Norridge Gardens

Based on observation, interviews and record review, facility failed to implement fall precautions to prevent falls with injuries.

This applies to 2 out of 3 residents (R2, R3) reviewed for fall precautions.The findings include:1.On 8/19/25 at 10:25 AM, R2 was lying in bed. R2's left arm was in a bandage. R2 was alert with some confusion.

Bed was at average height and not at its lowest position.

There were no landing pads next to the bed. R2's call light was tied to the grab bar and was hanging downwards. R2 searched for her call light and stated she cannot find her call light. R2's table was towards the lower half of her body and she could not reach her cup of water. On 8/19/25 at 10:40 AM V6 (LPN-Licensed Practical Nurse) verified R2's bed was not in the lowest position and her call-light was out of her reach. On 8/19/25 at 11:30 AM V10 (CNA- Certified Nursing Assistant) observed and stated R2's water was out of her reach and bed was not in lowest position. On 8/20/25 at 8:45 AM, R2 was lying in bed. R2's bed was at average height and not at the lowest level. R2's call light was under her upper back. R2 stated she is not able to find her call light and stated the call light should have been where she can reach for it.On 8/20/25 at 10:00 AM, V13 (PTA-Physical Therapy Assistant) and V4 (Director of Rehab) stated R2 need two people to transfer from bed to wheelchair and R2 can move her legs out of the bed, not her upper body. V13 and V4 stated it is recommended for R2 to have her bed in lowest position and have call lights within reach. R2's 6/9/25 fall risk evaluation showed a score of 19 with a scale that showed a score of 10 or higher means at high risk for falls. R2's care-plan dated 7/25/25 showed to ensure R2's personal items and call light were within reach and to use her call light when assistance is needed. R2's care-plan showed R2 had falls in the facility on 11/15/24, 12/21/24, 6/3/25 and 7/5/25. On 8/19/25 at 2:42 PM V3 (Restorative Nurse) stated one of the post fall interventions for R2 was to keep bed at lowest position. On 8/20/25 at 10:10 AM, V5 (NP - Nurse Practitioner) stated R2 had the potential to fall again as R2 does not follow the nursing instructions. V5 stated R2 must have her call light within reach, her bed in the lowest position, and have landing pads to minimize injuries. 2.On 8/20/25 at 9:27 AM, R3 was sitting on her bed with her feet on the floor on the left side of the bed. R3 stated she wanted to use the bathroom and then go to the dining room for breakfast and needed to call for help, but her call light is out of her reach. R3's call light was tied to the grab bar on the right side of the bed and hanging to the floor. V9 (CNA) verified R3's call light was out of her reach.On 8/19/25 at 9:50 AM, V8 (RN-Registered Nurse) and V12 (RN) stated fall precautions include keeping bed at lowest position, having the call light and other personal items near resident, and frequent monitoring/rounding.On 8/19/25 at 10:40 AM V6 (LPN-Licensed Practical Nurse) stated anyone with history of previous falls must have their beds in the lowest position and their call lights within their reach.

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 REPRESENTATIVE'S SIGNATURE

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