Other·May 19, 2026

483.25(d) Accidents. The facility must ensure that - 483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR 72521(a) Administrative Policies and Procedures. (a)Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. 22 CCR 72523 (a) Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR 72311(a)(1)(A), (a)(2) Nursing Services-General (a)Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 4/14/25 at 9:30 a.m., an unannounced abbreviated survey was conducted at the facility to investigate a Facility Reported Incident of a patient fall with injury on 4/6/25, requiring transportation to the emergency department (ED) for treatment. The investigation found the facility failed to: 1. Ensure Resident 9 received adequate supervision and assistance to meet her needs and prevent accidents. Resident 9 was assessed as needing staff supervision to ambulate (walk) more than 50 feet and was allowed to ambulate unsupervised outside to the memory care unit patio, a distance over 50 feet. 2. Update Resident 9's person-centered care plan with effective interventions addressing the resident's known behaviors of putting herself on the floor, walking in the facility with her eyes closed and lying on the ground and banging her head. These failures resulted in Resident 9 ambulating outside with no supervision and resulted in Resident 9 sustaining a laceration to the back of her head and was transported to the Emergency Department (ED) for assessment and treatment of her injury. Resident 9 was admitted to the facility on 3/24/17 with diagnoses that included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), dementia (progressive loss of memory and thinking), epilepsy (nerve cell activity in the brain is disturbed causing seizures [burst of sudden electrical activity]), abnormalities of gait (manner of walking) and mobility (ability to move freely), muscle weakness and difficulty in walking. Resident 9 had severely impaired cognition (mental processes including thinking, attention, language, learning and memory). During an observation on 4/14/25 at 11:03 a.m., in the memory care unit, Resident 9 was observed sitting in the activities room. Resident 9 was sitting in a chair with her eyes half closed and appeared drowsy . During an observation on 4/14/25 at 11:05 a.m., a cement pathway connected the patio to the main exit to the main exit. Surrounding the cemented patio was a grassy area and a fence protected the entire outside area. The distance from the main exit to the back patio was over 50 feet. During a review of Resident 9's Acute Care Hospital (ACH) document titled "ED Assessment," dated 4/6/25, the document indicated, "... Chief Complaint: Fall ... Stated Complaint: GROUND LEVEL FALL/HEAD PAIN ... Patient had an unwitnessed fall from a chair onto the ground ... sustained a small laceration to the back of her head which does not need repair because of that less than 1 cm wide and is not bleeding ... Diagnosis ... Fall ... Laceration of scalp ..." During an interview on 4/14/25 with CNA 1, CNA 1 stated she was usually assigned to Resident 9 and was caring for her today. CNA 1 stated she was aware Resident 9 had a recent fall but was not working at the time of the fall. CNA 1 stated Resident 9 had known behaviors of putting herself on the ground and walking around the facility with her eyes closed. CNA 1 stated Resident 9 had sustained a laceration to her head during the fall, but she was unsure if the resident had sutures or not. CNA 1 stated Resident 9 was known to be a high fall risk but would ambulate alone in the hallway and out on the patio. CNA 1 stated "when she is outside, we keep an eye on her." CNA 1 stated the staff would check on Resident 9 every 15 to 20 minutes while she was outside on the patio. During a concurrent interview and record review on 4/14/25 at 2:48 p.m. with the MDSC, Resident 9's MDS "Section GG-Functional Status," dated 2/17/25 was reviewed. The MDS indicated Resident 9 could walk 10 feet but required set up and assistance prior to or after the activity. For walking 50 feet and walking 150 feet, Resident 9 required supervision or touching assistance. The MDSC stated Resident 9's MDS indicated she should have supervision to ambulate, and a CNA should always be with the resident when she was ambulating. The MDSC stated supervision during ambulation meant to have contact guard (to provide light guiding contact) from an employee. The MDSC stated Resident 9 should not have been on the patio without staff supervision. The MDSC stated she was familiar with Resident 9 having known behaviors of putting herself on the floor and walking with her eyes closed, increasing her need for supervision. During an observation on 4/15/25 at 11:36 a.m., in the memory care hallway, Resident 9 was observed walking in the hallway independently with her eyes half closed. Resident 9 did not verbally respond when spoken to. CNA 1 took Resident 9 to her room. During a concurrent interview and record review on 4/15/25 at 2:54 p.m. with the ADON, Resident 9's "Change in Condition," (CIC-documentation regarding a significant change from baseline) dated 4/6/25, was reviewed. The CIC indicated, "... CNA Notified Charge Nurse that resident was found sitting on the floor outside in station 6 patio. Charge Nurse went to assess resident and noted Resident sitting on the floor with her legs extended out in front of her and arms in her lap..." The ADON stated Resident 9 had an unwitnessed fall on the memory care unit outside patio on 4/6/25. Resident 9's "Post-Fall Review," dated 4/6/25 was reviewed, and indicated, the date of the fall was 4/6/2025 at 3:18 p.m. and the fall was unwitnessed. Resident 9 was found on the outside patio and was noted to have had a cut to the back of her head. Resident 9 was bleeding and it was noted that Resident 9 had a history of hitting her head on the ground. The "Post Fall Review" stated Resident 9 may have placed herself on the floor or due to poor safety awareness and impaired mobility due to self-transfer could have resulted in a fall. The "Post Fall Review" stated Resident 9 had a pattern of laying on her back raise her head and drop it on the ground repeatedly. The ADON stated Resident 9 sustained a laceration to the back of her head and was sent to the ED for assessment but did not require sutures so she was sent back to the SNF. Resident 9's fall risk care plan, dated 2/24/25 was reviewed. The care plan indicated Resident 9 was at risk for falls with injury related to epilepsy, anxiety (feeling of worry), difficulty in walking, muscle weakness generalized. The care plan stated Resident 9 throws self on the floor, impaired cognition, poor safety awareness, history of falling with common behaviors of walking with eyes closed. Interventions put into place were to anticipate and meet the Resident 9's ADL care needs, to encourage the use of appropriate footwear, to keep bed in lowest position, Physical Therapy (PT), Occupational therapy (OT) evaluation and treatment as needed. The care plan stated Resident 9 could walk 10 feet but required set up and assistance prior to or after the activity. For walking 50 feet and walking 150 feet, Resident 9 required supervision or touching assistance. The ADON stated Resident 9 had known behaviors of sitting herself on the ground and walking with her eyes closed. The ADON stated Resident 9's care plan indicated she was supposed to have supervision to walk 50 feet and did not have supervision while on the patio at the time of her fall. The ADON stated the memory care unit patio was further than 50 feet from the memory care unit hallway and she should have had supervision. The ADON stated, "we cannot prevent her from falling because of her behaviors." During a concurrent interview and record review on 4/15/25 at 4:25 p.m. with the DON, Resident 9's "Post Fall Review," dated 4/6/25, was reviewed. The DON stated Resident 9's fall on 4/6/25 was unwitnessed and happened on the memory care unit's patio. The DON stated Resident 9's MDS dated 2/17/25, indicated she needed supervision to ambulate more than 50 feet, and the memory care unit hallway was more than 50 feet. The DON stated Resident 9 had dementia (decline in mental ability severe enough to interfere with daily life) and Alzheimer's Disease and was unable to make decisions regarding her safety. The DON stated, "we cannot stop her from what she is doing." The DON stated she had been told by staff Resident 9 frequently went out to the patio unsupervised with no issues. The DON stated Resident 9 could go to the patio, but the DON declined to state if Resident 9 needed supervision while she was outside. The DON reviewed Resident 9's fall risk care plan and stated there were no interventions to address her known behaviors of putting herself on the floor until after the fall on 4/6/25. During a telephone interview on 4/16/25 at 9:08 a.m. with the Director of Rehabilitation (DOR ), the DOR stated Resident 9 was started on therapy after her fall on 4/6/25. The DOR stated she did a therapy screen for Resident 9, and she was started on physical therapy. The DOR stated Resident 9 was independent for ambulation indoors but was not safe to ambulate outside on uneven surfaces by herself. The DOR stated Resident 9 needed staff supervision while outside on the patio. During a review of the facility's policy and procedure titled "Falls and Fall Risk, Managing," dated 2/7/24, the P&P indicated, "... Based on previous evaluations and current data, the nursing 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 ... Fall Risk Factors ... Resident conditions that may contribute to the risk of falls ... other cognitive impairment ... pain ... lower extremity weakness ... poor grip strength ... medication side effects ... functional impairments ... Medical factors that contribute to the risk of falls ... heart failure ... neurological disorders ... balance and gait disorders ... implement a resident-centered fall prevention plan to reduce their specific risk factor(s) of falls for each resident ..." The investigation found the facility failed to: 1. Ensure Resident 9 received adequate supervision and assistance to meet her needs and prevent accidents. Resident 9 was assessed as needing staff supervision to ambulate (walk) more than 50 feet and was allowed to ambulate unsupervised outside to the memory care unit patio, a distance over 50 feet. 2. Update Resident 9's person-centered care plan with effective interventions addressing the resident's known behaviors of putting herself on the floor, walking in the facility with her eyes closed and lying on the ground and banging her head. These failures resulted in Resident 9 ambulating outside with no supervision and resulted in Resident 9 sustaining a laceration to the back of her head and was transported to the Emergency Department (ED) for assessment and treatment of her injury. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents and constitutes as a "B" Citation.