Country Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement interventions to prevent a fall for one resident (R1) of three residents reviewed for falls in a sample list of three residents.

This failure caused R1 to fall sustaining an acute nasal Fracture and a laceration to (R1's) nose requiring five sutures to close.Findings Include:R1's Care Plan updated 10/14/25 includes the following diagnoses: Osteoarthritis, Heart Disease, Lumbar Disc Displacement, Anxiety, Vertigo, Repeated Falls, Glaucoma, Type II Diabetes, Difficulty in Walking, and Psychotic Disturbance with Hallucinations.R1 Fall Risk assessment dated [DATE] document R1 as being at high risk for falls and having a recent history of falls. R1 has current physician's orders for the following narcotics and psychotropic medications: Haldol (Antipsychotic) one mg (Milligram) every eight hours as needed, Dilaudid (Narcotic) two mg every four hours as needed, and Fentanyl (narcotic) transdermal patch 50mcg/Hr (Microgram/Hour).

Change patch every 72 hours.

All these medications list an increased risk for falls as a side effect in manufacturer's inserts. R1s Fall Incident Report and progress notes dated10/4/25 at 7:10AM document R1 was found on the floor while alone in R1's room.

R1's emergency room report dated 10/4/25 at 9:05AM documents R1 required five sutures to repair the laceration on R1s nose resulting from the fall at the nursing home and sustained an acute nasal bone fracture. On 10/21/25 at 10:41AM, V3 Certified Nurse's Aide (CNA) verified V3 was the first staff to respond to R1 on 10/4/25. V3 stated I got report on 10/4/25 from an agency CNA who told me (R1) had been restless during the night, but she was now asleep in her room. A little later I heard (R1) call out and went right to (R1's) room.

There were no fall mats on the floor.

The bed was not in the low position.

The nightstand was between the wall and the bed on (R1's) right side. R1 was under the bed from the waist down.

The nightstand and the bed were covered in blood. I called and V4, Certified Nurse's Aide (CNA) came into the room with the nurse. We got (R1) out from under the bed and put her on the bed.

The nurse cleaned (R1's) face and found the big cut on her nose. (R1) was then sent out to the emergency room and came back with bruises and stitches. On 10/21/25 at 10:45AM, V4 CNA stated I came to (R1's) room with (V6), Licensed Practical Nurse (LPN) when I heard (V3) calling for help. (R1) is a high fall risk, but the fall mats were not in place, and the bed was not low, because (R1) had her legs and hip all the way under the bed between the wall and the bed.

The nightstand on the side (R1) fell was covered with blood. We helped the nurse clean up (R1) and the nurse sent (R1) out to the hospital to get stiches. R1 was observed on 10/20/25 at 1:35PM lying in her bed.

The bed was not in the lowest position. V2 Director of Nursing verified the bed was not in the lowest position. V2 lowered the bed to its lowest position. V2 verified if the bed had been in the lowest position at the time of the 10/4/25 fall it would not have been possible for R1 to have gotten her lower half under the bed as the space is too small between the bed and the floor.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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