Quality Center For Rehabilitation And Healing Llc

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

a charge nurse, put on a shower sheet if CNA finds one.the nurse would report it to Administrator and myself, call on call staff, and notify family, complete a skin assessment. The Administrator was asked if a timeline was completed with Resident #2's injury, if staff members were called or questioned in person, and why staff did not sign the typed statement. The Administrator stated, .they [staff] don't sign it.it doesn't say whether it is in person or by phone.it doesn't include a timeline.no way to know what happened.it was pathological, no way to pinpoint. The Administrator was asked if any education was given to the staff related to the injury with Resident #2. The Administrator stated, .nothing in particular.nothing reported to the state agency.I did not believe it was an injury of unknown origin. The Administrator was asked if an injury of unknown origin should be reported to the state agency. The Administrator stated, .report within 2 hours. On 9/25/2025 at 3:33 PM, a voice message was left with Hospital #1's Accreditation and Regulatory Specialist to set up a call with MD #3. During an interview on 9/26/2025 at 10:27 AM, MD #2 was asked if he was aware of the origin of Resident #2's injury when he evaluated her during her hospital stay. MD #2 stated, .I don't really know, 2 broken legs.Nobody [referring to staff at Facility #1] gave me evidence of really what happened.terrible thing that this happened.sure her bones were not in alignment.there was a fair amount of swelling.I don't recall saying this was a spontaneous fracture.it is clear that I can't say what caused the injury. This surveyor stated to MD #2 it is my understanding that Osteoporosis does not cause a fracture but may be a contributing factor. MD #2 stated, .Yes, that is correct on your understanding of Osteoporosis.[FM F] loves her.I seen him at the hospital and I saw him Tuesday in my office when she [Resident #2] came back for follow up.the fractures are healing.[FM F] did question the injury.I would have been angry [Resident #2's injuries]. A (Named videoconference call) meeting was conducted on 10/8/2025 at 10:30 AM, with MD #3 and Accreditation and Regulator Specialist for Hospital #1. MD #3 was asked if he was the admitting physician for Resident #2 on 5/5/2024. MD #3 stated, Yes. MD #3 was asked why Resident #2 was admitted as a Trauma Level Activation Level 1. MD #3 stated, .we have 3 tiers the hospital goes by so we can make sure appropriate resources are there for the injuries.in her case [Resident #2] was hypotensive status with systolic pressure of the 80's so that is highest level of activation. MD #3 was asked if he was notified by Facility #1 on how Resident #2's injuries occurred. MD #3 stated, .I was not notified by the facility which is not uncommon.EMS told me patient complained of pain after using the lift to get her up to a chair.she was confused and she couldn't tell me what happened.I did not see family with her when she arrived at the hospital which was around 5:05 AM when I saw her. MD #3 was asked what was his physical assessment of Resident #2. MD #3 stated, .pain and tenderness in her lower extremities.I spent maybe 20-30 minutes with her and the trauma service assumed care for her. MD #3 was asked when he normally sees this type of injury. MD #3 stated, .Motor Vehicle injuries or with a fall which can cause a force or stress to the bone.

MD #3 was asked if Osteoporosis can cause this type of fracture or some type of injury must occur. MD #3 stated, .Osteoporosis is a weakening of the bone but there has to be some type of external pressure or force that would lead to the fracture.

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