Resident #2 had a documented history of falls and was identified as needing fall prevention interventions. The facility's care plan specified "place fall mat beside bed on floor when resident is in bed" but failed to indicate whether mats should go on the left side, right side, or both sides.
On June 17, 2025, the resident fell from bed again.
When inspectors interviewed the Director of Nursing on August 27, she could not explain the care plan's requirements. The DON stated that the intervention meant placing the fall mat "on the side of the bed that the resident was falling to previously."
But she couldn't identify which side that was.
The DON reviewed the clinical record for Resident #2 during the interview and admitted she "could not state which side of the bed the resident was falling to prior to her fall on June 17, 2025."
She acknowledged the care plan provided no specificity. It "did not specify if the resident was supposed to have a fall mat on the left side, the right side, or both sides of the bed."
Only after inspectors pressed the issue did the DON conclude that "for Resident #2, a fall mat should have been on both sides of the bed."
The confusion extended beyond this single case. The DON explained that interventions are supposedly discussed in morning clinical meetings to determine the best approaches for residents. Staff can access care plans through the electronic medical record to see which interventions apply to each resident.
Yet the system failed to provide clear direction for a resident with an established fall pattern.
The facility's own policy, revised in January 2024, requires comprehensive person-centered care plans for each resident. These plans must include "measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs."
The policy states that each resident's plan will "describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being."
Federal regulations mandate that nursing homes develop and implement comprehensive care plans with measurable objectives and timeframes. The intent is to ensure each resident receives person-centered care that addresses their medical, physical, mental and psychosocial needs.
For Resident #2, that system broke down at a fundamental level. Despite having a documented fall risk and previous incidents, the care plan remained vague enough that nursing leadership couldn't determine basic safety requirements.
The DON's acknowledgment during the inspection interview revealed the depth of the problem. She stated that fall risk assessments are completed to identify at-risk residents, and interventions are discussed in morning meetings. Yet when confronted with a specific resident's needs, she couldn't interpret the facility's own care plan.
The June 17 fall occurred despite the resident being identified as high-risk and having interventions supposedly in place. The ambiguous care plan language left staff without clear guidance on protective measures.
Inspectors found that the interdisciplinary team is supposed to revise care plans as needed, including when dictated by changes in resident condition or to address changes in behavior and care. The policy requires updates at regular intervals and whenever appropriate or necessary.
But for Resident #2, the care plan remained unclear even after the documented fall history.
The case illustrates broader questions about care plan implementation at Prescott Village. If nursing leadership cannot interpret basic safety interventions for high-risk residents, the facility's entire care planning system may be compromised.
The DON's interview responses suggest systemic confusion about translating care plan requirements into actual protective measures. Her inability to identify which side of the bed had been problematic for the resident, despite reviewing clinical records, points to inadequate documentation or poor communication between shifts.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. But for Resident #2, the consequences were direct and physical.
The resident's fall on June 17 occurred in a facility where staff supposedly monitor fall risks and implement targeted interventions. Instead, nursing leadership couldn't determine the most basic requirement for preventing injury: where to place protective mats around a bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prescott Village Nursing & Rehabilitation from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
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