KALAMAZOO, MI - A federal inspection at Alamo Nursing Home Inc revealed critical staffing shortages that contributed to multiple resident falls, including one that resulted in a cervical spine fracture requiring hospitalization.
Dangerous Fall Pattern Emerges
The most serious incident involved Resident #114, who experienced five separate falls over four days in early January. The third fall on January 3rd was particularly severe - the resident struck his head, developed a visible lump above his eyebrow, and was transported to the hospital where doctors discovered a fracture of the C3 cervical vertebra. He returned to the facility wearing an Aspen neck collar.
The cervical spine, composed of seven vertebrae in the neck region, protects the spinal cord that controls vital functions throughout the body. A C3 fracture poses significant risks including potential spinal cord damage, nerve impairment, and complications with breathing or swallowing. Such injuries typically require immediate medical intervention and careful monitoring to prevent permanent disability.
During the investigation, staff repeatedly reported being unable to adequately supervise residents due to insufficient staffing levels. One Licensed Practical Nurse stated she "was not able to find a CNA to assist with Resident #114's fall right away" and by the time she returned, "he had crawled into the hallway."
Critical Understaffing Documented
Federal inspectors found the facility was operating with dangerously low staff-to-resident ratios. For 80 residents on the night shift, the facility scheduled only four CNAs across all units, with one "float" CNA responsible for covering an entire hall plus assisting other areas and managing lunch breaks.
"Each CNA would have approximately 17 residents on their assignment" when fully staffed, reported the scheduler. However, staff frequently worked short-handed, with some CNAs responsible for residents on multiple halls simultaneously.
Multiple staff members described the impact on patient care. One CNA reported having to "leave her assigned hall for 30 minutes at a time to assist on other halls with residents." Another stated that "staff are quitting due to burn out and not being able to provide adequate care to the residents."
The facility had recently reduced licensed nursing staff from three to two on the night shift, leaving each nurse responsible for multiple halls. This reduction occurred despite having numerous residents requiring two-person assistance for transfers and other care activities.
Additional Safety Concerns
The understaffing crisis extended beyond the falls issue. Inspectors identified two other residents with extensive fall histories:
Resident #108, described as "very restless almost all of the time," experienced six documented falls between October and December 2024. One incident involved a nightstand falling on his head, requiring hospital evaluation for head trauma.
Resident #106 fell eight times between September and November 2024, with incidents including being found "hanging off the bed, with the bottom half of her body on the floor."
Infection Control Failures
The inspection also revealed improper implementation of Enhanced Barrier Precautions (EBP) for residents with chronic wounds. Federal guidelines require staff to wear gowns and gloves during high-contact care activities for residents with wounds or medical devices to prevent transmission of multidrug-resistant organisms.
Inspectors observed CNAs transferring residents with wounds using mechanical lifts without proper protective equipment. One staff member incorrectly believed protective gear was only required during wound care procedures, not routine care activities.
Food Service Deficiencies
Additional violations included failure to provide adequate snacks for residents outside meal hours. Multiple residents reported that evening snacks were unavailable, with some staff purchasing food from vending machines with their own money to meet resident needs.
The dietary manager acknowledged that recent kitchen staff reductions made it "harder to get dinner and beverages served on time." Nourishment rooms that should have been stocked with sandwiches and snacks were found to contain minimal supplies.
Regulatory Response
These violations represent significant departures from federal nursing home standards that require facilities to maintain adequate staffing to meet residents' care needs and ensure their safety. The Centers for Medicare & Medicaid Services requires nursing homes to have sufficient nursing staff to provide care and services to each resident according to their individual care plans.
The facility's Director of Nursing acknowledged starting a fall improvement plan in December 2024 due to the high number of incidents, though the plan did not address staffing levels or competency issues that contributed to the problems.
Federal regulators will continue monitoring the facility's corrective actions to ensure residents receive appropriate care and supervision.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alamo Nursing Home Inc from 2025-01-08 including all violations, facility responses, and corrective action plans.
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