Three Springs Sr Living & Rhab

F 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation.

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

down on the ground. Assisted resident to back and large bruise and swelling noted above right eye.

Resident alert and able to answer questions appropriately. Resident c/o (complained of) pain to right hip area. This nurse contacted (Physician) and received order to send to (Hospital) for evaluation. EMS (emergency Medical Service) services contact and arrived shortly. Resident transferred to stretcher without incident and transported to hospital. Resident R3's Hospital Records dated 8/28/2025 at 12:50 PM, documents, Patient sent from (Facility), reported she fell out of her wheelchair hitting her forehead. Large purple hematoma noted above right eyebrow. History of stroke with right side weakness aphasia. The patient spilled forward out of the wheelchair and struck her forehead, baseball size swelling and ecchymosis over

the forehead. On 8/28/2025 at 2:33 PM, Resident R3 was sitting outside and has an abrasion to the front of her head

in the middle of her forehead approximately 6 millimeters in length and 4 millimeters in width , a black eye with a darken circle area is present on her entire left eye with a small blackish area under part of her eye on

the right side, only 1/4 of the eye is covered in a black streak. On 8/28/2025 at 3:45 PM, V8 (Licensed Practical Nurse/LPN) stated (V15 Corporate) came and got me because (Resident R3) is on my hall. She told me (Resident R3) had fallen outside. (Resident R3) is hard to understand and she does moan out loud, really loud when she needs something because she can't communicate very well. I think (V12 LPN) took her outside. I am not sure why she did not stay with her. (Resident R3) likes to go outside and we have several residents that like to go outside but they are more alert than (Resident R3). We are supposed to stay with (Resident R3) when she is outside. I just got call from the hospital. I am not aware of her having any previous falls. She has never had behaviors and/or threw herself on the ground that I am aware of. On 8/28/2025 at 3:53 PM, V12 (LPN) stated, (Resident R3) cannot walk on her own and she uses a wheelchair. You have to really pay attention to (Resident R3) to know what she wants. (Resident R3) moans a lot when she wants something. She had a stroke. She just recently lost her husband;

they were roommates here together. (Resident R3) was in the dining room today, and she was wanting her cigarettes, and she only had a small cigarette left so I took her outside. She likes to go outside. She only had a part of a cigarette and after she finished, (Resident R3) did not want to come back in. (Resident R3) has never thrown herself on the floor before, and I did not lock her wheelchair. I did not bring her back in because (Resident R3) did not want to come back. I am not sure if she needed supervision or if she could stay outside unsupervised. I don't know. I know she does need supervision for the cigarettes, but I did not think about it for being outside because she loves to go outside. The Facility Fall Policy with a revision date of March 2018 documents, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to try to prevent the resident from falling and try to minimize complications from falling. The Facility Smoking Policy with a revision date of July 2017 documents, Any resident with restricted privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times when smoking.

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