POMONA, CA - State health inspectors found that Park Avenue Healthcare & Wellness Center failed to develop and implement proper fall prevention care plans for a high-risk resident, resulting in a preventable fall and injury in March 2025. The facility also documented inaccurate assessment records following the incident, potentially compromising future care decisions.
Critical Fall Prevention Failures Led to Resident Injury
The California Department of Public Health investigation revealed that Resident 2, who was identified as high-risk for falls upon admission on January 11, 2025, never received the required care plan to address this vulnerability. Despite scoring 14 on the Fall Risk Assessment - well above the threshold of 10 that indicates high risk - nursing staff failed to create the mandated interventions that could have prevented the resident's March 8 fall from bed.
The resident, who had severely impaired cognition and required total assistance with most daily activities including transfers and mobility, was found on the floor next to the bed with a skin tear to the left elbow. Medical records showed the resident could not walk and was completely dependent on staff for bed positioning and transfers.
CNA 2, who discovered the resident after hearing shouts for help, told investigators: "I did not know Resident 2 was at high-risk for falls before the fall on 3/8/2025." The aide added that had they known about the fall risk status, they would have checked on the resident every 10 minutes instead of standard rounds.
Documentation Errors Compounded Safety Risks
Following the fall incident, Registered Nurse 2 incorrectly completed a new Fall Risk Assessment that showed the resident was no longer at high risk, despite having just experienced a fall. The nurse failed to document the recent fall history, which dropped the risk score from 14 to 9 - below the high-risk threshold.
This documentation error had serious implications for ongoing care. When fall risk assessments are inaccurately low, residents may not receive appropriate monitoring frequency, assistive devices, or environmental modifications that help prevent subsequent falls. Falls in elderly residents with cognitive impairment and mobility limitations can result in fractures, head injuries, extended hospitalizations, and accelerated functional decline.
The facility's MDS Nurse acknowledged the gravity of these failures, stating that without proper care plans, "staff did not have a road map for what interventions needed to be done for the resident."
Medical Significance of Fall Prevention Protocol Violations
Falls represent one of the most serious safety risks in nursing homes, particularly for residents with cognitive impairment and mobility limitations. Standard medical protocols require immediate risk stratification upon admission, followed by individualized intervention plans that address specific vulnerabilities.
For high-risk residents like Resident 2, evidence-based interventions typically include frequent monitoring rounds, low bed positioning, floor mats, enhanced supervision during transfers, and proper positioning devices. The absence of these basic safety measures significantly increases the probability of falls and resulting injuries.
The facility's own Fall Management Program policy required licensed nurses to develop care plans for all residents identified as high-risk and to add them to a special monitoring list. Resident 2 was not added to this fall management program until after the preventable fall occurred - nearly two months after admission.
Additional Issues Identified
Inspectors also documented several related deficiencies in the facility's fall prevention systems:
- The facility failed to implement its own policies requiring care plan development for high-risk residents - Staff were not properly informed about residents' fall risk status - The interdisciplinary team did not review or update fall risk assessments at required intervals - No interventions were documented or implemented despite clear risk factors including severe cognitive impairment, inability to walk, and dependence for all transfers
The Director of Nursing acknowledged to investigators that Resident 2 should have been added to the fall management program immediately upon admission when the initial assessment showed high risk. Multiple staff members, including RN 2 and the MDS Nurse, confirmed that the fall and injury could potentially have been prevented with proper care planning and interventions.
These violations affected multiple residents and demonstrated systematic failures in the facility's approach to fall prevention, risk assessment accuracy, and care plan development - fundamental aspects of nursing home safety protocols that protect vulnerable residents from preventable harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Avenue Healthcare & Wellness Center from 2025-03-28 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.