Crystal Creek Post-acute

DON acknowledged that Resident 2's injury was preventable.

During an interview on 1/29/26, at 4:06

install bed rails on a resident's bed, the staff notified Maintenance.

The MD further stated that the

risk for falls, he borrowed the bed rails from a sister facility.

The MD confirmed that the staff notified Maintenance of an order to place bed rails on Resident 2's bed on 1/26/26, so he reached out to a sister facility to get bed rails for Resident 2, and it took a day to get the bed rails.

The MD further confirmed that the bed rails were installed on Resident 2's bed on 1/28/26.

The MD stated that lots of residents requested bed rails for their beds and the facility did not have an issue with being low on supplies of bed rails.During a phone interview on 1/30/26, at 3:02 p.m., with Resident 2's treating physician at the facility (Physician 1), Physician 1 confirmed that he was Resident 2's treating physician at the facility.

Physician 1 stated that he was not aware that only one CNA provided incontinent care to Resident 2 on the day when Resident 2 fell (1/23/26).

Physician 1 further stated the facility CNAs needed training.

Physician 1 stated that there should have been two CNAs providing incontinent care to Resident 2.A review of a facility P&P titled, Proper Use of Bed Rails, revised December 2016, indicated, .Purpose.The purpose of these guidelines are [sp] to ensure the safe use of bed rails as resident mobility aids.General Guidelines.2.

Bed rails are only permissible if they are used.to assist with mobility and transfer of residents.3. An assessment will be made to determine.reason for using bed rails.9.

Consent for bed rail use will be obtained from the resident.after presenting potential benefits and risks.A review of a facility P&P titled, Fall Risk Assessment, revised March 2018, indicated, .Policy Statement.The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.Policy Interpretation and Implementation.1.

Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time.2.

The nursing staff will ask the resident and/or his/her family about any history of the resident falling.7.

The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including.mobility.activities of daily living (ADL) capabilities.continence.9.

The staff and attending physician will collaborate to identify and address modifiable risk factors and interventions.A review of the facility P&P titled, Safe Lifting and Movement of Residents, revised July 2017, indicated, .1.

Resident safety, dignity, comfort and medical condition will be incorporated into decisions regarding the safe lifting and moving of residents .