and reason in the notes. RN #1 said there should have been documentation on the resident's condition. RN #1 said he did not know why the resident was given one tablet of Tylenol for pain after his fall 2/1/23, instead of the Norco ordered on admission. The controlled drug count sheet was requested for the Norco for January and February 2023. RN #1 said he did not have one. He said to check with the director of nursing (DON). RN #2 was interviewed on 7/6/25 at 9:20 a.m. He said he knew Resident #1. RN #2 said Resident #1 was on Trazadone (antidepressant) for pain. -However, the resident was not on Trazodone for pain, but for depression. RN #2 said the Resident #1 had an order for Norco which he said the resident received for pain. RN #2 said the licensed nurses did not currently document a routine pain level. He said a pain level was only assessed and documented if the resident or someone else came and reported pain. He said he heard the facility was going to start doing pain assessments routinely, but he did not know when that was to start, and could not remember who told him this. The DON and assistant director of nursing (ADON) were interviewed on 7/6/23 at 9:34 a.m. The DON said she had been at the facility a little over a month. She said if a resident fell, there should be an assessment completed by the RN, and an event was initiated in the electronic medical record (EMR). She said the nurses should document in the progress notes for the next 72 hours, and observe for any injury or pain. She was not familiar with the fall for Resident #1 on 2/1/23. The DON said pain was assessed quarterly and as needed. She said pain was documented in the resident's weekly summary in the progress notes. -However, the weekly summaries reviewed for the last 90 days, when done weekly, did not contain information about pain. The ADON said pain should be assessed every shift and documented on the resident's MAR and when any pain medication was given. The DON said there was no count sheet for the Resident #1's Norco during the time prior to the resident's transfer to the hospital on 2/3/23. The DON said she had spoken to the pharmacy and the Norco had not been ordered. The ADON said the Norco was ordered and administered as needed after the resident returned form the hospital on 2/6/23. The ADON said she had started a performance improvement plan (PIP) for pain management yesterday (7/5/23) and would provide a copy. IV. Facility follow-upA document titled Performance Improvement Plan, Project Name: Pain Assessment and Management, initiated 7/5/23, was received from medical records on 7/6/23 at 5:58 p.m.. The plan documented the goal was to have a complete record of the resident's pain levels with a start date of 7/5/23. Action items initiated were, add pain question to daily Grand Rounds 7/7/23, no responsible person was listed, electronic health record will prompt nurses for basic pain assessment every shift as well as during administration of medications and treatments start 8/1/23, no responsible person was listed. Educate nurses on regular pain documentation every shift especially 72 hours after a fall or when new orders obtained with diagnosis of pain example, new order for tylenol or x-ray, no date or responsible person was listed, all medications for pain will have associated pain scales initiated on approved by medical director no date or responsible person was listed, policy update to reflect changes 7/6/23, final approval with medical director and interdisciplinary team 7/24/23, no responsible person listed. Indicators and Measures documented there would be electronic medical record documentation audits, it was unclear what would be audited, there was no start date, frequency, or responsible person identified. The PIP documented incidents would be audited for complete documentation by ADON weekly, and quarterly comprehensive pain assessments by the MDS coordinator.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents remained as free from accident hazards as possible. The facility failed to ensure interventions were implemented to prevent major injury from falls for Resident #1. Interviews during the survey revealed the facility still was not implementing interventions for toileting per the care plan. Furthermore, interviews and documentation revealed the staff did not provide transfer assistance to the resident with two person assistance as ordered. Due to the facility's failures to implement effective interventions, Resident #1 sustained a fracture of the left hip from a fall on 2/1/23. Additionally, the facility delayed assessing and monitoring Resident #1's injuries and related pain after the fall on 2/1/23, when the resident complained of having severe pain in his leg for two days after the fall (cross-reference S701). The facility failed to implement effective interventions when Resident #1 returned from the hospital on 2/6/23 which caused him to sustain additional falls. Finding include: I. Facility policy and procedureThe Falls and Fall Risk Management policy, revised March 2018, was received from the director of nursing (DON) on 7/6/23 at 12:15 p.m. The policy documented in pertinent part, "Based on previous evaluations and current data, the staff will identify interventions related to the resident' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. "Resident conditions that may contribute to the risk of falls, incontinence."The nurse shall assess and document/report the following when a fall has occurred: Vital signs, the condition in which the resident was found-resident found lying on the floor between bed and chair, any injury, especially fracture or head injury, subsequent first aid administered, musculoskeletal function, observing for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred, pertinent medication, especially those associated with dizziness or lethargy."Nursing staff will observe for delayed complications of a witnessed fall for 72 hours. Vital signs will be taken at the time of the fall and then every shift for the first 24 hours, then everyday on day shift for two subsequent days, Nursing staff will follow the fall, neurological record frequency for obtaining vital signs and neurological checks if a fall is unwitnessed and or head trauma is suspected."The staff, with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out."II. Resident #1A. Resident statusResident #1, age 88, admitted on 8/23/22 and readmitted on 2/6/23. According to the July 2023 computerized physician orders (CPO) diagnosis included history of left femur fracture and left hip pain, neuropathy (weakness, numbness from nerve damage) and repeat falls. The 5/15/23 facility assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of nine out of 15. The resident required extensive two person assistance with transfers and toileting; and extensive one person assistance with bed mobility, dressing and personal hygiene, The resident had almost constant pain which limited daily activity. The assessment documented he had no falls since his prior assessment. -However, the resident fell on 1/18/23, 2/1/23 and 2/10/23; then again on 4/1/23 just before the above facility assessment was completed (see below). B. Resident and resident representative interviewsTwo of the resident's representatives were interviewed via telephone on 7/6/23 at 10:19 a.m. The first representative said the resident called her all night in pain on 2/1/23. On 2/2/23 the representative called the facility and spoke to registered nurse (RN) #1. The representative requested the resident be sent to the hospital for an x-ray. The representative said the facility did not send Resident #1 to the hospital but had a mobile x-ray come out to the facility on 2/2/23. The representative said she had also asked the nurse about pain medication and the nurse said they were giving the resident pain medication. The representative later found out the resident had only received one Tylenol. The representative said there were no x-ray results on 2/2/23. She had called the facility multiple times as Resident #1 was in so much pain. The representative said Resident #1 called her all night again on 2/2/23 with complaints of pain to his left leg and inability to move the leg. The representative said she called the facility again 2/3/23, in the morning, to see if the x-ray results were available and was told the results were not back. The first representative said she received a call, a short time later that morning from the facility, to notify her the resident had a hip fracture and was being sent to the hospital. A second resident representative joined the telephone interview. The second resident representative said Resident #1 had called her all night on 2/1/23 and 2/2/23 with stabbing pain to his left leg. She said the resident told her his leg was displaced "out to the side" and he could not move the leg. The second representative was getting ready in the morning to head to the facility, while the first resident representative kept calling the facility to get the resident help. While on the way the representative said she received the information that the resident had a fracture of the left hip and was being sent to the hospital. The second representative said Resident #1 laid in bed for two days in pain, even after the first representative requested that the facility send Resident #1 to the hospital. The first representative said he continued to have a lot of pain to this day. Resident #1 was interviewed on 7/6/23 at 11:28 a.m. Resident #1 said he remembered when he fell and broke his hip. He said he had fallen in the bathroom. Resident #1 said he had a lot of pain for a few days and could not move his leg. He said anytime he tried to move it the pain was severe, but if he did not move it then it was not as bad. He said the nurses gave him Tylenol but that did not help much. He said the pain was a sharp pain and remembered he could not move his leg. He said the nurses had an x-ray done and then he went to the hospital for surgery. Resident #1 said he still had pain, and it was difficult to put any weight on his left leg. Resident #1 said the staff did not check with him throughout the day to offer assistance with toileting. He said he had to call them, and they were slow to answer the call light. C. Record reviewThe fall care plan, initiated 8/29/22, documented potential for falls and injury related to osteoarthritis, history of falls, cognitive impairment, balance issues, unsteady gait, activity intolerance, bilateral lower extremity weakness, history of hip fracture from fall. Interventions included: physical therapy (PT) evaluation and treatment for transfer safety 8/29/22, 2/2/23 and 6/5/23, Dycem (anti slip material) in recliner 5/15/23, walker for short distance, transfers and wheelchair for long distance 5/15/23, two assist for transfers 2/14/23, urinal to be given at bedtime for night usage 2/13/23, visual aide to close footrest on recliner before getting up 11/22/22, resident forgets to lock brakes on wheelchair, anti roll backs in place 11/21/22, reacher, grabber encourage resident to use it to reach out of reach items 11/14/22, non skid strips in bathroom, gripper socks 10/3/22, toilet riser 9/26/22, education provided on proper footwear and ensuring shoes are on correctly, and how to use grabber reacher 9/21/22, bed bars to aide in bed mobility 8/31/22, orange nameplate alert placed to increase staff awareness of increase fall frequency 8/30/22, grab bars in bathroom 8/29/22, call light in reach 8/29/22, keep personal items in reach maintain clean clutter free environment 8/29/22, observe resident and room frequently for any safety needs 8/29/22. The urinary incontinence care plan, initiated 8/29/23 documented the resident needed assistance with toileting, offer and aide in bathroom or use of urinal before and after meals, approximately every two hours while awake and as indicated. Fall historyOn 1/18/23 at 6:10 a.m., the nursing progress notes documented the resident was observed on the floor in the bathroom with a gash to his head and left arm. He was seen to the ER. The progress note documented the day shift would notify the physician. The resident returned to the facility in approximately two hours, with no new orders.-There were no progress notes indicating the physician was notified. The hospital transfer form documented the resident was alert and oriented and was independent with transfers, toileting and dressing. -However, the urinary care plan, dated 8/31/22, documented Resident #1 needed to be offered and assisted to the bathroom before and after meals, and every two hours while awake. The care plan documented the resident had an overactive bladder and would attempt to toilet himself. On 1/19/23 at 11:34 a.m. the nursing progress notes documented the resident sustained a skin tear to the left forehead one centimeter (cm) by 0.9 cm and a skin tear to the left arm three cm by 2.8 cm.-There were no new interventions documented in the progress notes or the care plan (see above). On 1/23/23 at 11:17 a.m. the nursing progress notes documented the resident was on a bowel and bladder program and should be encouraged, offered and assisted to the bathroom every two hours from 2:00 p.m. to 10:00 p.m. On 2/1/23 at 4:51 p.m. the nursing progress notes documented the resident had taken himself to the bathroom and fell pulling up his pants, obtaining a skin tear to the left wrist and abrasion to the low back. No other injuries noted. The family and physician were notified.-However, the resident did develop pain by midnight and was administered Tylenol (see below). On 2/2/23 at 7:55 a.m., a restorative progress note documented restorative was held due to recent fall and the resident was in bed. The certified nursing aide (CNA) documentation for 2/1/23 to 2/3/23 was reviewed. -There was no documentation after the fall on 2/1/23 until 2/2/23. On 2/2/23 under transfers, the CNA documented that it did not occur. -There was no documentation for 2/3/23. On 2/2/21 at 1:31 p.m. the nursing notes documented PT evaluation and treatment due to fall. On 2/3/23 at 7:55 a.m. the nursing notes documented the resident's daughter called about the x-ray results. The nurse documented the facility had not received them yet. -There was no documentation in the medical record regarding why or when an x-ray had been ordered. There was no further assessment of the resident documented since the fall 2/1/23 at 4:51 p.m. There was no further assessment of his left leg or hip. On 2/2/23 at 8:29 a.m. the nursing notes documented the x-ray results were received and the physician was notified. Orders were received to transfer the resident to the hospital with a hip fracture. The x-ray report documented the x-ray was done on 2/2/23 at 3:26 p.m. -There were no records in the facility progress notes regarding an x-ray having been done. On 2/3/23 at 12:53 a.m. (after the resident is sent to the hospital) a late entry was added to the progress notes for 2/2/23. The note documented the resident had an unwitnessed fall in his restroom. The resident was in the restroom and was attempting to pull up his pants, the resident lost his balance and fell resulting in a skin tear to his left wrist and an abrasion to his low back. The resident has had two falls in the last 90 days and eight total falls since his admission. Current interventions that were in place at the time of the fall and that remain to be deemed appropriate include: visual aide in room to remind resident to put the feet of his recliner down, anti-roll backs added to w/c (wheelchair), time pattern of falls reviewed with no time pattern noted, non-skid strips placed in bathroom, gripper socks were offered and provided, orange name plate (used to identify resident as high fall risk) and bed bars to aide in independent bed mobility. New intervention, PT to eval. The hospital record dated 2/3/23, documented Resident #1 was admitted after a fall from a standing height. He was hypoxic (low oxygen levels) due to atelectasis (collapsed lung or section of lung) after "laying around for two to three days post fall." The left hip was x-rayed and confirmed an acute fracture. The resident had surgery to repair the left hip on 2/3/23.-However, the investigation did not identify that the last two falls occurred in the bathroom and there were no new interventions on 1/18/23. In addition, no new interventions related to toileting the resident for the fall on 2/1/23. The February 2023 medication administration record (MAR) and treatment administration records (TAR) were reviewed there were no pain assessments for Resident #1. Resident #1 received Tylenol 325 mg one tablet as needed, on 2/2/23 at 12:33 a.m., 2/2/23 at 12:54 p.m. and 2/3/23 at 7:34 a.m. for undocumented pain levels. The Tylenol was documented as not effective 2/2/23 at 12:54 p.m. and 2/3/23 at 7:34 a.m. There was no follow up documented for the residents pain (cross-reference S701, pain management)The February 2023 TAR had an order dated 2/1/23, Monitor status for 72 hours for bruising, change in mental status or condition, pain or other injuries. However, the resident was in pain, with an externally rotated and shortened left leg as documented in the ER report. The facility nurses gave Resident #1 Tylenol and documented it was not effective. Despite initially the TAR, the licensed nurses did not follow up timely on the resident's change of condition, pain, or injury to the left hip. The July 2023 CPO documented to transfer with assistance of two persons, dated 2/14/23. The weekly summaries in the nursing progress notes were reviewed for May 2023 through 7/5/23. The progress notes revealed the following:On 5/3/23 at 1:26 a.m. the weekly summary documented the resident was ambulatory (ability to get around) with his wheelchair. -There was no documentation regarding the level of transfer assistance. There were no further weekly summaries for May 2023. On 5/23/23 at 10:47 a.m., the interdisciplinary (IDT) note documented Resident #1 required two person assistance with transfers. On 6/7/23 at 12:59 a.m., the weekly summary documented the resident requiring one person assistance with transfers. On 6/14/23 there were two weekly summaries. The one at 12:59 a.m., documented the resident was a one person assist with transfers. The weekly summary at 11:19 a.m. documented the resident was independent with a cane and wheelchair. On 6/21/23 at 12:36 a.m., the weekly summary documented the resident required two person assistance with transfers. On 6/28/23 at 1:19 a.m., the weekly summary documented the resident required two person assistance with transfers. On 7/5/23 at 12:55 a.m., the weekly summary documented the resident required two person assistance with transfers. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/5/23 at 2:07 p.m. RN #1 looked at his laptop and said there was no documentation about the resident's condition or pain after the fall; but there should have been. RN #1 said he had sent a text to the physician for an x-ray on 2/2/23. He could not remember the resident's pain level at that time or what prompted him to call for an x-ray. RN #1 said he should have documented the x-ray order and reason in the notes. RN #1 said there should have been follow up documentation on the resident's condition. He said the resident was independent with toileting and ambulation in his room at the time. RN #1 said he was not supposed to be independent, but he was. RN #1 said Resident #1 now required the assistance of one person when using the bathroom.-However, the resident's medical record documented that prior to the fall Resident #1 was a two person assist with transfers (see above). Certified nurse aide (CNA) #1 was interviewed on 7/6/23 at 9:10 a.m. CNA #1 had been working at the facility for five months and had started at the end of February 2023. CNA #1 said she was not working at the facility when the resident fell and broke his hip. CNA #1 said she was familiar with Resident #1 and was usually assigned to the hall he lived on. CNA #1 said Resident #1 would call if he needed to use the toilet. She said he did not need to be prompted or cued. She said he also had a urinal that he used. While in the resident's room she looked around for the resident's urinal but could not find it near the resident; but found the urinal in the resident's bathroom. CNA #1 said maybe the resident only used the urinal at night. CNA #1 said the resident required extensive one person assistance to transfer. She then said she thought maybe it was supposed to be two persons to assist with transfers, after looking on his wall (where his transfer status was posted) and seeing it indicated he needed two people. There were two apples on the resident's wall. The CNA said this meant he needed two person assistance. She then said he could transfer with one person's assistance. -However, the resident care plan and facility assessment documented that the resident required two person assistance. RN #2 was interviewed on 7/6/25 at 9:20 a.m. RN #2 said he was familiar with Resident #1. RN #2 said he was not the resident's nurse when he fell and broke his hip. RN #2 said the resident required one person assistance ambulating to the bathroom. RN #2 said if a resident had a fall the process was for the RN to assess the resident, call the physician and notify the family. If the fall was unwitnessed or witnessed and the resident hit their head, the nurse would do neurological checks. He said he did not know if there was any follow up documentation that needed to be in the nursing progress notes. He said sometimes there was a place on the resident's TAR where the nurse signed off that they monitored the resident for 72 hours. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 7/6/23 at 9:34 a.m. The DON said she had been at the facility a little over a month. She said if a resident fell, there should be an assessment completed by the RN, and an event was initiated in the resident's electronic medical record (EMR). She said the nurse should notify the physician and family. The DON said neurological checks should be done for an unwitnessed fall or a fall with head injury. She said the nurses should document in the progress notes for the next 72 hours and observe for any injury or pain. She was not familiar with the fall for Resident #1 on 2/1/23. IV. Additional fallsA. Record reviewOn 2/10/23 at 2:15 a.m. the nursing progress notes documented Resident #1 had a fall from bed. "The Resident's brief was wet, but not soaked." There was no injury. A urinal was provided on 2/13/23 for use at night. On 4/1/23 at 9:05 p.m. the nursing progress notes documented the resident was found on the floor near his bed. He was on his back fully dressed. He stated he had pushed the call light and was trying to get into the bed. His wheelchair was about two feet from where he was found on the floor. The nurse documented his vital signs and neurological checks were normal. On 4/1/23 at 2:51 a.m. the same nurse documented the resident had been sleeping most of the night. No further complaints of pain. Vital signs were stable at this time. Neuro (neurological) checks were within normal limits. -However, there were no vital signs or neurological checks in the record. There were no interventions implemented. There was no further documentation or update to the care plan. On 7/5/23 at 12:55 a.m. the nursing progress notes documented Resident #1 had a fall on 7/3/23, no injuries were noted. -There was no documentation before the 7/5/23 note that the resident had fallen on 7/3/23. There was no assessment, notifications or further information. B. Staff interviewThe DON and ADON were interviewed on 7/6/23 at 9:34 a.m. The DON said she did not know why there was no follow up from the 4/1/23 fall. She said she did not have any neurological checks or vital signs. She said there had been no new interventions added to the care plan for that fall. The DON said the resident's care plan told the staff how a resident should be transferred; gave bowel and bladder information; and information for toileting and incontinence care. Additionally, the information was put on the resident's room wall. The DON said if the resident had one apple posted on the wall in their room, the resident required a one person transfer assist, if two apples they were two person assist. The DON said she thought it had been an agency nurse who documented the 4/1/23 fall but he had not returned to the facility since that night. The DON reviewed the nursing notes dated 7/5/23 regarding a fall 7/3/23. The DON said she did not remember a fall in the past week for Resident #1. The DON thought the note might have been an error. The DON said he would investigate-No further information was provided by the end of the survey on 7/6/23. V. Facility follow-upA Performance improvement Project Guide, Reduce number of falls, dated 3/30/23, with review date set for 7/30/23, was received from medical records (MR) on 7//23 at 6:25 p.m. The form documented three items under plan, 1. Educating on orange nameplate and banner (used to identify resident as a high fall risk); Check In program for high reported to staff on floor at that time, the start date was listed as ongoing 2. Weekly rounds with Restorative RN, Director of Rehabilitation (DOR) and MDS, start date 4/6/23. 3. All staff inservice: Removing clutter/trip hazards Examples to avoid falls. Reporting decline or concerns. Day. Answering call lights, started 4/17/23, completed 4/17/23. -There was no further documentation on the plan indicating when it was reviewed for effectiveness, since it was written three months prior to the survey. A copy of a text sent 2/2/23 at 3:50 p.m. to the physician for Resident #1, was received from MR on 7/6/23 at 8:30 a.m. The text documented, "Resident #1 was stating his left hip was hurting after a fall, may we get in house x-ray." The physician responded at 3:53 p.m., "yes." -However, the x-ray results documented the x-ray was done at 3:26 p.m.

A survey prompted by #CO32678 was conducted on 7/5/23 to 7/6/23. Two deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of three sample residents remained as free from accident hazards as possible. The facility failed to ensure interventions were implemented to prevent major injury from falls for Resident #1. Interviews during the survey revealed the facility still was not implementing interventions for toileting per the care plan. Furthermore, interviews and documentation revealed the staff did not provide transfer assistance to the resident with two person assistance as ordered. Due to the facility's failures to implement effective interventions, Resident #1 sustained a fracture of the left hip from a fall on 2/1/23. Additionally, the facility delayed assessing and monitoring Resident #1's injuries and related pain after the fall on 2/1/23, when the resident complained of having severe pain in his leg for two days after the fall (cross-reference F697). The facility failed to implement effective interventions when Resident #1 returned from the hospital on 2/6/23 which caused him to sustain additional falls. Finding include: I. Facility policy and procedureThe Falls and Fall Risk Management policy, revised March 2018, was received from the director of nursing (DON) on 7/6/23 at 12:15 p.m. The policy documented in pertinent part, "Based on previous evaluations and current data, the staff will identify interventions related to the resident' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. "Resident conditions that may contribute to the risk of falls, incontinence."The nurse shall assess and document/report the following when a fall has occurred: Vital signs, the condition in which the resident was found-resident found lying on the floor between bed and chair, any injury, especially fracture or head injury, subsequent first aid administered, musculoskeletal function, observing for change in normal range of motion, weight bearing, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last physician visit, precipitating factors, details on how fall occurred, pertinent medication, especially those associated with dizziness or lethargy."Nursing staff will observe for delayed complications of a witnessed fall for 72 hours. Vital signs will be taken at the time of the fall and then every shift for the first 24 hours, then everyday on day shift for two subsequent days, Nursing staff will follow the fall, neurological record frequency for obtaining vital signs and neurological checks if a fall is unwitnessed and or head trauma is suspected."The staff, with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out."II. Resident #1A. Resident statusResident #1, age 88, admitted on 8/23/22 and readmitted on 2/6/23. According to the July 2023 computerized physician orders (CPO) diagnosis included history of left femur fracture and left hip pain, neuropathy (weakness, numbness from nerve damage) and repeat falls. The 5/15/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of nine out of 15. The resident required extensive two person assistance with transfers and toileting; and extensive one person assistance with bed mobility, dressing and personal hygiene, The resident had almost constant pain which limited daily activity. The assessment documented he had no falls since his prior assessment. -However, the resident fell on 1/18/23, 2/1/23 and 2/10/23; then again on 4/1/23 just before the above MDS assessment was completed (see below). B. Resident and resident representative interviewsTwo of the resident's representatives were interviewed via telephone on 7/6/23 at 10:19 a.m. The first representative said the resident called her all night in pain on 2/1/23. On 2/2/23 the representative called the facility and spoke to registered nurse (RN) #1. The representative requested the resident be sent to the hospital for an x-ray. The representative said the facility did not send Resident #1 to the hospital but had a mobile x-ray come out to the facility on 2/2/23. The representative said she had also asked the nurse about pain medication and the nurse said they were giving the resident pain medication. The representative later found out the resident had only received one Tylenol. The representative said there were no x-ray results on 2/2/23. She had called the facility multiple times as Resident #1 was in so much pain. The representative said Resident #1 called her all night again on 2/2/23 with complaints of pain to his left leg and inability to move the leg. The representative said she called the facility again 2/3/23, in the morning, to see if the x-ray results were available and was told the results were not back. The first representative said she received a call, a short time later that morning from the facility, to notify her the resident had a hip fracture and was being sent to the hospital. A second resident representative joined the telephone interview. The second resident representative said Resident #1 had called her all night on 2/1/23 and 2/2/23 with stabbing pain to his left leg. She said the resident told her his leg was displaced "out to the side" and he could not move the leg. The second representative was getting ready in the morning to head to the facility, while the first resident representative kept calling the facility to get the resident help. While on the way the representative said she received the information that the resident had a fracture of the left hip and was being sent to the hospital. The second representative said Resident #1 laid in bed for two days in pain, even after the first representative requested that the facility send Resident #1 to the hospital. The first representative said he continued to have a lot of pain to this day. Resident #1 was interviewed on 7/6/23 at 11:28 a.m. Resident #1 said he remembered when he fell and broke his hip. He said he had fallen in the bathroom. Resident #1 said he had a lot of pain for a few days and could not move his leg. He said anytime he tried to move it the pain was severe, but if he did not move it then it was not as bad. He said the nurses gave him Tylenol but that did not help much. He said the pain was a sharp pain and remembered he could not move his leg. He said the nurses had an x-ray done and then he went to the hospital for surgery. Resident #1 said he still had pain, and it was difficult to put any weight on his left leg. Resident #1 said the staff did not check with him throughout the day to offer assistance with toileting. He said he had to call them, and they were slow to answer the call light. C. Record reviewThe fall care plan, initiated 8/29/22, documented potential for falls and injury related to osteoarthritis, history of falls, cognitive impairment, balance issues, unsteady gait, activity intolerance, bilateral lower extremity weakness, history of hip fracture from fall. Interventions included: physical therapy (PT) evaluation and treatment for transfer safety 8/29/22, 2/2/23 and 6/5/23, Dycem (anti slip material) in recliner 5/15/23, walker for short distance, transfers and wheelchair for long distance 5/15/23, two assist for transfers 2/14/23, urinal to be given at bedtime for night usage 2/13/23, visual aide to close footrest on recliner before getting up 11/22/22, resident forgets to lock brakes on wheelchair, anti roll backs in place 11/21/22, reacher, grabber encourage resident to use it to reach out of reach items 11/14/22, non skid strips in bathroom, gripper socks 10/3/22, toilet riser 9/26/22, education provided on proper footwear and ensuring shoes are on correctly, and how to use grabber reacher 9/21/22, bed bars to aide in bed mobility 8/31/22, orange nameplate alert placed to increase staff awareness of increase fall frequency 8/30/22, grab bars in bathroom 8/29/22, call light in reach 8/29/22, keep personal items in reach maintain clean clutter free environment 8/29/22, observe resident and room frequently for any safety needs 8/29/22. The urinary incontinence care plan, initiated 8/29/23 documented the resident needed assistance with toileting, offer and aide in bathroom or use of urinal before and after meals, approximately every two hours while awake and as indicated. Fall historyOn 1/18/23 at 6:10 a.m., the nursing progress notes documented the resident was observed on the floor in the bathroom with a gash to his head and left arm. He was seen to the ER. The progress note documented the day shift would notify the physician. The resident returned to the facility in approximately two hours, with no new orders.-There were no progress notes indicating the physician was notified. The hospital transfer form documented the resident was alert and oriented and was independent with transfers, toileting and dressing. -However, the urinary care plan, dated 8/31/22, documented Resident #1 needed to be offered and assisted to the bathroom before and after meals, and every two hours while awake. The care plan documented the resident had an overactive bladder and would attempt to toilet himself. On 1/19/23 at 11:34 a.m. the nursing progress notes documented the resident sustained a skin tear to the left forehead one centimeter (cm) by 0.9 cm and a skin tear to the left arm three cm by 2.8 cm.-There were no new interventions documented in the progress notes or the care plan (see above). On 1/23/23 at 11:17 a.m. the nursing progress notes documented the resident was on a bowel and bladder program and should be encouraged, offered and assisted to the bathroom every two hours from 2:00 p.m. to 10:00 p.m. On 2/1/23 at 4:51 p.m. the nursing progress notes documented the resident had taken himself to the bathroom and fell pulling up his pants, obtaining a skin tear to the left wrist and abrasion to the low back. No other injuries noted. The family and physician were notified.-However, the resident did develop pain by midnight and was administered Tylenol (see below). On 2/2/23 at 7:55 a.m., a restorative progress note documented restorative was held due to recent fall and the resident was in bed. The certified nursing aide (CNA) documentation for 2/1/23 to 2/3/23 was reviewed. -There was no documentation after the fall on 2/1/23 until 2/2/23. On 2/2/23 under transfers, the CNA documented that it did not occur. -There was no documentation for 2/3/23. On 2/2/21 at 1:31 p.m. the nursing notes documented PT evaluation and treatment due to fall. On 2/3/23 at 7:55 a.m. the nursing notes documented the resident's daughter called about the x-ray results. The nurse documented the facility had not received them yet. -There was no documentation in the medical record regarding why or when an x-ray had been ordered. There was no further assessment of the resident documented since the fall 2/1/23 at 4:51 p.m. There was no further assessment of his left leg or hip. On 2/2/23 at 8:29 a.m. the nursing notes documented the x-ray results were received and the physician was notified. Orders were received to transfer the resident to the hospital with a hip fracture. The x-ray report documented the x-ray was done on 2/2/23 at 3:26 p.m. -There were no records in the facility progress notes regarding an x-ray having been done. On 2/3/23 at 12:53 a.m. (after the resident is sent to the hospital) a late entry was added to the progress notes for 2/2/23. The note documented the resident had an unwitnessed fall in his restroom. The resident was in the restroom and was attempting to pull up his pants, the resident lost his balance and fell resulting in a skin tear to his left wrist and an abrasion to his low back. The resident has had two falls in the last 90 days and eight total falls since his admission. Current interventions that were in place at the time of the fall and that remain to be deemed appropriate include: visual aide in room to remind resident to put the feet of his recliner down, anti-roll backs added to w/c (wheelchair), time pattern of falls reviewed with no time pattern noted, non-skid strips placed in bathroom, gripper socks were offered and provided, orange name plate (used to identify resident as high fall risk) and bed bars to aide in independent bed mobility. New intervention, PT to eval. The hospital record dated 2/3/23, documented Resident #1 was admitted after a fall from a standing height. He was hypoxic (low oxygen levels) due to atelectasis (collapsed lung or section of lung) after "laying around for two to three days post fall." The left hip was x-rayed and confirmed an acute fracture. The resident had surgery to repair the left hip on 2/3/23.-However, the investigation did not identify that the last two falls occurred in the bathroom and there were no new interventions on 1/18/23. In addition, no new interventions related to toileting the resident for the fall on 2/1/23. The February 2023 medication administration record (MAR) and treatment administration records (TAR) were reviewed there were no pain assessments for Resident #1. Resident #1 received Tylenol 325 mg one tablet as needed, on 2/2/23 at 12:33 a.m., 2/2/23 at 12:54 p.m. and 2/3/23 at 7:34 a.m. for undocumented pain levels. The Tylenol was documented as not effective 2/2/23 at 12:54 p.m. and 2/3/23 at 7:34 a.m. There was no follow up documented for the residents pain (cross-reference F697, pain management)The February 2023 TAR had an order dated 2/1/23, Monitor status for 72 hours for bruising, change in mental status or condition, pain or other injuries. However, the resident was in pain, with an externally rotated and shortened left leg as documented in the ER report. The facility nurses gave Resident #1 Tylenol and documented it was not effective. Despite initially the TAR, the licensed nurses did not follow up timely on the resident's change of condition, pain, or injury to the left hip. The July 2023 CPO documented to transfer with assistance of two persons, dated 2/14/23. The weekly summaries in the nursing progress notes were reviewed for May 2023 through 7/5/23. The progress notes revealed the following:On 5/3/23 at 1:26 a.m. the weekly summary documented the resident was ambulatory (ability to get around) with his wheelchair. -There was no documentation regarding the level of transfer assistance. There were no further weekly summaries for May 2023. On 5/23/23 at 10:47 a.m., the interdisciplinary (IDT) note documented Resident #1 required two person assistance with transfers. On 6/7/23 at 12:59 a.m., the weekly summary documented the resident requiring one person assistance with transfers. On 6/14/23 there were two weekly summaries. The one at 12:59 a.m., documented the resident was a one person assist with transfers. The weekly summary at 11:19 a.m. documented the resident was independent with a cane and wheelchair. On 6/21/23 at 12:36 a.m., the weekly summary documented the resident required two person assistance with transfers. On 6/28/23 at 1:19 a.m., the weekly summary documented the resident required two person assistance with transfers. On 7/5/23 at 12:55 a.m., the weekly summary documented the resident required two person assistance with transfers. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/5/23 at 2:07 p.m. RN #1 looked at his laptop and said there was no documentation about the resident's condition or pain after the fall; but there should have been. RN #1 said he had sent a text to the physician for an x-ray on 2/2/23. He could not remember the resident's pain level at that time or what prompted him to call for an x-ray. RN #1 said he should have documented the x-ray order and reason in the notes. RN #1 said there should have been follow up documentation on the resident's condition. He said the resident was independent with toileting and ambulation in his room at the time. RN #1 said he was not supposed to be independent, but he was. RN #1 said Resident #1 now required the assistance of one person when using the bathroom.-However, the resident's medical record documented that prior to the fall Resident #1 was a two person assist with transfers (see above). Certified nurse aide (CNA) #1 was interviewed on 7/6/23 at 9:10 a.m. CNA #1 had been working at the facility for five months and had started at the end of February 2023. CNA #1 said she was not working at the facility when the resident fell and broke his hip. CNA #1 said she was familiar with Resident #1 and was usually assigned to the hall he lived on. CNA #1 said Resident #1 would call if he needed to use the toilet. She said he did not need to be prompted or cued. She said he also had a urinal that he used. While in the resident's room she looked around for the resident's urinal but could not find it near the resident; but found the urinal in the resident's bathroom. CNA #1 said maybe the resident only used the urinal at night. CNA #1 said the resident required extensive one person assistance to transfer. She then said she thought maybe it was supposed to be two persons to assist with transfers, after looking on his wall (where his transfer status was posted) and seeing it indicated he needed two people. There were two apples on the resident's wall. The CNA said this meant he needed two person assistance. She then said he could transfer with one person's assistance. -However, the resident care plan and MDS assessment documented that the resident required two person assistance. RN #2 was interviewed on 7/6/25 at 9:20 a.m. RN #2 said he was familiar with Resident #1. RN #2 said he was not the resident's nurse when he fell and broke his hip. RN #2 said the resident required one person assistance ambulating to the bathroom. RN #2 said if a resident had a fall the process was for the RN to assess the resident, call the physician and notify the family. If the fall was unwitnessed or witnessed and the resident hit their head, the nurse would do neurological checks. He said he did not know if there was any follow up documentation that needed to be in the nursing progress notes. He said sometimes there was a place on the resident's TAR where the nurse signed off that they monitored the resident for 72 hours. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 7/6/23 at 9:34 a.m. The DON said she had been at the facility a little over a month. She said if a resident fell, there should be an assessment completed by the RN, and an event was initiated in the resident's electronic medical record (EMR). She said the nurse should notify the physician and family. The DON said neurological checks should be done for an unwitnessed fall or a fall with head injury. She said the nurses should document in the progress notes for the next 72 hours and observe for any injury or pain. She was not familiar with the fall for Resident #1 on 2/1/23. IV. Additional fallsA. Record reviewOn 2/10/23 at 2:15 a.m. the nursing progress notes documented Resident #1 had a fall from bed. "The Resident's brief was wet, but not soaked." There was no injury. A urinal was provided on 2/13/23 for use at night. On 4/1/23 at 9:05 p.m. the nursing progress notes documented the resident was found on the floor near his bed. He was on his back fully dressed. He stated he had pushed the call light and was trying to get into the bed. His wheelchair was about two feet from where he was found on the floor. The nurse documented his vital signs and neurological checks were normal. On 4/1/23 at 2:51 a.m. the same nurse documented the resident had been sleeping most of the night. No further complaints of pain. Vital signs were stable at this time. Neuro (neurological) checks were within normal limits. -However, there were no vital signs or neurological checks in the record. There were no interventions implemented. There was no further documentation or update to the care plan. On 7/5/23 at 12:55 a.m. the nursing progress notes documented Resident #1 had a fall on 7/3/23, no injuries were noted. -There was no documentation before the 7/5/23 note that the resident had fallen on 7/3/23. There was no assessment, notifications or further information. B. Staff interviewThe DON and ADON were interviewed on 7/6/23 at 9:34 a.m. The DON said she did not know why there was no follow up from the 4/1/23 fall. She said she did not have any neurological checks or vital signs. She said there had been no new interventions added to the care plan for that fall. The DON said the resident's care plan told the staff how a resident should be transferred; gave bowel and bladder information; and information for toileting and incontinence care. Additionally, the information was put on the resident's room wall. The DON said if the resident had one apple posted on the wall in their room, the resident required a one person transfer assist, if two apples they were two person assist. The DON said she thought it had been an agency nurse who documented the 4/1/23 fall but he had not returned to the facility since that night. The DON reviewed the nursing notes dated 7/5/23 regarding a fall 7/3/23. The DON said she did not remember a fall in the past week for Resident #1. The DON thought the note might have been an error. The DON said he would investigate-No further information was provided by the end of the survey on 7/6/23. V. Facility follow-upA Performance improvement Project Guide, Reduce number of falls, dated 3/30/23, with review date set for 7/30/23, was received from medical records (MR) on 7//23 at 6:25 p.m. The form documented three items under plan, 1. Educating on orange nameplate and banner (used to identify resident as a high fall risk); Check In program for high reported to staff on floor at that time, the start date was listed as ongoing 2. Weekly rounds with Restorative RN, Director of Rehabilitation (DOR) and MDS, start date 4/6/23. 3. All staff inservice: Removing clutter/trip hazards Examples to avoid falls. Reporting decline or concerns. Day. Answering call lights, started 4/17/23, completed 4/17/23. -There was no further documentation on the plan indicating when it was reviewed for effectiveness, since it was written three months prior to the survey. A copy of a text sent 2/2/23 at 3:50 p.m. to the physician for Resident #1, was received from MR on 7/6/23 at 8:30 a.m. The text documented, "Resident #1 was stating his left hip was hurting after a fall, may we get in house x-ray." The physician responded at 3:53 p.m., "yes." -However, the x-ray results documented the x-ray was done at 3:26 p.m.

Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#1) of three residents reviewed out of three sample residents. Resident #1 fell on 2/1/23 in the bathroom. He had increased pain, at the facility, for two days until 2/3/23, when an x-ray confirmed he had a fracture of the left hip. Two resident representatives were interviewed. Both representatives said Resident #1 had called them all night long on 2/1/23 and 2/2/23 complaining of being in pain and being unable to move his left leg. The representatives said they had requested the resident be sent to the emergency room (ER) on 2/2/23 for an x-ray of the left hip. However, the facility had an x-ray at the facility, without results until 2/3/23. Resident #1 was interviewed on 7/6/23. He said he had severe stabbing pain and had been unable to move his leg for two days after falling in the bathroom on 2/1/23. He said he was then sent to the ER, from the facility, after a couple days of being in pain and had surgery related to injuries from the fall. There was no additional documentation of facility staff monitoring the resident's condition for pain or evaluation of the resident's change of condition after the initial fall evaluation on 2/1/23, between 2/1/23 to 2/3/23. Resident #1 was given only one tablet of 325mg (milligrams) of acetaminophen (Tylenol) for pain three times as needed from 2/1/23 to 2/3/23 for an undocumented (unknown) pain level. On 2/2/23 and 2/3/23 the Tylenol was documented as not effective. There was no documentation of what was done for the resident when the one tablet of Tylenol was not effective. The resident had an order for Norco pain medication as needed on admission 8/23/22; however, the facility staff said it had never been ordered from the facility pharmacy and therefore was not available to administer for the resident's unresolved pain, during the 2/1/23 to 2/3/23 time period. The 2/3/23 emergency room assessment notes documented the resident was in pain with any motion and his leg was externally rotated and shortened. The resident had surgery to repair the fracture and returned to the facility on 2/6/23. Resident #1 continued to complain of daily pain and difficulty placing weight on the left leg during the survey period. Cross-reference F689 accident hazards for the facility's failure to implement effective fall interventions that caused a fall with major injury and subsequent falls after he returned to the facility. Findings include:I. Facility policy and procedureThe Pain Clinical Protocol, revised March 2018, was received from medical records (MR) on 7/5/23 at 5:50 p.m. The policy documented in pertinent part, "The nursing staff will assess each individual for pain whenever there is a significant change in condition. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level."II. Resident #1A. Resident statusResident #1, age 88, admitted on 8/23/22, and readmitted on 2/6/23. According to the July 2023 computerized physician orders (CPO) diagnosis included, history of left femur fracture and left hip pain, neuropathy (nerve pain), chronic low back pain and repeat falls. The 5/15/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) with a score of nine out of 15. The resident required extensive one person assistance with bed mobility, dressing and personal hygiene; and required extensive two person assistance with transfers, and toileting. The assessment documented the resident reported his worst pain level on a 0 to 10 scale (with 10 being the worst pain on the scale); was 4 out of 10. The assessment further documented that the resident said he had almost constant pain that limited his daily activity. B. Resident and resident representative interviewsTwo of the resident's representatives were interviewed via telephone on 7/6/23 at 10:19 a.m. The first representative said the resident called her all night complaining of being in pain on 2/1/23. On 2/2/23 the representative called the facility and spoke to registered nurse (RN) #1. The representative requested the resident be sent to the hospital for an x-ray. The representative said the facility did not send Resident #1 to the hospital but had a mobile x-ray come out to the facility on 2/2/23. The representative said she had asked the nurses on the phone about pain medication and they said they were giving the resident pain medication. The representative later found out the resident had only received one Tylenol for his pain. The representative said there were no x-ray results on 2/2/23. She had called the facility multiple times requesting alternative treatment for the resident, as Resident #1 was in so much pain. The representative said Resident #1 called her all night again on 2/2/23 with complaints of pain to his left leg and inability to move the leg. The representative said she called the facility again 2/3/23, in the morning, to see if the x-ray results were available, and was told the results were not back yet. The representative said she received a call, a short time later that morning (2/3/23) from the facility, to notify her the resident had a hip fracture and was being sent to the hospital. A second resident representative joined the telephone interview with the first resident representative. The second resident representative said Resident #1 had also called her all night on 2/1/23 and 2/2/23 complaining of stabbing pain to his left leg. She said he told her his leg was out to the side and he could not move the leg. The second representative was getting ready in the morning to head to the facility on 2/3/23, while the first resident representative kept calling the facility. The second representative said that while on the way to the facility she received the information that the resident had a fracture of the left hip and was being sent to the hospital. The second representative said Resident #1 layed in bed for two days in pain, even after being asked by the first representative that the resident be sent to the hospital. The second representative said the facility only gave the resident Tylenol which was ineffective for pain from a fractured hip. The first representative said he continued to have a lot of pain to this day. Resident #1 was interviewed on 7/6/23 at 11:28 a.m. Resident #1 said he remembered when he fell and broke his hip. He said he had fallen in the bathroom. Resident #1 said he had a lot of pain for a few days and could not move his leg. He said anytime he tried to move it the pain was severe, but if he did not move it then it was not as bad. He said the nurses gave him Tylenol but that did not help much. He said the pain was a sharp pain and remembered he could not move his leg. He said the nurses had an x-ray done and then he went to the hospital for surgery. Resident #1 said he still had pain, and it was difficult to put any weight on his left leg. Resident #1 said the staff did not check with him throughout the day to offer assistance with toileting. He said he had to call them, and they were slow to answer the call light. C. Record reviewThe pain care plan, initiated 8/26/22, documented in pertinent part, potential for alteration in comfort related to chronic back low back pain, osteoarthritis, peripheral neuropathy, and history hip surgery which was added on 5/17/23. Interventions included:-Monitoring for side effects of Tylenol, dated 8/26/23. Monitoring for side effects of narcotic pain medications, dated 8/26/22. -Give medications as ordered, dated 8/26/22, and monitor for side effects, and effectiveness. -Notify the physician if there were side effects or if medication were consistently ineffective. -Report to nurse vocal and non verbal indication of pain. Pain assessment quarterly and as indicated. It documented the resident's acceptable level of pain was "extreme." Use dementia face scale if needed. Try alternate methods of pain relief such as repositioning rest, stretching, ambulating, warmth, coolness, and distraction. On 2/1/23 at 4:51 p.m. the nursing progress notes documented the resident had taken himself to the bathroom, and fell pulling up his pants, obtaining a skin tear to the left wrist and abrasion to the low back. No other injuries noted (cross-reference F689). On 2/3/23 at 7:55 a.m. the nursing notes documented the resident's daughter called about the x-ray results. The nurse documented the facility had not received them yet. -There was no documentation in the medical record regarding why or when an x-ray had been ordered. There was no further assessment of the resident documented since the fall 2/1/23 at 4:51 p.m. On 2/2/23 at 8:29 a.m. the nursing notes documented the x-ray results were received and the physician was notified. Orders were received to transfer the resident to the hospital with a hip fracture. The hospital record dated 2/3/23, documented Resident #1 was admitted after a fall from a standing height. He was hypoxic (low oxygen levels) due to atelectasis (collapsed lung or section of lung) after "laying around for two to three days post fall." The left hip was x-rayed and confirmed an acute fracture. The resident had surgery to repair the left hip on 2/3/23. The February 2023 medication administration record (MAR) and treatment administration records (TAR) were reviewed. -There were no pain assessments documented for the resident. The MAR documented the resident was on routine acetaminophen (Tylenol) 325 mg one tablet three times per day. The MAR documented the resident had an order for as needed (PRN) Tylenol 325 mg every four hours as needed for pain, dated 10/25/22. The MAR documented the resident had an order for Hydrocodone-acetaminophen (Norco) 5-325 mg by mouth every six hours as needed for pain (scale 4-10), ordered 8/23/22. On 2/1/23 the resident did not receive any PRN Tylenol. On 2/2/23 at 12:33 a.m. the resident received as needed Tylenol for pain. It documented the Tylenol was effective.-There was no pain level documented. On 2/2/23 at 12:54 p.m. the resident received PRN Tylenol. The pain medication was documented as not effective. -No pain levels were documented and here was no follow up on the resident's pain. On 2/3/23 at 7:34 a.m., the resident received Tylenol and the pain medication was documented as not effective. -The was no pain level documented. The nursing notes documented at 7:55 a.m. the physician would be called about getting the resident's Norco (hydrocodone and acetaminophen 5-325 mg, opioid narcotic analgesic) refilled.-However, the resident was admitted to the facility with the order for Norco. The interviews (see below) revealed the facility had never sent the Norco order to the pharmacy and therefore it had never been filled or available for the resident. An Interview for Pain Assessment, dated 2/13/23, after the resident's hip fracture, was reviewed. The assessment documented the resident had a history of neuropathy, chronic low back pain and pain in the left hip due to a history of fracture. The pain assessment documented Resident #1 was on schedule pain medication and had received PRN pain medication. It documented he had received non-medication interventions. The interview documented the pain was occasional and made sleeping difficult. On a scale of 1 to 10, Resident #1 rated his pain at a 10 for the worst it had been. -There was no information on what exacerbated the pain or made it better. There was no information on what an acceptable level of pain was or pain goal. There was no description of the pain, characteristics of the pain or the location of the pain. There were no listed non-medication interventions listed on the pain assessment. -The May 2023 Interview for Pain Assessment was requested from the DON and not received by the end of the survey on 7/6/23. The MDS assessment, dated 5/23/23, documented the resident had constant pain which affected his activities of daily living. Weekly nursing charting in the progress notes was reviewed for the last 90 days. There was a weekly summary twice in April 2023, once in May 2023 and four times in June 2023. -The weekly charting, when it was done weekly, did not contain documentation regarding pain. It did not document whether the resident had pain or not. The June and July 2023 medication administration records revealed the following:-Resident #1 received Tylenol 325mg (milligrams), by mouth, three times daily routinely, order date 2/6/23 for June and July 2023. -Resident #1 received gabapentin (antiseizure medication used for nerve pain) 600 mg three times per day routinely for neuropathy, order date 2/6/23, for June and July 2023. Additionally, the resident had as needed (PRN) orders started on 5/1/23 for Hydrocodone-acetaminophen (Norco) 5-325 mg by mouth every six hours as needed for pain (scale 4-10). Tylenol (acetaminophen) capsule 325 mg, one tablet by mouth every four hours as needed for pain. The June 2023 MAR documented Resident #1 received Norco 6/11/23, 6/15/23 two times, 6/23/23, 6/24/23 and 6/25/23 for pain of 8 out of 10. Pain included the lower extremities, lower back, and reddened buttocks. On 6/16/23, there was no Norco signed out as administered. However, on 6/16/23 at 11:46 p.m, the nurse documented that the Norco was documented as somewhat effective. However, there was no time documented for when it was given or what pain level. Resident #1 received PRN Tylenol for an undocumented pain level on 6/10/23 and 6/30/23. The MAR from 7/1/23 to 7/5/23, documented Resident #1 received Tylenol for pain of 4 out of 10 on 7/3/23. -However, the orders were to give Norco for pain levels of 4 to 10. On 6/12/23 at 12:14 p.m., the nursing progress notes documented the resident had pain to the buttocks on 6/12/23 at 12:14 p.m. The buttocks were documented as red, shiney and sore. -There were no pain levels and no PRN Tylenol or Norco given per the nursing notes and MAR. On 6/16/23 at 1:58 p.m., the nursing progress notes documented the resident complained of pain to his buttocks and coccyx. The area was documented as red and the resident requested to go to the hospital due to the pain. -There was no pain level documented and no PRN Tylenol or Norco documented as given. The nursing notes documented again at 6:22 p.m. that the resident complained of pain to the reddened buttocks. -It is unknown if Norco was given, or at what time and for what level of pain on 6/16/23 (see above). There was no pain level. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/5/23 at 2:07 p.m. RN #1 looked at his laptop and said there was no documentation about the resident's condition or pain level after the fall. He said there should have been. RN #1 said he had sent a text to the physician for an x-ray on 2/2/23 due to the resident being in pain. He could not remember the resident's pain level at that time or what prompted him to call for an x-ray. RN #1 said he should have documented the x-ray order and reason in the notes. RN #1 said there should have been documentation on the resident's condition. RN #1 said he did not know why the resident was given one tablet of Tylenol for pain after his fall 2/1/23, instead of the Norco ordered on admission. The controlled drug count sheet was requested for the Norco for January and February 2023. RN #1 said he did not have one. He said to check with the director of nursing (DON). RN #2 was interviewed on 7/6/25 at 9:20 a.m. He said he knew Resident #1. RN #2 said Resident #1 was on Trazadone (antidepressant) for pain. -However, the resident was not on Trazodone for pain, but for depression. RN #2 said the Resident #1 had an order for Norco which he said the resident received for pain. RN #2 said the licensed nurses did not currently document a routine pain level. He said a pain level was only assessed and documented if the resident or someone else came and reported pain. He said he heard the facility was going to start doing pain assessments routinely, but he did not know when that was to start, and could not remember who told him this. The DON and assistant director of nursing (ADON) were interviewed on 7/6/23 at 9:34 a.m. The DON said she had been at the facility a little over a month. She said if a resident fell, there should be an assessment completed by the RN, and an event was initiated in the electronic medical record (EMR). She said the nurses should document in the progress notes for the next 72 hours, and observe for any injury or pain. She was not familiar with the fall for Resident #1 on 2/1/23. The DON said pain was assessed quarterly and as needed. She said pain was documented in the resident's weekly summary in the progress notes. -However, the weekly summaries reviewed for the last 90 days, when done weekly, did not contain information about pain. The ADON said pain should be assessed every shift and documented on the resident's MAR and when any pain medication was given. The DON said there was no count sheet for the Resident #1's Norco during the time prior to the resident's transfer to the hospital on 2/3/23. The DON said she had spoken to the pharmacy and the Norco had not been ordered. The ADON said the Norco was ordered and administered as needed after the resident returned form the hospital on 2/6/23. The ADON said she had started a performance improvement plan (PIP) for pain management yesterday (7/5/23) and would provide a copy. IV. Facility follow-upA document titled Performance Improvement Plan, Project Name: Pain Assessment and Management, initiated 7/5/23, was received from medical records on 7/6/23 at 5:58 p.m.. The plan documented the goal was to have a complete record of the resident's pain levels with a start date of 7/5/23. Action items initiated were, add pain question to daily Grand Rounds 7/7/23, no responsible person was listed, electronic health record will prompt nurses for basic pain assessment every shift as well as during administration of medications and treatments start 8/1/23, no responsible person was listed. Educate nurses on regular pain documentation every shift especially 72 hours after a fall or when new orders obtained with diagnosis of pain example, new order for tylenol or x-ray, no date or responsible person was listed, all medications for pain will have associated pain scales initiated on approved by medical director no date or responsible person was listed, policy update to reflect changes 7/6/23, final approval with medical director and interdisciplinary team 7/24/23, no responsible person listed. Indicators and Measures documented there would be electronic medical record documentation audits, it was unclear what would be audited, there was no start date, frequency, or responsible person identified. The PIP documented incidents would be audited for complete documentation by ADON weekly, and quarterly comprehensive pain assessments by the MDS coordinator.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/05/2023 and 06/11/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A complaint survey, prompted by #CO31992 and #CO31986 was conducted on 5/8/23 to 5/11/23. No deficiencies were cited.

A revisit survey was completed on 2/6/23 for all previous deficiencies cited on 11/29/22. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 2/6/23 for all previous deficiencies cited on 11/29/22. The facility is in compliance with all regulations surveyed.