Saint John Paul II Center: Skipped Safety Checks - CT
The incident occurred at Saint John Paul II Center on July 22, when Resident #2 fell sometime around 2:50 AM. Licensed Practical Nurse #2 found the resident lying on their back on the floor next to the bed, with their head positioned at the bottom of the bed.
"Resident #2 was yelling out for help, so she ran down to the room," according to LPN #2's account to federal inspectors. The nurse immediately called for the registered nurse on duty, who assessed the resident and found no injuries.
Staff used a mechanical lift to get the resident back into bed. RN #1 initiated neurological checks, which are standard protocol after any unwitnessed fall to monitor for potential head injury or other complications.
LPN #2 began conducting the neurological evaluations every 15 minutes as required. She continued the assessments from 2:50 AM until 4:50 AM without incident.
But at approximately 5:20 AM, the resident fell asleep.
Rather than wake the resident to continue the mandatory safety checks, LPN #2 simply stopped. She documented at 5:20 AM, 5:50 AM, 6:20 AM and 6:50 AM that "Resident #2 was asleep" and ceased evaluating the resident's neurological status entirely.
The nurse left her shift at 7:00 AM, having abandoned the safety protocol for over an hour and a half.
The neurological evaluation flow sheet wasn't completed again until 7:20 AM on July 20 through 2:00 AM on July 21, indicating the resident's neurological status was eventually assessed by other staff.
When inspectors interviewed the Director of Nursing on August 21, she made clear this violated facility expectations. Her policy requires that "anytime a resident has an unwitnessed fall neurological evaluations are initiated and conducted per the frequency on the neurological flow sheet until complete."
The DON was explicit about what should have happened: "On 7/20/25 when Resident #2 was sleeping, LPN #2 should have woken up Resident #2 and assessed Resident #2's neurological status."
The fall itself appeared serious enough to warrant concern. Nurse Aide #4, who was working the 11 PM to 7 AM shift, described hearing LPN #2 "yelled to her to come down to Resident #2's room." When the aide arrived, she found the resident "on his/her back lying on the floor next to the bed with his/her head next to the bottom of the bed."
Despite the concerning positioning, the resident was "alert, awake, and talking" when found, according to the nurse aide's account.
RN #1, who responded to assess the resident after the fall, told inspectors the resident "was alert and responsive, denied hitting his/her head, denied any pain, and no injuries were noted." The RN confirmed the resident's "neuros were within normal limits" during the initial assessment.
But that initial assessment wasn't the end of the safety protocol. Neurological checks after falls are designed to catch delayed symptoms that might not be immediately apparent, particularly in elderly residents who may not show immediate signs of head trauma.
The facility's neurological flow sheet establishes the frequency for these ongoing evaluations. Federal inspectors requested the facility's neurological assessment policy during their investigation, but the facility failed to provide it.
LPN #2's decision to let the resident sleep rather than wake them for the safety checks represents a fundamental misunderstanding of post-fall protocols. The evaluations are specifically designed to detect changes in neurological status that could indicate delayed complications from the fall.
By stopping the assessments because the resident was asleep, the nurse created a gap in monitoring during a critical period when neurological changes could have occurred without detection.
The timing made the lapse particularly concerning. The resident fell at 2:50 AM, and neurological checks continued until 4:50 AM. But from 5:20 AM until at least 7:00 AM when the nurse's shift ended, no evaluations occurred.
That represents nearly two hours without the safety monitoring specifically required after unwitnessed falls.
Federal inspectors classified this as a violation with minimal harm or potential for actual harm, affecting few residents. But the incident highlights how individual nursing decisions can undermine facility-wide safety protocols designed to protect vulnerable residents after potentially serious incidents.
The resident who fell required mechanical lift assistance to return to bed, suggesting mobility limitations that could have made the fall more dangerous. Yet the nurse's decision to prioritize the resident's sleep over required safety monitoring left a significant gap in care during the critical hours following the incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Saint John Paul II Center from 2025-08-21 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
SAINT JOHN PAUL II CENTER in DANBURY, CT was cited for violations during a health inspection on August 21, 2025.
The incident occurred at Saint John Paul II Center on July 22, when Resident #2 fell sometime around 2:50 AM.
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.