KILLEEN, TX - Federal inspectors issued immediate jeopardy violations to The Rosewood Retirement Community after a high-risk resident fell from her wheelchair and hit her head while left unsupervised in her room, resulting in neurological symptoms and hospitalization.
Multiple System Failures Led to Preventable Fall
The April 18, 2025 inspection revealed that the facility failed to implement critical safety measures for a stroke patient with cognitive impairment and mobility issues. The resident, who had been discharged from the hospital with orders to be placed on fall precautions, was left alone in her room despite her high-risk status.
On March 29, 2025, staff found the resident face-down on the floor with her wheelchair positioned on her upper back. The resident reported hitting her head and face, and staff observed nystagmus - rapid, involuntary eye movements that can indicate neurological injury. She complained of pain on the left side of her face and head and was transported to the hospital for evaluation.
Baseline Care Plan Failures
Federal regulations require nursing homes to develop baseline care plans within 48 hours of admission that address each resident's specific needs and risk factors. The inspection found that Rosewood failed to create an adequate baseline care plan for the resident despite her obvious fall risk factors.
The resident's medical history included stroke, brain swelling, brain bleeding, respiratory failure, and mobility abnormalities. Her admission assessment noted severe cognitive impairment, incoherent speech, and inability to recognize her own needs. Despite these clear indicators of fall risk, no fall interventions were documented in her initial care plan.
The admission nurse acknowledged that checking the "high fall risk" box should have triggered fall risk interventions to be added to the care plan and Kardex system, but admitted she "did not know how to open the care plan to even see what was on the care plan."
Hospital Discharge Orders Ignored
The facility failed to implement the hospital's discharge order placing the patient on fall precautions. When inspectors reviewed the facility's order summary, no fall precautions order was found, indicating staff either missed or ignored this critical safety directive.
Fall precautions typically include measures such as ensuring the resident is not left alone when mobile, providing easy access to call systems, and implementing frequent safety checks. These standard interventions could have prevented the March 29 incident.
Inadequate Staff Training and Communication Systems
The inspection revealed significant gaps in staff knowledge about the facility's care planning and communication systems. The Kardex system, which provides direct care staff with essential safety information, failed to include fall risk information even for residents with documented fall histories.
A certified nursing assistant demonstrated during the inspection that she could not locate fall risk information in the computer system for six residents who were known to have fallen previously. Staff reported they "usually got fall risk information in report every morning from the nurse" rather than having it documented in accessible care planning systems.
This communication breakdown meant that direct care staff responsible for supervising residents lacked critical safety information needed to prevent accidents.
Medical Consequences of Inadequate Supervision
The resident's fall resulted in immediate medical complications. Nystagmus, the rapid eye movements observed after her fall, can indicate brain injury or neurological disturbance. Given the resident's existing brain bleeding condition called amyloid angiopathy, any head trauma posed serious risks.
Amyloid angiopathy involves protein buildup in brain blood vessel walls, making patients extremely vulnerable to additional bleeding episodes. A fall with head impact in such patients can trigger new bleeding or worsen existing hemorrhages, potentially leading to stroke, seizures, or other life-threatening complications.
The facility's nurse practitioner confirmed that "a fall with a head injury could cause nystagmus" and noted the resident's impulsive behavior and tendency to attempt unsafe transfers without assistance.
Standard Fall Prevention Requirements
Federal nursing home regulations require comprehensive fall risk assessments and intervention plans for all residents, particularly those with mobility limitations, cognitive impairment, or recent hospitalization. Standard fall prevention protocols include:
- Completing fall risk assessments within 48 hours of admission - Implementing specific interventions based on identified risk factors - Ensuring call systems are within reach and functional - Providing appropriate supervision levels - Training staff on fall prevention strategies - Documenting all interventions in accessible care planning systems
The Director of Nursing acknowledged that "everyone who comes in this building was a fall risk, especially for the first three days and for three days after a room change." Despite this recognition, the facility failed to implement appropriate safeguards.
Immediate Jeopardy Determination
Federal inspectors determined that the facility's failures created immediate jeopardy - a designation reserved for situations where residents face serious injury, harm, or death. The combination of multiple system failures created a likelihood of serious adverse outcomes.
The immediate jeopardy was temporarily removed on April 4 after the facility implemented corrective actions, including staff education on care planning processes and fall prevention protocols. However, the facility remained out of compliance during the inspection period as officials evaluated the effectiveness of the corrections.
Facility Response and Corrective Actions
Following the immediate jeopardy determination, Rosewood implemented several corrective measures:
- Comprehensive staff education on baseline care plan development and fall prevention - Review of all current resident care plans for accuracy - Implementation of daily monitoring of admission assessments and care plans - Enhanced training on the Kardex system and its proper use
The facility committed to conducting weekly skills validations and daily review of admission orders for two months to ensure compliance with federal requirements.
The case highlights the critical importance of proper care planning and staff communication in preventing serious accidents in nursing home settings. When multiple safety systems fail simultaneously, vulnerable residents face significant risks of injury or death from preventable incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rosewood Retirement Community from 2025-04-18 including all violations, facility responses, and corrective action plans.
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