Casa De Las Campanas

During a review of Resident 1's Progress Notes, the Fall Note dated 8/1/25 at 10:19 A.M. indicated, .found resident on the floor, left side of the bed, head slightly under the bed.

When asked, [Resident 1] stated he wanted to reach his wheelchair to go to the bathroom and hit his head on the side of the bed.

Assessment done, skin tear on the back of the head slightly bleeding, and pain with level of 7 on the right hip.

The Progress Note indicated Resident 1 was transported to the hospital via 911, per physician's order.On 8/22/25 at 9:50 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated she was the supervising nurse on duty when Resident 1 sustained a fall on 8/1/25. LN 1 stated she assessed Resident 1 while he was still on the floor. LN 1 stated Resident 1's call light was not activated when she entered his room. LN 1 stated resident was sent to the hospital immediately, and returned the same day. LN 1 stated the new interventions initiated by the facility to prevent Resident 1 from sustaining any additional falls include, .we reiterated that he needs to press the call light. If he's in bed it needs to be in the lowest position, and fall mats. LN 1 stated she does not remember if the interventions were implemented when Resident 1 returned to the facility.On 8/22/25 at 10:23 A.M., a joint interview and record review was conducted with the Interim Director of Nursing (IDON).

The IDON stated there were no new interventions documented in Resident 1's record when he returned from the hospital.

The IDON stated, I would have done something like move him closer to the nurses station.

The IDON stated Resident 1's care plan should have been accelerated to reflect the fall.

The IDON stated it was important to prevent future falls, to try to avoid injury and cause harm to the resident.On 8/22/25 the facility's policy was reviewed.

The facility's policy titled Falls- Clinical Protocol revised March 2018, the policy indicated, The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.

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.

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