The resident, identified as R5 in inspection records, has a complex medical history including metabolic encephalopathy, orthostatic hypotension, chronic atrial fibrillation, major depressive disorder, and a documented history of falling. Her July assessment showed she was moderately cognitively impaired and required supervision or assistance with transfers.
On August 3 at 4:20 PM, R5 got herself up unattended in the dining room. Her alarm sounded and staff found her on the floor. The fall was witnessed, with no head involvement noted.
Five days later, it happened again.
On August 8 at 3:49 PM, staff called a licensed practical nurse to the dining room. The nurse found R5 sitting on her buttocks in front of her wheelchair. No injury was noted, and her range of motion remained within normal limits.
Despite these two falls, inspectors discovered that basic safety equipment outlined in R5's care plan was missing entirely. Her undated care plan specifically identified her as at risk for falls and required two interventions: non-skid socks and a non-skid mat below and on top of her wheelchair pad.
On August 11 at 10:53 AM, an inspector observed R5 sitting in her wheelchair in the dining room. She was wearing black and white socks with no non-skid material on the soles.
The next day, the inspector returned with the facility administrator to examine R5's wheelchair. The administrator stood R5 up and raised the wheelchair cushion to check for the required non-skid mat.
There was nothing there.
No mat was observed below or on top of R5's wheelchair pad. The administrator confirmed that R5's fall intervention equipment was not in place as required by her care plan.
At 2:53 PM that same day, the administrator told the inspector she expects resident fall interventions to be in place per their care plans.
The facility's own Falls and Fall Risk Managing policy, dated March 2018, requires staff to identify interventions related to each resident's specific risks and causes to prevent falls and minimize complications. The policy emphasizes resident-centered approaches and states that staff will implement fall prevention plans to reduce specific risk factors for each resident at risk or with a history of falls.
The policy provides detailed guidance for systematic evaluation and intervention. It requires staff to prioritize interventions when multiple approaches are identified, including examples such as exercise and balance training, room furniture rearrangement, improved footwear, and better lighting.
For residents like R5, the policy mandates that if falling recurs despite initial interventions, staff must implement additional or different approaches until falling is reduced or stopped, or until the continuation of falling is identified as unavoidable.
The policy also addresses alarm systems, stating they should not be used as the primary intervention but rather to help staff identify patterns and routines. Staff must respond to alarms in a timely manner and monitor their effectiveness.
R5's case represents a fundamental breakdown in this system. Despite having a documented history of falls, despite being cognitively impaired and requiring assistance with transfers, despite falling twice in the dining room within five days, the most basic safety equipment remained absent.
Her care plan wasn't complicated or experimental. It called for non-slip socks and wheelchair mats — simple, standard interventions that nursing homes routinely provide to prevent falls.
The violation occurred during a complaint inspection on August 13, 2025. Federal inspectors classified it as minimal harm or potential for actual harm, affecting few residents.
But for R5, the consequences were more than minimal. She experienced two falls in an environment where staff knew she was at high risk and had specific tools available to help protect her. The facility's own administrator acknowledged that the required safety measures weren't in place, despite having clear expectations that they should be.
R5 continues to face the daily risk of falling without the basic protective equipment her care team determined she needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Three Springs Sr Living & Rhab from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
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