The woman, identified as R2 in state inspection records, had a fall risk score of 19 on a scale where anything above 10 indicates high risk. Her bed remained at average height instead of the lowest position required by her care plan. Her water cup sat beyond her reach.
"She cannot find her call light," inspectors noted as they observed the resident on August 19. "The call light should have been where she can reach for it," the resident told them the next day, when inspectors found the device wedged under her upper back.
Federal inspectors cited Norridge Gardens for failing to implement fall precautions for two residents during their August complaint investigation. The violations occurred despite documented falls, high-risk assessments, and care plans specifically requiring the safety measures that staff ignored.
R2's fall history painted a troubling pattern. She had fallen on November 15, December 21, June 3, and July 5. Each incident should have reinforced the need for basic precautions. Her left arm was bandaged during the inspection, though records don't specify whether this injury resulted from a recent fall.
The resident required two people to transfer from bed to wheelchair and could move her legs but not her upper body, according to the physical therapy assistant and rehab director. Both emphasized that R2 needed her bed in the lowest position with call lights within reach.
Her care plan, dated July 25, explicitly stated staff should "ensure R2's personal items and call light were within reach" and that she should "use her call light when assistance is needed." The restorative nurse confirmed that keeping the bed at its lowest position was a post-fall intervention specifically implemented for R2.
Yet on both days inspectors observed her, the bed remained at average height. On August 19, an LPN and CNA both verified the bed was not in the lowest position and confirmed the call light was out of reach. The table holding her water cup was positioned toward the lower half of her body, making it impossible for her to reach.
"R2 had the potential to fall again as R2 does not follow the nursing instructions," the nurse practitioner told inspectors. But the inspection findings suggest the facility, not the resident, failed to follow basic safety protocols.
The second resident, R3, faced identical problems. Inspectors found her sitting on her bed with feet on the floor, stating she wanted to use the bathroom and go to breakfast but needed help. Her call light was tied to a grab bar on the right side of her bed, hanging to the floor and completely out of reach.
"She wanted to use the bathroom and then go to the dining room for breakfast and needed to call for help, but her call light is out of her reach," inspectors documented. A CNA verified the call light was inaccessible.
The facility's own nursing staff understood the requirements. An RN and another RN told inspectors that fall precautions include keeping beds at the lowest position, having call lights and personal items near residents, and conducting frequent monitoring rounds. An LPN stated that "anyone with history of previous falls must have their beds in the lowest position and their call lights within their reach."
The nurse practitioner treating R2 was explicit about what was needed: "R2 must have her call light within reach, her bed in the lowest position, and have landing pads to minimize injuries." None of these basic safety measures were consistently implemented.
Landing pads were notably absent from R2's bedside during the inspection, despite her documented fall history and high-risk status. The combination of an elevated bed, inaccessible call light, and lack of floor padding created multiple opportunities for serious injury.
The violations affected residents who had already demonstrated their vulnerability through repeated falls. R2's four documented falls over eight months should have triggered heightened attention to prevention measures. Instead, inspectors found the most basic safety protocols ignored on consecutive days.
Staff members repeatedly acknowledged knowing what should be done, making the failures more striking. When nursing personnel can articulate proper fall prevention techniques but don't implement them for high-risk residents, the gap between policy and practice becomes a safety hazard.
The inspection occurred in response to a complaint, suggesting someone outside the facility recognized problems that internal oversight had missed or ignored. The findings were classified as causing minimal harm or potential for actual harm, affecting few residents.
For R2, searching unsuccessfully for her call light while lying in an elevated bed with a bandaged arm, the distinction between potential harm and actual harm may be academic. Her next fall could be the one that causes serious injury or death.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Norridge Gardens from 2025-08-21 including all violations, facility responses, and corrective action plans.