Fall Mats Not Positioned Beside Bed for High Fall-Risk Resident
Summary
The facility failed to follow fall prevention interventions for Resident 23 when bilateral fall mats were not placed on the ground alongside the resident’s bed while the resident was in bed. Resident 23 was admitted and readmitted with diagnoses including bilateral primary osteoarthritis of the knee, restless leg syndrome, and age-related osteoporosis. The resident’s MDS dated 10/6/2025 indicated moderately impaired cognition and substantial to maximal assistance needed for toileting and personal hygiene. The resident’s fall risk evaluation dated 1/6/2026 identified a high fall risk, and a progress note from the same date documented intermittent confusion and a fall risk score of 11. Resident 23’s care plan, initiated 1/7/2026, identified fall risk related to a history of falls, impaired mobility, urinary incontinence, and cognitive impairment with poor safety awareness, and it included floor mats on the sides of the bed as an intervention. During observation on 3/12/2026, the resident’s floor mats were seen propped against the wall while the resident was lying in bed. LVN 4 stated the mats needed to be on the ground while the resident was in bed because the resident got up unassisted. CNA 2 stated no one informed her that the mats were not alongside the bed and that the resident was more confused in the evening and had tried to get out of bed unassisted before. The PT and DON both stated that when the resident was in bed, fall prevention included keeping the bed low and placing mats alongside the bed, and the DON stated that if the mats were not used, the resident was at increased risk of injury if a fall occurred.
Plan Of Correction
F0689 CFR(s): 483.25(d) Free of Accident Hazards/Supervision/Devices Root Cause: The root cause of the deficient practice was failure to consistently implement and maintain fall prevention interventions (specifically floor mats) in accordance with the resident's care plan, along with lack of clear accountability and oversight to ensure interventions were in place during required timeframes. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: On 3/12/2026, for Resident #23, the floor mat intervention was immediately implemented at bedside per the care plan. The resident's care plan was reviewed and updated to ensure clarity of fall prevention interventions, including when floor mats must be in place. Staff were re-educated on proper placement and use of floor mats to reduce fall risk. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 3/13/2026, the Director of Nursing (DON) or designee conducted a 100% audit of all residents with floor mat interventions to verify:Floor mats are present at bedsideFloor mats are placed appropriately when the resident is in bedFloor mats are not stored, folded, or propped against the wallInterventions are consistent with the individualized care planAny identified noncompliance was immediately corrected at the time of observation, and responsible staff were re-educated. No additional residents were identified to be out of compliance. If any discrepancies had been identified, immediate correction and care plan review would have been completed. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: To prevent recurrence, the facility has implemented the following measures: On 3/31/2026 the DON conducted mandatory in-service training for all nursing staff (licensed nurses and CNAs) on fall prevention interventions, including proper use and placement of floor mats. Education emphasized that floor mats must be in place at bedside whenever the resident is in bed, in accordance with the individualized care plan.Define (sic) Accountability:CNAs are responsible for placing floor mats at bedside when the resident is in bed and ensuring proper positioning during routine care.Licensed Nurses are responsible for verifying implementation of fall interventions each shift and ensuring care plan accuracy.The DON or designee is responsible for oversight, compliance monitoring, and staff accountability.Trigger Conditions Clarified:Floor mats must be in place whenever the resident is in bed, unless contraindicated or otherwise specified in the care plan.Floor mats must be removed only when the resident is out of bed to prevent tripping hazards, as appropriate. How the facility plans to monitor its performance to ensure that solutions are sustained: The facility will maintain a 100% compliance threshold for implementation of floor mat interventions per care plan.Monitoring Plan:The DSD, or designee will conduct weekly audits of a minimum of 5 residents with fall interventions for 4 weeks, followed by monthly audits of 5 residents for 2 months.Audits will verify:Floor mats are in place at bedside while the resident is in bedFloor mats are not stored, folded, or propped against the wallInterventions are consistent with the care plan Interventions are consistent with the care plan Corrective Action Process: Any identified noncompliance will be corrected immediately at the time of observation. The responsible staff member will receive re-education prior to the end of the shift. The licensed nurse will verify correction within the same shift. A follow-up audit within 24 hours will be completed to ensure sustained compliance. Repeated noncompliance will be addressed through progressive discipline per facility policy. Reporting & Oversight: Audit findings will be reported weekly to the DON and Administrator during the monitoring period. Results will be presented at the monthly Quality Assurance (QA) Committee Meeting. The QA Committee will monitor compliance monthly until sustained 100% compliance is achieved. Responsible Parties: CNAs: Implementation and placement of floor mats Licensed Nurses: Verification and documentation each shift DON/Designee: Oversight, audits, and enforcement Completion Date: 4/13/2026
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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