Park Avenue Healthcare: Fall Prevention Failures - CA
POMONA, CA - Federal inspectors found Park Avenue Healthcare & Wellness Center failed to implement critical fall prevention measures for a cognitively impaired resident who was identified as high-risk upon admission, resulting in a preventable fall and injury two months later.
Systematic Failure in Fall Prevention Protocols
The March 28, 2025 inspection revealed the facility admitted a resident on January 11, 2025, with documented lack of coordination and osteoarthritis affecting both the right hip and knee. The resident's initial fall risk assessment that same day assigned a score of 14, significantly above the threshold of 10 that triggers high-risk classification.
Despite this clear indicator, nursing staff failed to develop the required care plan for fall prevention. The facility's own policies mandate immediate care plan creation when residents score as high-risk, yet no such plan existed for this resident during the entire two-month period before the incident.
The resident's condition presented multiple risk factors beyond the initial assessment score. Medical records showed severely impaired cognition and complete dependence on staff for essential activities including toileting, bathing, dressing, and all bed mobility tasks. The resident required substantial assistance even for eating and personal hygiene. Walking assessments were not even attempted due to medical and safety concerns.
Critical Incident and Its Preventability
On March 8, 2025, at 4:15 PM, a certified nursing assistant discovered the resident on the floor beside the bed after hearing calls for help. The resident was found lying on their back with a skin tear to the left elbow. The CNA who discovered the resident stated during interviews that they had no knowledge the resident was at high risk for falls and did not know how frequently to check on them.
This lack of awareness stemmed directly from the absence of a care plan. The MDS Nurse explained to inspectors that without a care plan, "staff did not have a road map for what interventions needed to be done for the resident." Multiple staff members, including registered nurses and the Director of Nursing, confirmed that the fall and injury could potentially have been prevented if proper protocols had been followed.
Medical Implications of Protocol Failures
When facilities fail to implement fall prevention measures for high-risk residents, particularly those with cognitive impairment, the consequences extend beyond immediate physical injuries. Skin tears in elderly residents with compromised mobility can lead to infection risks, prolonged healing times, and decreased quality of life. For residents with severe cognitive impairment who cannot reliably communicate pain or discomfort, unaddressed injuries may worsen before detection.
The combination of osteoarthritis, lack of coordination, and severe cognitive impairment creates a particularly vulnerable profile. These residents cannot recognize their own limitations or call for assistance before attempting unsafe movements. Standard fall prevention protocols exist specifically to protect these vulnerable individuals through increased monitoring, bed positioning strategies, and environmental modifications.
Industry Standards and Required Interventions
Federal regulations and industry standards require comprehensive fall management programs that begin immediately upon identifying risk factors. Park Avenue's own Fall Management Program policy, last revised March 13, 2021, clearly states that facilities must "implement a fall management program" and that licensed nurses must "complete a fall risk assessment" with documented interventions on the care plan when risk factors are identified.
The facility maintains a fall management program list for high-risk residents requiring increased monitoring frequency. According to the Director of Nursing, residents on this list receive more frequent checks to prevent falls and recurrences. However, this resident was not added to the monitoring list until after the March 8 fall - two months after the initial high-risk assessment.
The facility's Comprehensive Person-Centered Care Planning policy requires care plan development within seven days of assessment completion. This timeline was not met, leaving the resident without documented interventions for nearly two months. The interdisciplinary team should have initiated, reviewed, and updated fall risk status and care planning at multiple required intervals, including upon admission and quarterly reviews.
Regulatory Findings and Facility Response
Inspectors cited the facility under federal regulation F689 for failing to ensure the resident area was free from accident hazards and for not providing adequate supervision to prevent accidents. The deficiency was categorized as causing minimal harm or potential for actual harm, affecting few residents.
The investigation revealed two specific failures: the facility did not ensure licensed nurses developed and implemented a care plan with fall prevention interventions after determining high fall risk, and failed to include the resident in the fall management program when initially assessed. These systematic failures in following established protocols directly contributed to the preventable fall and injury on March 8, 2025.
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.
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