Sunset Rehabilitation And Health Care

not informed of the new interventions (frequent checks) put into place post R1's fall.2. R3 was admitted on [DATE] with diagnoses of Schizophrenia, Diabetes Mellitus with Neuropathy, Urine Retention, Congestive Heart Failure, Osteoarthritis, COPD, Depression, Anxiety Disorder, and Traumatic Brain Injury.The current care plan documents R3 has limited physical mobility related to weakness and deconditioning. R3 can walk with a walker as tolerated with stand by assistance; behavior problem of fidgeting; resistive to Activities of Daily Living (ADL) cares; monitor for attention seeking behaviors and putting self on the floor.The Fall log documents R3 sustained a fall on 10/22/25 with hospitalization.R3's Progress Note documents R3 was hospitalized on [DATE] and returned to the facility on [DATE].On 10/28/25 at 3:30 PM, V23 (Certified Nurse Aide/CNA) stated on 10/24/25 while trying to take R3 to the shower, R3 went down on both knees. V23 stated R3 likes to put himself on the floor and I don't think he had an injury, but it wasn't assessed by the nurse (V3) who also witnessed the change of plane.10/28/25 at 3:45 PM, V24 (Certified Nurse Aide) stated R3 fell and hit hard in the dining room on 10/24/25 between 4:00 PM-5:00 PM. V23 and V24 did the vital signs and assessed R3 because V3 (Licensed Practical Nurse) left and never came back.On 10/30/25 at 11:00 AM, V3 (LPN) stated R3 did have a change of plane in the dining room on 10/24/25 and a post fall assessment was not conducted, nor was a Risk Management Incident report initiated, the physician nor the family were notified and follow assessments were not conducted because she considered the change of plane to be intentional related to behaviors and not a fall. V3 stated she did not document R3's behaviors because behaviors do not need to be documented. V3 stated she was aware that R3 had returned from the hospital the same day and was actively undergoing treatment for Sepsis (a life-threatening medical emergency caused by your body's overwhelming response to an infection).On 10/29/25 at 9:11 AM, V5 (Licensed Practical Nurse/LPN) stated R3 is her brother and was not notified that a change of plane occurred on 10/24/25.10/30/25 at 8:53 AM, V2 (Director of Nursing/DON) stated she was unaware R3 had a change of plane on 10/242/5. V2 stated R3 can ambulate independently although it's not encouraged and will sit on the floor when he wants to. V2 stated after interviewing V3, V3 felt R3's change of plane was a behavior issue and not a fall.On 10/30/25 at 1:45 PM, V1 (Administrator) agreed a thorough investigation had not been conducted after R1's fall to determine the root cause. V1 stated R3's change of plane should have been documented and reported so an investigation could have been conducted to assist in identifying the root cause.

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