Davis Health And Wellness Center At Cambridge Vill

Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #2 had severe cognitive impairment and required partial to moderate assistance for transfers. Resident #2 was coded for a fall prior to admission and one fall without injury since admission to the facility.

The MDS admission assessment further noted the care area assessment (CAA) for falls was triggered for a care plan to be initiated.Review of Resident #2's care plan initiated on 9/17/25 revealed no care plan was in place for fall risk.The nursing progress note dated 9/18/25 at 8:04 am revealed Resident #2 was found on the floor in room with no apparent injury.The nursing progress note dated 10/02/25 at 3:30 pm revealed Resident #2 had a witnessed fall with no injury noted.The nursing progress note dated 10/03/25 at 7:00 pm revealed Resident #2 had a witnessed fall in room with no injury noted.A telephone interview was conducted with the MDS Nurse on 10/08/25 at 12:26 pm who confirmed Resident #2 did not have a care plan for fall risk in place.

She stated she would normally have developed the fall risk care plan when she completed the MDS and care area assessment, but she must have missed it. An interview was conducted with the Interim Director of Nursing (DON) on 10/08/25 at 12:21 pm, who revealed the IDT team had a weekly meeting at which time each resident was discussed and the goal was to ensure that the care plan reflected what was discussed for each resident.

The Interim DON stated the care plan should have been updated during the weekly IDT meeting by the MDS Nurse, but she stated the MDS Nurse was not present for the weekly IDT meetings to ensure the care plans reflected the needs of the resident.

During an interview on 10/08/25 at 1:00 pm with the Administrator she revealed the MDS Nurse was responsible to develop the fall risk care plan for Resident #2.

Facility ID: