Maples Benzie County Medical Care: Fall After No Grip Socks - MI
The fall happened on July 25, 2025, at Maples Benzie County Medical Care. Federal inspectors documented the incident during a complaint inspection completed August 13.
The resident, identified in inspection records as R3, was known to staff as impulsive and at high risk for falls. His care plan required him to wear non-skid grip socks whenever he was out of bed. That afternoon, his bed alarm sounded.
CNA C responded, found R3 in the bathroom, and noticed he wasn't wearing grip socks. She told him she was going to grab a pair from the storage room and left him there. He was usually fine in the bathroom alone, she later told inspectors. When she reached the storage closet, there were none. So she left the unit entirely to look for a pair somewhere else in the building.
She came back to find LPN D already in the room, crouched over R3 on the floor.
LPN D's fall report described what she found: a loud bang, R3 on his right side facing the bathroom, his head propped against the wall, a visible hematoma forming above his right eye. He had tried to transfer himself. Nobody was there when he went down.
CNA B, a separate aide who had also been involved in R3's care that day, told inspectors she had gone to the linen storage room for grip socks before the fall and also found none stocked. She admitted she was too busy to track down a replacement pair before leaving R3 in bed. Asked whether R3 had been care planned for grip socks at the time of the fall, she said, "He is now. I'm unsure if he was at the time."
The Director of Nursing told inspectors R3 should have been wearing grip socks per his care plan, and confirmed that if none were available on the unit, staff were expected to find them somewhere else in the facility. That is what CNA C did. The problem is that she left a man she described as impulsive, alone in a bathroom, mid-transfer, while she went to look.
LPN D, when asked whether R3 was care planned for grip socks, said, "I would assume he's care planned for gripper socks." An assumption, not a check.
CNA C put it plainly when she learned R3 had been wearing regular socks instead of grip socks at some point: "I don't understand why anybody would put him in regular socks. He shouldn't have had those socks in his room to begin with."
She was right. And yet the unit had run out of the right kind, nobody had restocked them, and when two different aides discovered the gap on the same day, neither one resolved it before leaving R3 on his own.
The Assistant Director of Nursing confirmed to inspectors that R3 was transferred to an acute care hospital after the fall because of increasing right hip pain. He was eventually readmitted to the facility.
Inspectors cited the violation at a level of minimal harm or potential for actual harm, affecting a few residents. The finding fell under F0689, the federal tag covering accident hazards and supervision.
What the records show is a gap that was visible before R3 hit the floor. Two aides, same shift, same unit, same missing supply, same resident. Neither one closed the loop before walking away.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maples Benzie County Medical Care 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: July 5, 2026 · Our methodology
Maples Benzie County Medical Care in Frankfort, MI was cited for violations during a health inspection on August 13, 2025.
The fall happened on July 25, 2025, at Maples Benzie County Medical Care.
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.