The man fell from his bed at Woodland Park Nursing & Rehab on August 17, 2024, landing on the floor with a 5-centimeter swollen area on the right side of his head, a skin tear on his elbow, and facial swelling. A CT scan at the hospital revealed a fractured cervical vertebra. He returned wearing a neck brace ordered for eight weeks.
Federal inspectors declared immediate jeopardy conditions at the facility in April 2025, finding that three residents lacked proper fall prevention interventions despite being assessed as high-risk or having previous falls.
The injured resident had been assessed as high risk for falls twice before his accident, on July 6 and August 4, 2024. His comprehensive care plan, initiated July 8, contained no interventions addressing his fall risk assessment.
Records show staff placed him on a low air loss mattress August 16 for a pressure wound on his sacrum. The next day, he was found on the floor beside his bed.
"He was on the floor. He was assisted back to the bed," nursing notes recorded. "Resident said he did not know how he fell. He just knew he was on the floor."
Director of Nursing J, who worked at the facility during the incident, told inspectors the resident "had no issues with any falls prior to the fall but if he was a high risk according to the assessment then interventions should have been in place."
She explained what happened with the safety equipment: "She said she did remember the bed had partial rails on it prior to them having to put an air mattress on the bed due to an open wound. She said the air mattress obtained was too big, so they had to take the rails off. She said they had obtained one to fit the bed, but she guessed the rails were not put back on the bed and he fell the next day."
The nursing director acknowledged the air mattress created additional danger. "She said the air mattress could be an increased risk for falls since they are slick, and you can't put sheets on them."
Only after the resident fractured his neck did staff complete a bed rail evaluation, on August 18. The assessment noted he had "a history of falls" and "problems with balance or poor trunk control," recommending rails "as assist bar and bed bolsters used to help prevent legs from slipping over edge of the air mattress."
The resident was later discharged to a hospital September 16 and did not return to the facility.
A second resident experienced two falls without receiving adequate interventions. The woman, who has cerebral palsy and schizoaffective disorder, fell December 7, 2024. Her care plan noted she was "high risk for falls" and "had a fall with no injury," but the only intervention listed was "sent to ER for eval and treat of unrelieved pain."
She fell again February 11, 2025. Staff revised her care plan February 22, documenting the second fall but adding only medical reviews and psychiatric notifications. No fall prevention measures appeared in either care plan update.
When inspectors observed her room April 23, 2025, they found her bed was not in the lowest position and no fall mats were placed on the floor beside the bed.
A third resident fell January 22, 2025, while receiving a breathing treatment in her wheelchair. She told staff she saw a bug on the wall, rolled toward it, and leaned forward. "She forgot to lock the wheels. The wheelchair rolled out from under her. She landed flat on her bottom."
The woman rated her pain 9 out of 10. X-rays ruled out fractures to her spine and tailbone. Staff completed a fall risk assessment showing she was at high risk, but her care plan revision eight days later mentioned only adding bed rails "for safety/enabler." No care plan addressed the fall itself.
During the April inspection, her bed also was not in the lowest position with no fall mats on the floor.
The facility's fall prevention policy, revised in March 2018, requires staff to "identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling." The policy lists specific risk factors including cognitive impairment, lower extremity weakness, medication side effects, and functional impairments.
The policy mandates staff "implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls."
Director of Nursing H told inspectors her expectation was "for all residents at risk for falls or had a fall to have care plan initiated and updated with additional interventions."
The administrator said nursing staff were responsible for completing and updating all resident care plans.
Federal inspectors identified the immediate jeopardy violation April 23, 2025, at 4:44 p.m. The facility submitted a removal plan requiring all licensed staff to complete in-services on fall risk assessments, policy procedures, and care plan development.
Corporate and facility nursing staff reviewed all resident care plans and fall risk assessments April 24. Thirteen licensed employees completed mandatory training that day, with one staff member on family leave scheduled for later training.
The immediate jeopardy designation was lifted April 24 at 2:50 p.m., but the facility remained out of compliance due to the need to evaluate whether the corrective systems would prove effective.
The violations affected residents whose conditions made falls particularly dangerous. The man who broke his neck had traumatic brain injury from a car accident years earlier, paraplegia, arterial ulcers, and coordination problems. His cognitive assessment showed severely impaired mental function, and he required substantial assistance for transfers and daily activities.
The woman who fell twice had cerebral palsy affecting movement and muscle tone, plus bone infection in her lower leg and lymphedema causing tissue swelling. She also had severely impaired cognition and required substantial assistance for all daily activities.
The third resident had end-stage kidney disease, chronic lung disease, diabetes, heart failure, and irregular heartbeat. Though cognitively intact, she was dependent for transfers and required substantial assistance with most daily activities.
All three residents used wheelchairs and had been assessed as requiring careful monitoring to prevent accidents and injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodland Park Nursing & Rehab from 2025-04-24 including all violations, facility responses, and corrective action plans.
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