Unsupervised Toileting of High-Risk Resident Resulting in Serious Fall Injuries
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance with toileting for a resident with a known high risk of falls, resulting in a serious fall and injuries. The resident had dementia, a history of falls, periprosthetic fracture around an internal prosthetic of the left hip joint, a fracture of the neck of the left femur, age-related macular degeneration, and osteoarthritis. Her care plan, initiated and revised prior to the incident, identified her as at risk for falls due to dementia, decreased mobility, increased weakness, unsteady gait, and a history of multiple prior falls when attempting to stand, transfer, or ambulate without assistance. The care plan and fall risk evaluation documented that she required assistance from one to two staff for all transfers, ambulation, and toileting, had severely impaired cognition, and needed substantial or maximal assistance with toileting hygiene and transfers, as well as 24-hour supervision and assistance during ADLs and transfers. In the months preceding the incident, the resident experienced multiple falls, including events on 10/12/25, 10/29/25, 11/07/25, 12/02/25, and 12/25/25, each occurring when she attempted to stand, transfer, or ambulate without assistance. A fall risk evaluation dated 12/25/25 further documented that she was cognitively impaired, unable or unwilling to follow directions, and displayed behaviors such as restlessness, wandering, resisting care, and altered safety awareness. She was unsteady and only able to stabilize with assistance when moving from seated to standing, walking, moving on and off the toilet, and transferring between surfaces. Occupational therapy records indicated she required maximum assistance of one staff member for transfers from various surfaces and multimodal cues to increase ADL performance, reinforcing that she required continuous supervision and assistance during ADLs and transfers. On 03/21/26, despite these documented risks and needs, the resident was left unattended on the toilet by a CNA who was unfamiliar with her and her fall risks. According to the progress note and fall investigation, the CNA placed the resident on the toilet and then left the bathroom and bedroom to obtain new bedding and an adult brief from the hallway linen closet. While the CNA was away, the resident got herself off the toilet. When the CNA returned, she observed the resident coming out of the bathroom door and saw her fall backwards, striking her back and head on the sink. Initial documentation and the fall questionnaire indicated the CNA found the resident standing and that the resident became startled and fell back, with no mention that the CNA assisted her to the floor. The LPN who responded to the incident found the resident on the bathroom floor with a bruise on her back and a goose egg on the back of her head and documented that the CNA reported seeing the resident fall and being unable to reach her in time to assist. Subsequent hospital evaluation documented multiple rib fractures, a small hemopneumothorax, an acute T9 transverse process fracture, and hematomas, which were associated with this fall. The facility’s own investigation noted that the resident had been left alone in the bathroom and added an intervention for staff to remain in the bathroom until the resident finished toileting, underscoring that the lack of supervision during toileting led to the fall and resulting injuries. Additional interviews supported that residents with similar cognitive impairment and toileting needs were generally not left alone on the toilet and required frequent checks, with staff often remaining in or just outside the bathroom to monitor them. The LPN confirmed that this resident was known to frequently get up without assistance and, for that reason, was not typically left alone on the toilet. The administrator acknowledged that staff from other buildings, who were unfamiliar with residents and their risks and were unlikely to review care plans, were being used at the time of the incident. The facility’s fall management policy required ongoing review of care plans and use of fall risk evaluations to identify individualized fall risk factors, but in this case, the CNA did not follow the resident’s established need for continuous supervision and assistance during toileting, directly leading to the unsupervised toileting event and subsequent fall. The hospital records following the incident documented that the resident presented after a mechanical fall with chest wall pain and visible bruising to the left side. Imaging and physician notes identified left-sided rib fractures (seventh through eleventh ribs), a small left hemopneumothorax, an acute left T9 transverse process fracture, and hematomas of the left chest wall, retroperitoneum, and right iliacus muscle. The records stated it was unknown whether osteopenia or osteoporosis contributed to the fractures and did not characterize the fractures as pathological. The physician noted that the resident was at high risk of falls and had been sent to the emergency room after this fall, confirming that the injuries were associated with the incident in which she was left unattended while toileting. The facility’s documentation of the event, including the fall investigation and questionnaires, consistently indicated that the resident was left alone in the bathroom despite her documented need for assistance and supervision with toileting and transfers. The lack of a contemporaneous witness statement from the CNA and the later, typed statement created over a month after the fall introduced discrepancies about whether the CNA partially assisted the resident to the floor. However, the LPN’s account and initial documentation emphasized that the CNA reported seeing the resident fall and being unable to reach her in time, and that the resident struck her head and back on the sink. These facts, combined with the resident’s known fall risk profile and care plan requirements, form the basis of the deficiency for failing to ensure adequate supervision and assistance to prevent accidents during toileting. The facility’s fall management policy, revised 10/24/25, required that care plans be reviewed throughout treatment to ensure resident-specific fall reduction interventions were incorporated and that fall risk evaluations be completed on admission, after significant changes, quarterly, and as necessary. The resident’s care plan and evaluations had already identified her need for assistance and supervision with toileting and transfers, yet on the day of the incident, these interventions were not followed when the CNA left her unattended on the toilet. This failure to adhere to the resident’s individualized fall prevention measures and to provide adequate supervision in the bathroom directly preceded the resident’s unsupervised attempt to ambulate, her fall, and the serious injuries documented in the hospital records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents at risk for falls did not receive required fall prevention interventions as outlined in their care plans. One resident's garbage can was not kept within reach as specified, and another resident's visual reminder to call for assistance was not transferred to her new room. Both lapses were confirmed by staff and observed during the survey, indicating non-compliance with established fall prevention policies.
A resident with a history of falls and multiple medical conditions did not have required fall prevention interventions in place, including a body pillow, a sign to request help, and a bed in the lowest position, as specified in the care plan. These items were missing following a recent room change, and the DON confirmed the interventions had not been implemented as directed.
A resident with multiple chronic conditions sustained a laceration to her foot requiring sutures after contacting a torn and rough footboard while attempting to sit up in bed. The unsafe condition of the footboard was not addressed prior to the incident, and there was no evidence of a system for ongoing maintenance and timely repair of resident equipment to prevent injuries.
A resident with multiple comorbidities and on hospice care, identified as high risk for falls, experienced an unwitnessed fall resulting in a fractured arm and head injury. Despite ongoing behaviors indicating increased fall risk, staff did not update fall risk assessments or care plan interventions after admission, and the bed was found in a high position contrary to recommendations. The facility's failure to provide individualized and effective fall prevention measures led to actual harm.
A resident who was dependent on staff for transfers sustained a head injury and concussion when a Hoyer lift tipped and struck the resident during a transfer to bed. The incident occurred because the lift did not clear the raised bolsters of an air mattress, causing the lift to tip as two CNAs attempted the transfer. The resident required emergency care for a laceration and concussion. Staff interviews and documentation confirmed that the air mattress's design interfered with safe transfer procedures.
Medication and treatment carts were left unlocked and unattended at the nurses' station while an LPN was off the unit and a CNA was serving breakfast in the dining room. Several cognitively impaired residents, all able to ambulate independently and known to wander, had access to the area. Facility policy required carts to be locked when unattended, but this was not followed.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents identified as being at risk for falls. For one resident with diagnoses including anoxic brain damage, epilepsy, and major depressive disorder, the care plan required that her garbage can be kept within reach to prevent her from attempting to get up unassisted. Observation revealed that the garbage can was placed out of her reach, and both the resident and the Director of Nursing confirmed that this intervention was not being followed, despite its inclusion in the care plan. Another resident, with diagnoses such as adult failure to thrive, dizziness, hypertension, unspecified dementia, and difficulty walking, had a care plan intervention requiring a visual reminder in her room to call for assistance. Observation found that after the resident was moved to a new room, the visual reminder was not transferred with her. An LPN confirmed that the intervention was not in place in the new room and was unaware of the requirement, even though the sign had been present in the resident's previous room. The facility's policy on managing falls requires staff to implement resident-centered fall prevention plans based on individual risk factors. In both cases, the specific interventions designed to mitigate fall risk were not carried out as documented in the residents' care plans, resulting in non-compliance with the facility's own policies and procedures for fall prevention.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
A deficiency was identified when a resident with a history of falls, cerebrovascular disease, diabetes, seizures, and an absent right great toe did not have fall prevention interventions in place as outlined in their care plan. The resident had experienced three falls over several months, each resulting in new interventions being added to the care plan, such as hanging a sign to ask for help, moving personal items within reach, and using a low bed. The care plan also specified that the bed should be in the lowest position when occupied, a body pillow should be placed on the right side of the bed, personal items should be within reach, and a visual reminder should be present to use the call light for assistance. During an observation of the resident's room with the DON, it was found that the required body pillow and sign were missing, and the bed was not in the low position as specified in the care plan. The DON acknowledged that the resident had recently changed rooms and that the body pillow and sign had not been transferred to the new room. Additionally, the DON stated that she did not believe the resident wanted the bed in the lowest position and intended to update the care plan, but at the time of observation, the interventions were not in place as required.
Failure to Maintain Safe Resident Equipment Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident's bedroom furniture in a safe condition, resulting in an injury. The resident, who had a history of respiratory failure, COPD, and type II diabetes, sustained a laceration to the top of her right foot after her foot came into contact with a torn and rough footboard while she was attempting to sit up in bed. The incident happened in the early morning hours, and the wound required hospital treatment, including the placement of seven sutures. Documentation and interviews confirmed that the footboard was in a state of disrepair at the time of the incident. Further review and staff interviews revealed that the rough patch on the footboard had not been addressed prior to the injury. There was no evidence provided to show that the facility had an effective system in place for the ongoing maintenance and timely repair of resident equipment to prevent such injuries. The resident's medical condition, including significant leg swelling and fragile skin, increased her vulnerability to injury, but the unsafe condition of the footboard was the direct cause of harm.
Failure to Update Fall Risk Interventions Leads to Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate, individualized, and effective fall risk interventions for a resident identified as high risk for falls. The resident, who had multiple diagnoses including atrial fibrillation, anxiety disorder, morbid obesity, and acute kidney failure, was admitted to hospice care and was receiving medications such as morphine and Ativan. Despite being assessed as high risk for falls on admission, no further fall risk assessments were completed until after the resident experienced a fall with injury. The resident's care plan, which initially included fall risk interventions, was not updated to reflect changes in her condition or behaviors that increased her fall risk. Prior to the incident, the resident exhibited terminal agitation, including attempts to get out of bed and remove her clothing. Staff and family members observed these behaviors, and hospice staff recommended keeping the bed in the lowest position. However, on the night of the incident, the resident was found on the floor with her bed in a high position, having sustained a fractured left arm, a laceration to her forehead, and a bruise to her cheek. The bed remote, which controlled the bed's height, was found on the floor next to the resident. There was conflicting information regarding whether staff had entered the room to adjust the bed or provide care prior to the fall. Interviews with facility staff, the administrator, and the DON confirmed that the resident's fall prevention interventions and risk assessments had not been updated since admission, despite her ongoing risk factors and recent behavioral changes. The facility's policy required staff to implement resident-centered fall prevention plans based on current evaluations and data, but this was not done for the resident prior to her fall and injury. The lack of updated assessments and interventions directly contributed to the resident's unwitnessed fall and subsequent harm.
Resident Injured During Unsafe Hoyer Lift Transfer Due to Air Mattress Obstruction
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident who was dependent on staff for all transfers and required the use of a Hoyer lift. The resident, who had diagnoses including Parkinson's disease with dyskinesia, generalized muscle weakness, and chronic systolic heart failure, was being transferred from a wheelchair to bed using a Hoyer lift by two CNAs. The resident's care plan specified the use of a Hoyer lift with two staff and an air mattress with bolsters was in place on the bed as a pressure relief intervention. During the transfer, the Hoyer lift did not clear the raised bolsters of the air mattress. As the staff maneuvered the resident onto the bed, the lift tipped and the top-heavy part struck the resident on the head, resulting in a laceration and concussion. The incident was witnessed by the two CNAs performing the transfer, and the nurse on duty was called to assess the resident immediately after the injury occurred. The resident was transported to the emergency department, where he received six staples to close the wound and was diagnosed with a concussion. Interviews with staff revealed that the air mattress's height and bolsters interfered with the safe operation of the Hoyer lift, contributing to the tipping incident. The manufacturer's guidelines for the Hoyer lift warned of the risk of tipping and emphasized the need to keep the base widened for stability. The facility's policy required at least two staff for mechanical lift transfers and for staff to ensure resident safety and security during transfers. Despite these guidelines and policies, the transfer was not completed safely, resulting in actual harm to the resident.
Medication and Treatment Carts Left Unlocked and Unattended on Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when medication and treatment carts were left unlocked and unattended on the locked memory care unit. During an observation, both carts were found unsupervised and unlocked at the nurses' station, with no staff present in the immediate area. The only staff member on the unit at the time, a CNA, was serving breakfast trays in the dining room, while the LPN was downstairs administering medications. This left the medication and treatment carts accessible and out of view of any staff. Medical record reviews confirmed that seven residents on the memory care unit were severely impaired in daily decision-making, ambulatory, and capable of independently moving throughout the unit. Interviews with staff verified that these residents wandered the unit and could open the drawers of the carts. Facility policy required that medication carts be locked when out of sight or unattended, a standard not met during the observed incident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
