Thrive Of Lake County

prevent accidents.

to 1 of 3 residents (R1) reviewed for falls in the sample of 5.The findings include:R1's face sheet

abnormality of gait and mobility. R1's current care plan shows she has a cognitive deficit, is at high risk for falls, incontinent of bowel and bladder, and requires extensive assistance for bed mobility.R1's Fall Risk Evaluation completed on 12/9/25 shows she is at high risk for falls.A fall incident report completed by V3 (Licensed Practical Nurse/LPN) on 3/15/26 at 7:00 PM states, while nurse aide (V4) was changing resident, she slid off the side of the bed.

Resident was transferred to a local hospital for further evaluation.R1's Electronic Medical Record shows R1 is still at a local community hospital. R1's X-ray report of her left foot, from a local community hospital, shows the following, Osteopenia and Chronic Arthritic changes present involving the interphalangeal joints of the digits.

This is most evident at the second PIP joint with at least partial bony fusion present.

Impression: Fracture deformity distal medial aspect second proximal phalanx of indeterminate age but cannot exclude acute injury.On 3/25/26 at 10:50 AM, V3 (LPN) said when (R1) fell a (Certified Nursing Assistant/CNA (V4)) came and got me and said she had been changing (R1) and her sheets were lumpy and she had to pull on them and (R1) ended up falling out of bed on the right side facing the door. I did a full assessment and (R1) had no complaints of pain and said she was fine, but per protocol and because (R1's) daughter wanted, we sent (R1) to the hospital for evaluation.

Generally, we only need 1 staff member for turning and repositioning (R1). (R1) had chronic feet/toe pain and had lidocaine patches on both feet prior to her fall. On 3/25/26 at 1:05 PM, V4 (CNA) said, I was the only one in the room and I was changing (R1's) incontinent brief. I was beside the bed on her left side, and her brief was partially undone; I told her to roll over to the right side and grab the bar, and she rolled off the bed. I had the bed at elevated height to work with her and turn her. I didn't have time to grab her.

She fell off to the right side of her bed. It could be she was too far over on the bed, or she turned so quickly that she fell off the bed. (R1) said she was fine. On 3/25/26 at 1:09 PM, V7 (Restorative Nurse) said, When staff are turning residents in bed, they should be standing on the side of the bed they are turning the resident too not behind the resident to be a barrier to help prevent rolling off the bed. V7 said in this case, V4 should have walked around the bed and been on the right side of R1 when R1 was turning over.On 3/25/26 at 1:51 PM, V8 (R1's daughter) said, I was called by the nurse (V3) that a CNA had been changing mom, and the CNA pulled the sheet and she rolled off the bed.

The CNA should have been standing in from of her not behind her and she would not have fallen.

Mom is still at the hospital because of pneumonia and pain control. On 3/26/26 at 12:40 PM, V9 (Physician) said she was aware of R1 being rolled out of bed, however, based on the information, she cannot definitely say that the left toe fracture happened during this fall.

The facility provided Fall Prevention policy, dated November 2020, states, Each resident residing at this facility will be provided services and care that ensures that the resident's environment remains as free from accident hazards as possible.Hospital records for R1 were requested but not received prior to the exit of the survey.

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.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE