Ashley Healthcare Center: Resident Fractures Femur in Fall - MI
The July 20 incident at Ashley Healthcare Center involved a resident with autism and developmental disabilities who had a documented history of rolling herself out of bed. Federal inspectors found the facility failed to follow its own fall prevention plan for the resident.
Resident 203 had been admitted to the facility with diagnoses including autism, anxiety, and developmental disorder. Her care plan, updated in March, specifically directed staff to use a fall mat on the left side of her bed and keep the bed in the lowest position when not providing care.
The nursing assistant, identified as CNA J, was changing the resident and preparing to get her up for lunch when the fall occurred. According to the facility's investigation report, CNA J had placed a sling under the resident and raised the bed to hip level. She then left the room to get a Hoyer lift.
"Before I got to the doorway, I heard a thud and R203 had fallen to the floor," CNA J told inspectors during a demonstration of the incident on August 13.
The resident landed on her right side on the floor with a fractured right femur.
The nursing home administrator confirmed during an interview that CNA J had been educated that staff cannot leave the bedside of Resident 203 with the bed elevated. The administrator acknowledged the resident had a history of rolling herself out of bed.
CNA J's disciplinary record from July 29 documented the violation: "Providing care for resident when stepping out to grab hoyer, bed was still at hip level. Resident fell out of bed and ended in a fracture."
The nursing progress note from the day of the fall provided additional details. It stated that the certified nursing assistant "left the room to obtain the lift to get up the resident" and "heard a thud and observed resident lying on her R (right) side on the floor."
When inspectors visited the resident's room on August 13, they found another care plan violation. The call light was sitting on the bedside table, out of the resident's reach. Her care plan from March required staff to keep frequently used items, including the call light, within reach while she was in her room.
Another nursing assistant, CNA E, confirmed during an interview that Resident 203's call light should be left within reach because she was able to use it.
The facility's own fall prevention policy, reviewed in June 2024, required that each resident be assessed for fall risk and receive care according to their individualized risk level. The policy mandated that interventions be monitored for effectiveness and care plans revised as needed.
Federal inspectors determined the facility failed to ensure fall interventions were properly implemented, resulting in actual harm to the resident. The violation affected few residents but caused significant injury to Resident 203.
The inspection was conducted in response to a complaint about the facility's care practices. Inspectors found that despite having specific fall prevention measures in place for a resident with a known history of rolling out of bed, staff failed to follow basic safety protocols.
The incident occurred during routine care activities when the resident should have been most protected. The nursing assistant's decision to leave an elevated bed unattended directly contradicted both the resident's individualized care plan and standard fall prevention practices.
Resident 203's fracture required medical treatment beyond what the nursing home could provide. The injury represented exactly the type of preventable harm that federal regulations and facility policies are designed to avoid.
The facility's investigation and disciplinary action came nine days after the fall, but the damage to the resident had already been done. The fractured femur marked a significant decline in the resident's condition and mobility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ashley Healthcare Center from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Ashley Healthcare Center in Ashley, MI was cited for violations during a health inspection on August 13, 2025.
Federal inspectors found the facility failed to follow its own fall prevention plan for the resident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.