River City Post Acute

prevent accidents.

observation, interview, and record review, the facility failed to provide adequate supervision during

high risk for falls.This failure resulted in Resident 1's fall.

Findings:A review of the admission Record indicated Resident 1 was admitted [DATE] with diagnoses including paroxysmal atrial fibrillation (recurring episodes of irregular and fast heartbeat) and major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) indicated a Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify memory, orientation, and judgement status) which further indicated Resident 1 had moderate cognitive impairment with a score of 9 out of 15 (a resident with a BIM score of 13-15 is considered to be cognitively intact). A review of Resident 1's care plan revised 4/7/25 indicated Resident 1 was at high risk for falls related to attempted unsafe self-transfer, poor coordination & weakness of lower extremities.

The interventions included to anticipate and meet the resident's needs.During a concurrent observation and interview on 5/29/26 starting at 10:22 a.m., Resident 1 was awake and lying in bed. Resident 1 was asked if she had any incidence of fall, Resident 1 stated she had a fall a month ago in the shower. Resident 1 was further asked if she had injuries from the fall, Resident 1 stated she had pain all over her body.During a concurrent interview and record review on 5/29/26 at 2:01 p.m. with the Director of Nursing (DON), Resident 1's clinical record was reviewed.

The DON stated Resident 1 had a fall on 1/31/26.

The Interdisciplinary note (IDT) dated 2/2/26 indicated during shower time [Resident 1] was found lying down in shower room on the tiles at 10:30 a.m. [Resident 1] stated she slipped down from the shower chair.

The IDT note further indicated, [CNA 1] left to go get the hall nurse and when she came back [Resident 1] was on the floor . [CNA 1] educated on not to leave resident lone [sic] due to risk for fall.

During an interview on 5/29/26 at 2:11 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she was with Resident 1 when resident had a fall in the shower. CNA 1 further stated Resident 1 would take a shower for 30 minutes or longer. CNA 1 added she told Resident 1 she needed to call the nurse since resident refused to go out of the shower room. CNA 1 opened the shower door, CNA 1 talked to the nurse with the door open inside the shower room, and a few seconds later while CNA 1 was talking to the nurse, Resident 1 was on the floor.

During an interview on 5/29/26 at 3:37 p.m. with the DON, the DON stated CNA cannot leave a resident in the shower room unattended.During a review of the facility's policy and procedure revised July 2017 and titled, Safety and Supervision of Residents indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety.

The type and frequency of resident supervision is determined by the individual resident's assessed needs .

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE