The resident hit his head and was taken to the hospital at 3:22 a.m. on March 23, according to federal inspection records from Concordia Manor. The administrator didn't begin investigating until March 27, when corporate headquarters told her she needed to file a report.
"It was late," administrator admitted to inspectors in April.
The nursing assistant, identified as Staff A, was assigned to the resident during the 3 p.m. to 11 p.m. shift on March 22. She told inspectors she was changing the bed when the resident started to fall off.
"I tried to catch him to save the fall, but I could not," she said. "I was lowering the bed and was trying to lower it some more as I was holding on to him. I was alone in the room."
The resident could not hold onto the bed rail because his right hand was contracted. He had been readmitted to the facility with diagnoses including muscle wasting, cerebral infarction, weakness, sepsis, brain hemorrhage, paralysis on one side, speech problems and dementia.
Staff A knew better.
"I knew he needed two people. He cannot do anything for himself," she told inspectors. "I know I should have asked for help. It was my fault. I take responsibility for not asking for help."
She said they were understaffed that day because someone called off and there was no replacement.
The administrator suspended Staff A on March 24, two days after the fall. But she didn't ask the nursing assistant for a statement until March 27. She didn't interview any other staff or residents about what happened.
When inspectors asked why it took two days for her to be notified about the fall, the administrator said it was the weekend and the Director of Nursing and Director of Rehab were on leave.
She said their process was to wait until corporate gave her approval before contacting state agencies. "This process affects her reporting and investigation timeline," inspectors noted.
The administrator told inspectors she "could not answer to why staff did not call her that weekend." She thought they had notified the Director of Nursing instead.
"I did not do a timeline," she admitted.
The delay violated federal requirements for immediate investigation of incidents that could harm residents. The administrator reported the fall to the state Agency for Health Care Administration on March 27, five days late.
But the investigation failures at Concordia Manor extended beyond the fall case.
A second resident complained that staff members were "rough and loud" with her, filing a grievance in early March. "They can't talk to me just anyhow," the resident told inspectors.
The resident, identified as Resident #3, had been admitted in December 2024 with diagnoses including brain dysfunction, muscle wasting, weakness and severe obesity. A mental status assessment showed she had intact cognition.
On March 4, Resident #3 told staff that a nursing assistant was rough with her during care and she didn't like his approach. The facility's Social Services Director received the grievance on March 5.
The administrator suspended the nursing assistant, Staff F, for eight days. But she never asked him to write a statement about what happened. She never asked what "rough with her" meant. She didn't speak to other staff about the incident.
"I see. I could have asked more questions," the administrator told inspectors.
Staff F said he found out about the problem the following Monday. "I was told not to go to that room, they said she was making comments against me and to protect myself, I should stay away," he said.
He said the resident had made allegations about another male employee before. "I did not take it seriously."
Staff F never wrote a statement. "No one said anything about a statement," he told inspectors. When he returned from suspension, he made sure to avoid the resident. "I still do if I am scheduled to care for her, I switch out."
He received no education about the incident. "I just resumed my normal life. I just avoid her."
The administrator confirmed to inspectors she had not conducted a proper investigation into the abuse allegation. She had no statements from other staff or residents. "I do not have them right now," she said when inspectors asked to see them.
A third incident involved the same resident. In late February, a family member contacted the state Department of Children and Families to report that an occupational therapist physically shakes and yells at Resident #3 to wake her up during therapy sessions.
State investigators interviewed the resident but did not substantiate the allegation. They never interviewed the therapist, Staff G.
Neither did the administrator.
Staff G told inspectors he spoke briefly with the administrator but never provided a statement to her or state investigators. "Neither of them interviewed him," the inspection report noted.
He was suspended for five days. When he returned, he was told the allegation was unfounded. Like Staff F, he received no education about the incident.
The administrator interviewed only one nursing assistant who worked in the area where Resident #3 lived. That assistant said the resident sometimes yells "get out, don't touch me" at therapy staff, who then leave and come back later.
The administrator never followed up on these statements. She never interviewed other staff who were working the day of the alleged abuse.
During the inspection, the facility's Regional Risk Manager told inspectors they should have asked the accused staff members to provide statements. They should have spoken to other staff members about what they witnessed.
The administrator agreed. She confirmed she should have obtained statements and educated all staff about the incidents.
The facility's own policy requires comprehensive investigations that may include resident interviews, employee interviews, visitor interviews, observation of residents and staff, document review and re-enactment of events.
None of that happened.
The Director of Nursing also failed to follow basic care protocols. The facility's policy requires weekly skin evaluations for all residents to prevent pressure sores and identify changes in skin condition.
For the resident who fell and hit his head, only four skin checks were documented over four months from January through April 2025. The most recent checks on March 28 and 29 showed he had knots on his forehead and scalp.
"There should be more than that. They should be documented weekly," the Director of Nursing told inspectors after reviewing the electronic record. "I see they are not done. I don't know what to tell you. We missed it."
The resident who fell had been living at Concordia Manor since 2013, with a recent readmission for multiple serious conditions including muscle wasting, brain damage from stroke, weakness, blood infection, brain bleeding, paralysis and dementia.
Staff A, the nursing assistant who let him fall, said she was changing his bed when it happened. She knew he needed two-person assistance. She knew his right hand was contracted and couldn't grip the bed rail. She was alone anyway.
"Not much was said to her at the time," when she was suspended, she told inspectors. The investigation that should have started immediately didn't begin for five days, and then only because corporate headquarters intervened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Concordia Manor from 2025-04-23 including all violations, facility responses, and corrective action plans.