Arcadia Care On The Hill

facility, and he knows better to ask for help and use his call light.R2's MDS, dated [DATE], documented that his cognition was intact.R2's Physicians order sheet, dated November 2025, documented diagnoses of Type 2 Diabetes Mellitus without complications, Epilepsy and Anxiety Disorder.R2's Care Plan, dated 5/20/2024, documented, Be sure call light is within reach and encourage me to use it for assistance as needed.R2's Medical Chart did not document any Fall Risk Assessment prior to R2's falls on 10/27/2025 and 11/9/2025.On 11/26/25 at 2:10 PM, V14, LPN, stated, Anytime there is a resident fall, I go into (electronic medical record) and go under 'Risk Management' and answer all the questions it has.

Once you answer all of the questions, it determines what steps we take next. I follow it step by step. I complete a fall and incident report and will put what new intervention that I put in place. I would complete the fall risk assessment after each fall.

Once completed the Risk Management will automatically trigger certain forms and follow-ups that will need to be done for the next few days. I know that the call lights are supposed to be within the resident's reach, however, sometimes they unclip it or it falls on the floor.On 11/26/25 at 2:00 PM, V1, Administrator, stated, I expect all staff to follow a resident's fall interventions in order to keep them safe.

I expect the nurses to complete a fall risk assessment upon admission, quarterly, and after any fall the resident has. I expect all staff to keep the resident's call light in reach and to verbalize the placement of that call light to visually impaired residents.The facility's Fall Prevention Program Policy, dated 5/2025, documents in part Purpose: To assure the safety of all residents in the facility, when possible.

The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary.

Quality Assurance Programs will monitor the program to assure ongoing effectiveness.

Guidelines: Use and implementation of professional standards of practice.

Care Plan incorporates: Identification of all risk/issue, addresses each fall, interventions are changed with each fall, as appropriate, and preventive measures.

Standards: A Fall Risk Assessment will be performed by a licensed nurse at the time of admission.

The assessment tool will incorporate current clinical practice guidelines. A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition and after any fall incident.

Safety interventions will be implemented for each resident identified at risk.

Fall/Safety interventions may include but are not limited to: At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device.

The nurse call device will be placed within the resident's reach at all times.

The location of the placement will be verbalized for those residents with visual deficits.

Facility ID: