Legacy At Salina

dated 10/16/25 at 08:31 PM documented R1 cried earlier in the shift due to pain in her right leg, and the nurse had administered pain medication.The late entry Progress Note dated 10/16/25 at 10:14 PM documented R1 told staff all about her fall. R1 rated her pain at a five out of 10 on the pain scale.

The nurse documented no visible injuries and noted the resident was in a low bed, a CNA assisted the nurse with pulling R1 up in bed, and the resident tolerated it well.The Progress Note dated 10/17/25 at 01:23 AM documented R1 had ROM deficits.

The LN assessed and attempted ROM, but R1 could not move her legs on her own. R1 said it was painful, but did not yell out or seem in any increased distress than her normal demeanor. R1's legs appeared the same length, and R1 assisted the staff with turning.The Progress Note dated 10/17/25 at 09:16 AM documented the nurse called the physician's office due to R1's increased tearful episodes and complaints of pain related to her 10/16/25 fall.

The physician ordered the staff to send R1 to the emergency room for evaluation and treatment for right leg pain.On 10/27/25 at 09:30 AM, R1's bed had a perimeter mattress; however, R1 was not in the building for observation.On 10/27/25 at 09:30 AM, LN H stated the previous mattress on R1's bed before the fall was a plain air mattress.On 10/27/25 at 10:45 AM, LN G stated she was on the telephone when R1 fell out of bed on 10/16/25. LN G said she saw the resident seated on the floor, by her bed, with her legs straight out, and a CNA at her back helping her sit.

The resident held onto the bed cane rail on that side of the bed.

She verified two staff were to provide cares for R1 and said R1 had an air mattress.

She verified the CNA should not have rolled the resident without the assistance of another staff person.On 10/27/25 at 11:11 AM, CNA M stated she did not know R1 required two staff assistance for dressing, but she knew R1 required two staff assistance for transfers.

CNA M stated she used the walkie to request assistance to get R1 up and transferred to her wheelchair.

CNA M stated all the other staff replied they were busy in other rooms so she thought she could start providing activities of daily living (ADL) cares to R1, such as dressing, while she waited for help. CNA M stated when she finished dressing the resident, she told the resident she was going to roll her over to her side to pull her dress down and place a lift sling under her. R1 grabbed the cane rail and assisted (rolling to her side), but R1 pulled on the rail too much, and when rolled, she slid out of her bed. CNA M said R1 had an air mattress at that time, and R1 was still holding onto the rail when she sat on the floor (after falling out of the bed). CNA M said the other staff came into the room, and the nurses assessed the resident before we transferred her back to bed.On 10/27/25 at 08:22 AM, Administrative Nurse D stated R1 was still in the hospital due to a fractured femur.

Administrative Nurse D stated the facility educated CNA M post fall, and with a separate in-service on 10/17/25. On 10/27/25 at 09:35 AM, Administrative Staff A stated CNA M had an in-service regarding falls on 08/23/25, as part of her orientation to the facility. On 10/27/25 at 09:40 AM, Administrative Nurse D stated R1's mattress was a plain air mattress prior to the fall, but post-fall the facility added a concave mattress.

Administrative Nurse D stated before the fall, R1 required two staff members for most ADL.

Administrative Nurse D verified CNA M was the only staff in R1's room at the time of the fall, and verified CNA M had not followed the care plan.

The facility's Fall Prevention Program dated 12/23/21 stated all staff were to be aware of fall interventions for residents and know the residents who were at risk for falls.

The facility identified, implemented, and completed the following corrective actions by 10/17/25:1.

The facility placed a perimeter mattress on R1's bed on 10/16/25. 2.

All nursing staff attended or completed an in-service for the transfer of residents on 10/17/25.The facility completed corrective actions by 10/17/25, prior to the onsite survey; therefore, the deficient practice was deemed past noncompliance, at the scope and severity of a G (isolated, actual harm).

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