Health inspection·July 1, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to implement individualized interventions, including supervision to prevent avoidable falls for 1 (Resident #2) of 3 residents reviewed for accidents. Review of the clinical record for Resident #2 revealed an admission date of 5/22/25. Diagnoses included cerebral infarction, muscle wasting and atrophy, difficulty walking, lack of coordination, and aphasia (difficulty speaking).Review of the admission Nursing assessment dated [DATE] revealed Resident #2 had impaired vision, was incontinent of urine once or twice daily, during the day and nighttime.Review of the baseline care plan dated 5/23/25 revealed Resident #2 was always incontinent of bladder and bowel and required the assistance of 2 staff for transfer, and ambulation.The care plan noted the resident was at risk for falls related to impaired cognition, medication use, poor safety awareness, cardiac disease and decreased mobility. The goal was to minimize risk of falls. The interventions as of 5/23/25 included:Anticipate and meet the resident's needs, ensure the call light is within reach and encourage resident to use it to call for assistance, bilateral fall pads when in bed, placing under the bed when out of bed.Review of the Bowel and Bladder assessment dated [DATE] revealed the 3 Day Tracking Results showed conflicting information. The form noted Resident #2 was always incontinent of bladder and bowel and also noted the resident was continent of bowel and bladder. Resident #2 had impaired mobility/ambulation. The suspected cause of the incontinence was Functional (decreased mental awareness/decrease of loss of mobility or personal unwillingness).The treatment plan was, Check and change program- designed for residents who are physically unable to sit on toilet or have cognitive impairment or behaviors that make it difficult to use.Review of the facility incident log revealed Resident #2 had multiple falls from 5/27/25 through 6/4/25.Review of the fall investigations revealed:Fall #1:On 5/27/25 at 8:40 p.m., Resident #2 was found on the floor in her room. Resident #2 said she was trying to ambulate to the bathroom.On 5/27/25 the care plan was updated to post a sign to remind Resident #2 to call for help.Review of the Bladder Continence Log revealed on 5/27/25 Resident #2 was toileted at 12:25 a.m., then approximately 11 hours later at 11:19 a.m., at 3:59 p.m., and at 11:47 p.m.There was no documentation the fall investigation included the lack of documentation Resident #2 was provided incontinent care approximately 4.5 hours prior to the fall.Fall #2:On 5/28/25 at 6:09 p.m., Resident #2 was found on the floor in her room. Resident #2 stated, I wanted to go to the bathroom.On 5/28/25 the care plan was updated to ensure Resident #2 had nonskid socks, slippers, or shoes when she's out of bed for ambulation or mobilization in wheelchair; keep frequently used items within reach; and maintain a safe environment, free of clutter and wet floors, and ensure adequate lighting.Review of the Bladder Continence Log revealed on 5/28/25 Resident #2 was toileted at 9:24 a.m., 4:46 p.m., and 11:51 p.m.On 5/29/25 the facility performed a medication regimen review with reduction in the resident's Seroquel (antipsychotic) medication.Fall #3:On 5/30/25 at 10:00 a.m., Resident #2 was found on the floor in the bathroom. She stated she was Page 1 of 2 105864 105864 07/01/2025 Page Rehabilitation and Healthcare Center 2310 N Airport Road Fort Myers, FL 33907

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few trying to use the bathroom.On 5/30/25 the care plan was updated to ensure the bed was in the lowest position with bilateral fall pads, hipsters (padded hip protectors) to be worn at all times.Review of the Bladder Continence Log revealed on 5/30/25 Resident #2 was toileted at 3:06 a.m., 8:34 a.m., and 7:49 p.m.Fall #4:On 6/4/25 at 3:30 p.m., Resident #2 was found on the floor in her room. The resident said she slipped trying to go to the bathroom.On 6/4/25 the care plan was updated for Resident #2 to be checked every 15 minutes post-fall. The clinical record lacked documentation the 15 minutes checks were implemented.Review of the Bladder Continence Log revealed on 6/4/25 Resident #2 was toileted at 9:33 a.m., 6 hours before the fall, and was not toileted for 4.5 hours after the fall.The fall investigation did not include the lack of toileting for Resident #2 for 6 hours before the fall.On 7/1/25 at 11:30 a.m., an interview was held with the Director of Nursing to review Resident #2's multiple falls and interventions, including toileting to prevent further falls.The DON said Resident #2 should have been toileted before and after meals, before bed, and routinely throughout the day and night.When asked about documentation of the 15-minute checks initiated on 6/4/25 as a fall prevention intervention, the DON was not able to provide the documentation. She said, They are still looking. 105864 Page 2 of 2