Crystal Cove Post Acute

the window. Resident 1 stated they slid down to the floor.

The investigation showed the resident

shifted causing him to slide to the floor.

Intervention implemented was to ensure mattress was

sleeping. Resident 1's Falls Assessment, dated 10/22/2025, showed score 60 (high risk for > 45).Review of Resident 1's care plan, revised 10/24/2025, showed during safety rounds ensure the mattress was well secured.Fall #4

Review of the facility investigation, dated 11/29/2025 at 5:55 PM, showed Resident 1 had an unwitnessed fall in the resident's room.

The resident returned from dialysis around 12:00 PM. At 4:30 PM, Staff C, Certified Nursing Assistant (CNA) offered to transfer Resident 1 to his w/c but the resident stated he preferred to have dinner in his room while sitting at edge of the bed.

The resident was served his meal seated at the edge of the bed. Resident 1's roommate notified staff Resident 1 was on the floor.

The fall resulted in the resident sustaining a non-displaced (cracked but stays in alignment) right distal radial (forearm bone on the thumb side) metaphysis (weaker section of bone) fracture.Review of hospital documentation, dated 12/01/2025, showed the resident sustained a non-displaced distal right radial metaphysis fracture and suspected non-displaced ulnar metaphysis fracture without joint malalignment. A splint was applied to the right wrist and pain medication prescribed for pain control.Review of Resident 1's progress note, dated 12/08/2025, showed a splint was removed and cast applied.

During an interview on 12/31/2025 at 12:28 PM, Staff C, Physical Therapist, was asked if Resident 1 required staff assistance to transfer.

Staff C said Resident 1 required 2 staff and a mechanical lift to transfer the resident from bed to chair. He acknowledged Resident 1 should be out of bed and seated in a w/c for meals and activities.

Staff C stated Resident 1 had weakness to his left side, leaned to the left side and did not tolerate sitting in the w/c for long periods. He stated the resident preferred to sit at the edge of the bed.

Staff C was asked if it was safe for Resident 1 to be left seated at the edge of his bed without staff present? Staff C said .no it is not safe for Resident 1 to be seated at the edge of the bed without staff.he has already had a few falls.

During an interview on 01/02/2026 at 9:25 AM, Staff B, Certified Nursing Assistant (CNA) acknowledged they were the CNA that assisted Resident 1 on 11/29/2025, the resident required 2 staff and a mechanical lift to transfer, had problems with his balance, leaned to his left side all the time and had returned from dialysis on 11/29/2025.

Staff B stated the resident was very tired and did not want to transfer to the w/c for his meal.

Staff B acknowledged she positioned the resident at the side of the bed, served the resident his meal and left the resident seated at the bedside unattended.

She acknowledged the resident fell and sustained a fracture.

Staff B acknowledged Resident 1 requires staff assistance with eating his meals now due to a cast to his right arm.During an observation and interview on 01/02/2026 at 9:30 AM, Resident 1 was observed lying in his bed with a cast to his right forearm. Resident 1 was asked if he recalled falling and injuring his arm.

The resident said, Yes I do.I fell out of bed.

When asked if he was seated at the side of the bed when the fall occurred, the resident responded, yes.

The resident became drowsy, closed his eyes and was unable to continue the interview.

During an interview on 01/02/2026 at 11:53 AM, Staff C, Restorative Aid stated she worked with Resident 1 with bilateral strengthening and standing.

Staff D said Resident 1 always leaned to the left and was frequently drowsy during most therapy sessions.

Staff D stated the resident was very tired when he returned from dialysis.

Staff D was asked if she had observed Resident 1 seated at the edge of the bed? Staff D stated sometimes.

Staff D was asked if Resident 1 was safe to be seated at the edge of the bed unattended? Staff D stated, No it isn't safe because of his balance issues and fatigue.

During an interview on 01/02/2026 at 2:20 PM with Staff A, Director of Nursing Services (DNS), he said Resident 1 was high risk for falls and had three previous falls from his bed.

Staff A stated if a resident had balance issues, was fatigued and high falls risk the resident should have been left in bed or assisted to the w/c for his meal and should not have been left at the side of the bed unattended.

Staff A said the resident fractured their arm and required transfer to the hospital, had a cast applied and returned to the facility.