Both residents had documented histories of falls and cognitive impairment. One had fallen twice without injury during a recent assessment period and scored 16.0 on a fall risk evaluation, categorizing them as at risk. The other resident also required fall prevention measures according to their care plan.
When inspectors arrived at 1:44 PM on September 16, they found Resident #2 awake and resting in bed. The fall mat was folded up and leaning against furniture in the room, unused. Twenty-six minutes later, inspectors returned to find the mat still propped against the furniture.
The facility's own records showed Resident #2 had experienced their most recent fall on July 29. Their comprehensive care plan specifically called for fall prevention interventions including a fall mat initiated in March and a scoop mattress with defined edges to prevent rolling out of bed, implemented in May.
CNA B told inspectors she knew both residents required fall mats whenever they were in bed. She was unaware Resident #2's mat wasn't in place and theorized that physical therapy staff likely failed to replace it after helping the resident into bed following a therapy session.
"The possible harm to residents from not having care planned fall mats in place was fall with injury," she said.
LVN A, interviewed at 1:51 PM, confirmed both residents required fall mats for fall prevention. She said Resident #2 had been brought to the nurse's station after therapy earlier that day, not directly to his room. A CNA then assisted him to his room and into bed.
She was unaware the fall mat hadn't been implemented. LVN A said she rounded on all residents at least hourly to ensure fall prevention measures were in place, yet missed that the equipment sat unused against the furniture.
"The potential harm to residents from not having care planned fall mats implemented was serious injury," she told inspectors.
The Director of Nursing, interviewed at 3:00 PM, attributed the failure to a temporary agency staff member she had terminated earlier that day due to performance issues. She said staff had been made aware of the surveyor's observation about Resident #2's unused fall mat only after inspectors pointed it out.
Both residents showed significant cognitive impairment. Resident #2 scored 12 on a cognitive assessment, indicating moderately impaired cognition, and was unable to participate in an interview due to cognitive decline. Their care plan addressed physical and verbal aggression, actual falls related to poor balance and poor communication, and comprehensive safety awareness issues with an unsteady gait.
The facility's comprehensive care plan for Resident #2 specifically documented "actual falls" as an ongoing concern, yet the basic intervention of placing a fall mat remained unimplemented during the inspection.
The Director of Nursing told inspectors her expectation was that all staff, including facility employees, hospice workers, and agency personnel, would implement care-planned fall prevention measures at all times. She said she ensured any staff providing resident care had access to the electronic medical record system, including the Cardex which provided a synopsis of required interventions like fall mats.
The facility's own accident policy, printed during the inspection, stated that "individualized, person-centered interventions will be implemented, including adequate supervision and assistive devices, to reduce risks related to hazards in the environment."
Yet for at least 26 minutes during the federal inspection, two residents with documented fall risks and cognitive impairment lay in their beds without the basic fall prevention equipment their care plans required. The mats designed to cushion potential falls instead sat folded against furniture, serving no protective purpose.
CNA B had correctly identified that Resident #1's fall mat had also been moved earlier in the day by another staff member providing care, suggesting the problem extended beyond a single terminated agency worker. The pattern indicated systemic failure to maintain fall prevention measures that both the licensed nurse and certified nursing assistant acknowledged could result in serious injury.
The inspection revealed a gap between the facility's written policies and actual implementation of basic safety measures for vulnerable residents who had already demonstrated their propensity to fall.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Hills Health and Rehabilitation Center from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
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