COLVILLE, WA - Federal inspectors have cited Prestige Care & Rehabilitation - Pinewood Terrace with immediate jeopardy violations after finding that the facility failed to adequately prevent and monitor resident falls, resulting in multiple serious injuries including hip dislocations, bone fractures, and hospitalizations.
Pattern of Inadequate Fall Prevention Leads to Serious Injuries
The inspection, conducted on May 23, 2025, revealed a concerning pattern of falls among residents that resulted in significant injuries and multiple hospital transfers. The most alarming case involved one resident who fell 36 times over a 13-month period, while another resident sustained three separate fractures from repeated falls within six months.
Federal regulations require nursing homes to implement comprehensive fall prevention programs that include risk assessments, individualized interventions, and ongoing monitoring. These requirements exist because falls represent one of the leading causes of injury and death among nursing home residents, with the potential to cause life-altering complications.
The facility's failures in this area prompted inspectors to issue an immediate jeopardy citation on May 20, 2025, indicating that residents faced the risk of serious injury, harm, or death due to inadequate care practices.
Resident Experiences Multiple Fractures from Preventable Falls
One of the most serious cases documented involved a resident who sustained three major injuries from falls over a six-month period. The resident first suffered a dislocated hip on September 12, 2024, followed by a right femur fracture on January 14, 2025, and a back fracture on March 3, 2025.
This pattern of repeated injuries suggests fundamental failures in the facility's fall prevention protocols. Hip dislocations and femur fractures are particularly serious injuries for nursing home residents, often requiring surgical intervention and extensive rehabilitation. These injuries can lead to permanent mobility limitations, increased pain, and reduced quality of life.
Back fractures, especially in elderly residents, can be particularly devastating as they may affect the resident's ability to sit, stand, or move independently. Such injuries often result in chronic pain and may require long-term pain management strategies.
The medical significance of these injuries cannot be understated. Femur fractures in elderly adults carry a mortality risk of 20-30% within the first year following the injury. Hip injuries often mark the beginning of a decline in functional independence, with many residents never returning to their pre-injury mobility level.
Facility Records Show 36 Falls for Single Resident Over 13 Months
Perhaps the most striking example of systematic failure involved a resident who experienced 36 documented falls between April 4, 2024, and May 17, 2025. This frequency of falls - nearly three per month - indicates a complete breakdown in individualized care planning and fall prevention strategies.
When a resident falls multiple times, healthcare facilities are required to conduct comprehensive assessments to identify contributing factors and implement targeted interventions. These may include medication reviews, environmental modifications, assistive device evaluations, and enhanced supervision protocols.
The high frequency of falls for this resident suggests that either adequate assessments were not conducted, appropriate interventions were not implemented, or existing interventions proved ineffective and were not modified accordingly. The inspection found that several of these falls resulted in injuries severe enough to require hospital treatment.
Falls of this frequency place residents at extreme risk for serious complications beyond immediate injuries. Repeated falls can lead to a fear of falling, which often results in reduced activity levels, muscle weakness, and increased fall risk - creating a dangerous cycle that requires intensive intervention to break.
Third Resident Sustains Facial and Leg Fractures
The inspection also documented a third resident who experienced three falls resulting in significant injuries, including a fracture to the eye socket and a fracture of the left lower leg. Facial fractures, particularly around the eye socket (orbital fractures), can affect vision and may require specialized surgical treatment.
Lower leg fractures in nursing home residents often heal slowly due to factors such as poor circulation, medication effects, and underlying health conditions. These injuries typically require immobilization, which can lead to additional complications including blood clots, skin breakdown, and muscle atrophy.
The combination of facial and leg injuries suggests that this resident's falls may have been particularly severe, possibly indicating inadequate environmental safety measures or supervision protocols.
Medical Context: Understanding Fall Prevention Standards
Effective fall prevention in nursing homes requires a multi-faceted approach based on evidence-based practices. Facilities must conduct comprehensive fall risk assessments that evaluate factors including mobility status, medication effects, cognitive function, medical conditions, and environmental hazards.
Once risk factors are identified, facilities are required to develop individualized intervention plans. These may include physical therapy to improve strength and balance, medication reviews to identify drugs that increase fall risk, environmental modifications such as improved lighting or removal of hazards, and the use of assistive devices like walkers or wheelchairs.
Monitoring protocols should include regular reassessment of fall risk, documentation of all incidents, and analysis of patterns to identify opportunities for improvement. When falls do occur, facilities must investigate the circumstances and modify care plans accordingly.
The failure to implement these standard practices places residents at unnecessary risk and violates federal regulations designed to protect nursing home residents' safety and wellbeing.
Substance Use Disorder Assessment Failures
In addition to the fall prevention violations, inspectors found that the facility failed to properly assess and address substance use disorder risks for sampled residents. Specifically, the facility inadequately evaluated and implemented interventions for potential substance use disorders affecting one resident out of three reviewed cases.
Proper assessment of substance use disorders in nursing home settings is crucial because these conditions can significantly impact residents' health, medication effectiveness, and care needs. Facilities are required to screen for substance use issues and provide appropriate treatment and monitoring when identified.
The failure to address substance use disorders can lead to complications including medication interactions, withdrawal symptoms, behavioral issues, and compromised treatment outcomes for other medical conditions.
Additional Issues Identified
The inspection narrative indicates that additional behavioral health services violations were documented, though specific details were not provided in the available report sections. These findings suggest broader systemic issues with the facility's approach to comprehensive resident care and safety protocols.
The combination of fall prevention failures and substance use disorder assessment inadequacies points to potential gaps in staff training, care planning processes, and quality assurance programs that extend beyond individual incidents to systemic operational concerns.
The immediate jeopardy citation reflects the serious nature of these violations and the potential for continued harm if immediate corrective action is not taken. Facilities receiving such citations must develop and implement correction plans to address the identified deficiencies and prevent future occurrences.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prestige Care & Rehabilitation - Pinewood Terrace from 2025-05-23 including all violations, facility responses, and corrective action plans.
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