Center At Lincoln, Llc, The

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #1's room. LPN #2 said the resident had pain in her right knee and ankle after her fall and was given her scheduled Tylenol. LPN #2 said the results of the Xray confirmed a new fracture to the resident's left femur and she was sent out to the hospital. LPN #1 said she thought the resident was trying to get out of the shower by herself and that was the reason she fell. CNA #4 was interviewed on 11/5/25 at 1:39 p.m.

CNA #4 said residents at risk of falling typically received frequent checks and resided in rooms that were closer to the nurses' station. She said if a resident was at risk for falls, their doors and windows that opened to the hallway were left open, unless the staff were providing care. CNA #4 said the residents' abilities were assessed on admission by physical therapy and occupational therapy. She said the residents' needs were written on the communication board in the resident's rooms. CNA #4 said for residents who were alert and oriented but were at a fall risk, they relied heavily on the resident to communicate their needs. CNA #4 said

they let the residents do as much as they were capable of doing without intruding on their privacy.The director of nursing (DON), the nursing home administrator (NHA) and the regional nurse consultant were interviewed together on 11/5/25 at 3:51 p.m. The regional nurse consultant said the fall care plan for Resident #1 was created on 10/8/25. The DON said Resident #1 was evaluated on admission for individual fall interventions, and was at an increased risk for falls. The DON said the resident had a yellow fall band, a Call Don't Fall sign and required observation checks in the task section for the nursing staff. The DON said

after her fall, the facility had an IDT meeting to discuss the resident's needs. The NHA said Resident #1 was impulsive and confused. The NHA said Resident #1 was admitted in an observation room near the nurses' station with fall interventions including Call Don't Fall signage and the four- P's were added after fall. The DON explained that the four - P's were frequent assessments of needs to keep the resident content and decrease their fall risk. The DON said the fall happened because CNA #2 left the resident during her shower to retrieve a towel. The DON said CNA #2 should have called another staff member for the towel instead of leaving the resident by herself because she was impulsive and confused. The DON said the resident had reached her maximum functional level for discharge but was not independent with ADLs and still required assistance. The DON said the facility educated CNA #2 on fall interventions on the spot to call for instructions when assisting residents with showers. The DON said they had not done education specifically regarding the incident for the facility staff but planned to do so as soon as possible. The NHA said they had done their annual nursing staff training since the incident, included correct ADL and transfer techniques. CNA #2 was interviewed on 11/5/25 at 4:46 p.m. CNA #2 said she was assigned to assist Resident #1 with her shower the day of the fall (10/24/25). CNA #2 said she left the resident alone to get some towels and socks. She said when she left the room, Resident #1 fell out of the shower chair. CNA #2 said she knew she should not have left the resident alone in the shower. She said she could have called another staff member for supplies instead of leaving the resident to get supplies herself. CNA #2 said this was the first time she worked with the resident and she thought it was okay to leave her alone for a few minutes because the resident was getting discharged that day. CNA #2 said every resident in the facility was at a fall risk because it was a rehabilitation facility. She said she remembered the resident having on a yellow wrist band indicating she was a fall risk.

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