North Park Nursing Center
NORTH PARK NURSING CENTER in EVANSVILLE, IN — inspection on December 23, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
risk assessment dated [DATE] indicated Resident D was at a high risk for falls.Resident D's most recent Significant Change MDS assessment dated [DATE], indicated the resident had moderate cognitive impairment, used a wheelchair for mobility, was dependent for mobility and transfers, and had two or more falls with one with injury since the previous assessment.
Resident D's care plan included, but was not limited to, the resident at risk for falls due to a history of one ormore falls within the previous 6 months, age greater than or equal to 80, incontinence, oxygen use, takes one or more high fall risk drugs, requires assistance or supervision for mobility, transfer, has altered awareness of immediate physical environment, lack of understanding of one's physical and cognitive limitations and she is impulsive.
The resident often refuses to lie down after dinner (started 5/21/23 and last reviewed/revised 12/22/25).
Interventions included but were not limited to, if the resident declines to go to bed after dinner, provide a sensory activity or a busy box within staff's eyesight (started 11/26/25).
Resident D's nurse progress notes included, but were not limited to:11/25/25 at 8:45 P.M. - Staff heard the resident yelling out from the activity area.
Upon arrival, the resident was observed to be lying on the right side in front of the wheelchair.
The resident could not explain how fall occurred. 11/26/25 at 8:33 P.M. - IDT note - Determined root cause of fall: Resident initially refused to be placed into bed after dinner, then attempted to transfer self.
Intervention put in place to address root cause of fall: If the resident declines to go to bed after dinner, provide a sensory activity or a busy box within staff eyesight.11/28/25 at 7:24 P.M. - CNA reported to the nurse that resident was found seated on the floor in another resident's room.Resident C Fall Event for the fall that occurred on 11/28/25 at 7:24 P.M., indicated the fall was unwitnessed. On 12/23/25 at 12:45 P.M., the Facility Administrator supplied a facility policy titled Fall Management Policy, dated 6/2025.
The policy included, It is the policy of [company name] to ensure residents residing within the community have adequate assistance to prevent injury related to falls .
Communities will implement resident-centered fall prevention plans for each resident at risk for falls or who have a history of falls within the previous 6 months . 6.
All falls will be discussed by the interdisciplinary team at the next clinical meeting after the fall to determine the root cause and other interventions to prevent future falls . c.
The care plan will be reviewed and updated as necessary .This citation relates to intake
- 3.1-45(a)(1)
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