The March 7 incident at Graceland Rehabilitation and Nursing Care Center violated the facility's own two-person assist requirement for Resident #415, who had severe cognitive impairment and was completely dependent on staff for bathing, toileting and personal hygiene.
Federal inspectors found the facility placed residents in immediate jeopardy through preventable falls that caused serious injuries. The investigation revealed a pattern of staff abandoning safety protocols, delayed medical response, and inadequate supervision.
CNA B confirmed during interviews that she and CNA A were providing care to Resident #415 when the patient had a large bowel movement. "They did not have enough supplies in the room at that time, and CNA B was asked to go out of the room to get some rags," according to inspection records.
CNA A remained behind the resident, holding her on her side. "CNA B was in the hallway and CNA A called out 'She fell, she fell,'" CNA B told investigators.
The resident's weight shifted away from CNA A, who "couldn't catch" her. Resident #415 fell from the bed, which was positioned at waist height, striking the floor.
Licensed Practical Nurse G documented finding "a raised area on left side of res' head" and called the resident's daughter at 11:20 AM to report the fall and hospital transport. Hospital radiology results confirmed Resident #415 had suffered traumatic brain injury with left frontal lobe, right temporal lobe, and subarachnoid hemorrhage.
The facility's medical director was unequivocal about the preventable nature of the incident. "Never, ever leave the person in the room alone," he told inspectors. "It would take the 3rd person getting the supplies."
A second serious fall occurred four months earlier. Resident #515, a woman with Parkinson's disease and a history of repeated falls, was found on January 7, 2024, "screaming 'help'" and lying on her room floor near the bathroom door.
The resident complained of pain to her right hip and leg, telling staff "I can't move this side" and requesting X-rays. Despite these clear indicators of serious injury, the nurse moved Resident #515 using a mechanical lift and placed her in a wheelchair.
The facility's response proved inadequate and delayed. Progress notes show the nurse was "unable to reach MD" and administered only Tylenol for pain management. A medical transport service wasn't contacted until 6:40 PM, more than two hours after the fall was discovered.
Resident #515 remained at the facility for six hours and 28 minutes before transfer to the hospital. Emergency medical services documented her condition as "Critical (Red)" with "distal femur swelling pain 8/10" and noted she "should not be seated until fracture/injury determined."
Hospital evaluation revealed Resident #515 had sustained a displaced subcapital right femoral neck fracture. Her family member described the ordeal: "Mom kept calling saying she was hurting after she fell. I got at the facility. I told the nurse she is screaming in pain, I think we need an Xray and sent out to the hospital."
The family member said they "started to call 911 but the nurse told me it wasn't an emergency then we find out at the hospital her leg was broken."
Licensed Practical Nurse KK, who was on duty during Resident #515's fall, acknowledged the facility's preference against using emergency services. "Most times they don't want us to use 911," she told investigators. When asked when she would activate 911, LPN KK replied, "If patient was unresponsive."
The facility's Director of Nursing contradicted the nurse's actions, stating she would expect staff to "leave them in place" after an unwitnessed fall where a resident voiced inability to move their leg and complained of pain. "It could cause more injury and possibly cause the resident more pain," the DON explained.
The Administrator confirmed that when ambulance transport is delayed for a resident who experienced an unwitnessed fall and cannot move their leg, the expectation would be to "call 911."
Nurse Practitioner #1 raised broader concerns about patient safety at the facility during interviews. "I expressed concerns about patient safety. Fall education on proper body mechanics. I know of issues with falls with injury," the NP told investigators.
Beyond the fall incidents, inspectors documented multiple other safety violations throughout the facility. In the kitchen, they found rust and black buildup on stainless steel equipment, unlabeled and undated food items, and a malfunctioning dishwasher that wasn't reaching proper sanitization temperatures.
Staff continued using the broken dishwasher to clean dishes served to residents, despite temperatures reaching only 60 degrees Fahrenheit instead of the required 160-175 degrees for the wash cycle. The Administrator confirmed she wasn't informed of the equipment failure.
Infection control violations included staff entering isolation rooms without required personal protective equipment. Multiple residents were under contact isolation precautions for Candida auris, a dangerous multidrug-resistant fungus that spreads easily in healthcare facilities.
Housekeeping staff entered isolation rooms without gowns or gloves, while nursing staff touched contaminated equipment and moved between rooms without proper hand hygiene. One isolation patient was observed leaving his room and interacting with other residents without protective equipment.
Medication security failures included eight pills found unattended in a cup on a dresser in the room of a resident with severe cognitive impairment. The assigned nurse confirmed medications should never be left at bedside.
The immediate jeopardy designation was removed on May 9, 2025, after the facility implemented corrective measures including staff education on two-person assists, fall audits, and competency testing with return demonstrations.
However, the human cost of the violations remains. Resident #415's family member had to reduce work hours to provide additional care following the traumatic brain injury. Resident #515's family watched their mother endure hours of preventable pain from a broken hip that could have been diagnosed and treated immediately.
The facility's own policies required exactly what didn't happen: maintaining two-person assistance during resident care and ensuring proper medical evaluation after falls. As the medical director noted, the falls were entirely preventable through basic adherence to established safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Graceland Rehabilitation and Nursing Care Center from 2025-05-13 including all violations, facility responses, and corrective action plans.
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