Sunset Park Healthcare

stood up and landed on right side of her face and on both knees.

Discoloration observed on left and

in the shower room. CNA 1 stated, I transferred Resident 1 from bed to shower chair on my own, she

CNA 1 stated, during shower, Resident 1 suddenly stood up on her own from the shower chair and then she fell on both her knees and ended up on her cheeks. CNA 1 stated that Resident 1 was unable to communicate, and he (CNA 1) thought Resident 1 was unable to ambulate on her own. CNA 1 stated that after Resident 1 fell from the shower chair, he called for help and picked up Resident 1 from the floor and put her back on the shower chair. CNA 1 stated, I knew I shouldn't have done that, but I picker her up right away. CNA 1 stated that the licensed nurses must assess residents first if they fell or found them on the floor before moving the resident. CNA 1 stated that he was not supposed to lift the resident after a fall, the licensed nurse must assess resident first, but he didn't want to leave her on the floor.

During an interview with Director of Rehabilitation (DOR) on 2/26/2026 at 1:05 p.m., DOR stated, Resident 1 has history of falls and required two-person assist with transfer. DOR stated that Resident 1's dynamic balance is very poor and has cognitive issues due to her diagnoses. DOR stated that it does not matter how big or small a resident is, if resident requires two-person staff assist when transferring, staff need to follow the plan of care because an accident can happen.During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/26/2026 at 1:32 p.m., LVN 1 stated, she was the charge nurse for Resident 1 on 2/16/2026 when she was called by CNA 1 for help in the shower room. LVN 1 stated, she saw Resident 1 on the shower chair after CNA 1 reported that Resident 1 fell from the shower chair. LVN 1 stated, she did not witness and she did not evaluate Resident 1 on the floor after she fell.

During an interview with Director of Nursing (DON) on 2/26/2026 at 1:55 p.m., DON stated, if a resident was found on the floor, CNAs must stay with the resident until help arrives and resident must be evaluated by a licensed nurse before they move the resident. DON stated, if a resident had an accident such as fall and CNAs move the resident without being evaluated by a licensed nurse first, they can create more problems, because they won't know if resident had a fracture, etc. DON stated, it does not matter if resident is light and petite, staff must check if resident have the ability to bear weight, assess their cognition first and staff must not lift a resident on their own just because they think they can do it on their own.During a review of the facility's P&P titled, Falls - Clinical Protocol, reviewed on 11/2025, the P&P indicated that, The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, and observations of the events, etc.During a review of the facility's P&P titled, Falls and Fall Risk, Managing, reviewed on 5/2025, the P&P indicated that, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Environmental factions that contribute to the risk of falls include: wet floors; poor lighting; incorrect bed height or width; obstacle in the footpath; improperly fitted or maintained wheelchairs; and footwear that is unsafe or absent.

The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.