Prestige Gardens Rehabilitation And Nursing Center

prevent accidents.

observation, record review, staff interview, and facility policy review, the facility failed to timely

affected one (Resident #14) out of three residents reviewed for falls.

The facility census was 63.Findings Include:

Review of the medical record for Resident #14 revealed an admission date of 08/23/24.

Diagnoses included Huntington's disease, hypothyroidism, constipation, and dementia.

Review of the fall risk assessment dated [DATE] revealed the resident was at risk for falls.

Review of the plan of care dated 08/26/24 revealed the resident was at risk for falls due to increased need for assistance with bed mobility and transfers, Huntington's disease, overactive bladder, and history of falls.

Interventions included ensuring the call light was within reach, use of bolsters to the left side and bottom of the bed, dycem to the wheelchair, ensuring the resident was sitting fully back in the wheelchair prior to transfers, use of a floor mat to the left side of the bed, maintaining a low bed, use of nonskid footwear, supervision while in the bathroom, and staff to remain with the resident while in the bathroom.Observation on 04/28/26 at 2:18 P.M. revealed Resident #14 began to shake and fell out of bed onto a floor mat, onto her back.

The bed was in the low position.

Staff did not immediately respond until this surveyor alerted staff.

Two staff members then assisted the resident back into bed with a two person assist.

The resident was not immediately assessed when found on the floor or when she was back in bed, and vital signs were not obtained.

Interview on 04/28/26 at 2:58 P.M., Licensed Practical Nurse (LPN) #58 stated that the resident had Huntington's disease and had increased shaking over the past week. He stated he obtained assistance and completed a two person assist to return the resident to bed. He stated that no vital signs were taken immediately after the fall and at the time of the interview, had still not been completed. He stated an as needed (PRN) pain medication was administered after the fall but had been requested prior to the fall. He stated the resident had a care plan related to behaviors and a floor mat and reported that staff typically did not complete a fall assessment if the resident was found on the floor mat next to the bed.Review of Resident #14's nurse's notes on 04/29/26 at 7:38 A.M. revealed no documentation regarding the fall that occurred on 04/28/26.

Review of the nurse's notes dated 04/29/26 at 8:40 P.M. revealed the resident was found lying next to the bed and was assessed for injury with no injury noted, range of motion was within normal limits, and the resident denied pain.Interview on 04/28/26 at 3:21 P.M., the Administrator and Regional Nurse #500 stated that the resident frequently got out of bed and this was considered a behavior.

They stated that if staff observed the resident getting out of bed, they would not complete a fall assessment or obtain vital signs.

They stated that if the fall was unwitnessed, staff should complete a fall assessment, vital signs, and a head to toe assessment.

They further stated that if the resident was found on the fall mat, staff would typically not complete a fall assessment even if the fall was not witnessed.Review of facility policy titled Falls - Clinical Protocol, revised September 2012, revealed the facility required staff to assess and document all falls, including obtaining vital signs, assessing for injury, neurological status, pain, and changes in condition.

The policy required staff to identify possible causes of the fall within 24 hours, document contributing factors, and implement interventions to prevent recurrence.

The policy further required monitoring and follow up after a fall, including ongoing assessment of the resident's condition and response to interventions.This deficiency represents non-compliance investigated under Master Complaint Number 2990783 and Complaint Number 2734881.