The Waterview Shores Llc

all staff education on following care plan interventions for falls and alerting management if you are not seeing an intervention anymore that had been previously used.On 9/11/25 at 9:44 a.m., NA-D stated R1 was at risk for falls and staff were directed to keep him near nurse's station if he was restless or active, and if R1 was in bed he would require a low bed, fall mat which he has had quite a while, and a touch pad call light underneath him too.

Further, NA-D stated she was aware R1 had a fall and sustained a rib injury.

Following R1's fall, NA-D stated the DON, and administrator called her and provided education related to resident specific fall interventions and what to do if staff notice an intervention was missing.On 9/11/25 at 11:51 a.m., interim director of nursing (DON) stated R1's cognition was impaired and R1 required staff assistance with all ADLs. DON stated R1 was at risk for falls and interventions to prevent falls included: toileting every 2-3 hours, concave mattress, room and floor clean, floor mat next to bed, two signs posted in his room to use call light for assistance, and soft touch call light to the right hip.

Further, DON stated R1 had a fall on 6/19/25, with no injuries, and confirmed interdisciplinary team (IDT) determined a fall mat at R1's bedside was an appropriate intervention; however, DON confirmed the floor mat was not added to R1's care plan until 8/28/25. DON was unsure why the intervention was not added to R1's care plan immediately, but stated DON added the intervention as soon as we realized it was not identified in R1's care plan at the time of his fall on 8/28/25. DON stated R1 had another fall that occurred on 8/24/25, with no injuries, and IDT determined an appropriate intervention would be R1 to use a soft touch call light; however, R1's care plan was not updated until 8/29/25. DON stated all staff would not have been aware of those two interventions, the floor mat and the call light, at the time of R1's fall on 8/28/25, since they were not identified in R1's care plan and DON was unsure if the staff's care guide sheets were revised to include those at the time. DON stated following a fall, the floor nurse would notify the DON, and the DON and nurse would discuss root cause and determine an immediate intervention together.

The DON stated then the IDT would meet every morning on business days and go through the risk management/incident reports, which the IDT then would determine an appropriate intervention, and DON would revise the care plan as well as inform the staff verbally to pass on in report and add to the care sheets the floor staff utilize.

Review of facility policy titled Care Planning revised 11/24, indicated the care plan would be used in developing the resident's daily care routines and utilized by staff personnel for the purposes of providing care or services to the resident.

The plan of care would be utilized to provide care to the resident.

The care plan was to be modified and updated as the condition and care needs of the resident changes.Review of facility policy titled Fall Prevention and Management revised 2/24, indicate following a fall nursing staff would complete an incident review and analysis.

The IDT would review falls daily at morning meeting.

When a resident falls, the following information should be recorded in the resident's medical record: interventions, first aid, or treatment administered, and appropriate interventions taken to prevent future falls.

Further, follow up included care plans would be updated to reflect fall interventions.The facility implemented the following corrective action on 8/29/25 and this is being issued in past noncompliance. -R1's care plan was updated with current fall interventions,-All staff were educated on revisions and following care plans, if staff had questions or clarifications regarding interventions reach out to the floor nurse or DON-Audits weekly to ensure IDT interventions have been implemented and are in care plan-IDT process change to double check the intervention was added to the care plan and the care guide sheets prior to closing the risk management/incident report

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