Resident #24 at Avenue Care and Rehabilitation Center required substantial to maximal assistance from staff for basic activities including toileting, showering, and dressing due to moderately impaired cognitive function. His medical conditions included acute respiratory failure, end-stage renal disease, and a history of fainting episodes.
His care plan from June specified bilateral floor mats as a key intervention to prevent falls, along with keeping his call light within reach and having him sit in common areas when out of bed. The plan acknowledged his gait and balance problems made him vulnerable to dangerous falls.
But for nearly a week in August, inspectors found the same safety failure repeated daily. On August 6 at 10:13 a.m., they observed one fall mat positioned on only one side of his bed, which sat in the middle of the room rather than against a wall. The other side remained completely unprotected.
The pattern continued unchanged. August 7 at 11:15 a.m. — one fall mat, one side exposed. August 11 at 2:25 p.m. as the resident prepared for a nap — still only one mat protecting one side of the bed positioned in the middle of the wall.
On August 12, inspectors documented the same violation twice in the span of an hour. At 9:15 a.m., they found the resident resting in bed with one fall mat and one unprotected side. An hour later at 10:18 a.m., nothing had changed.
When confronted that morning, both the licensed practical nurse and registered nurse on duty acknowledged the obvious: Resident #24 had only one fall mat when his care plan required two.
The facility's own fall management policy, revised in December 2022, required licensed nurses to assess residents immediately after any fall and implement interventions to prevent future incidents. Their accident policy demanded immediate assessment of any resident involved in an unusual occurrence, with detailed documentation and physician notification.
Yet for six days, staff walked past a resident whose care plan explicitly called for bilateral fall mats and did nothing to correct the missing protection. The resident's bed placement in the middle of the room, rather than against a wall, made the missing second mat even more critical for his safety.
The inspection revealed this wasn't an isolated oversight but a sustained failure to follow the resident's individualized care plan. Each day brought the same risk — a cognitively impaired man with serious medical conditions and a documented fall history protected on only one side of his bed.
Resident #24's combination of conditions made falls particularly dangerous. His acute respiratory failure and end-stage renal disease meant any injury from a fall could prove catastrophic. His history of syncope and collapse episodes increased the likelihood that he might lose consciousness and fall without warning.
The facility's policies emphasized the importance of immediate intervention after falls occur. But in this case, staff failed to maintain basic preventive measures that were already identified as necessary in the resident's care plan. The bilateral floor mats weren't experimental treatments — they were standard fall prevention tools specifically prescribed for this vulnerable resident.
The violation occurred during a complaint investigation, suggesting family members or others had raised concerns about care quality at the facility. State inspectors found the fall mat deficiency while investigating multiple complaints filed against Avenue Care.
For Resident #24, the missing fall mat represented a daily gamble with his safety. Each time he got in or out of bed, shifted position during sleep, or experienced one of his fainting episodes, half his bed perimeter offered no cushioned protection from a potentially devastating fall to the hard floor below.
The facility's failure to provide complete fall protection for six consecutive days violated federal requirements for nursing homes to follow residents' individualized care plans and maintain a safe environment. The deficiency affected a resident whose cognitive impairment and multiple medical conditions made him among the most vulnerable to serious injury from falls.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avenue Care and Rehabilitation Center, The from 2025-08-13 including all violations, facility responses, and corrective action plans.
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