The Licensed Vocational Nurse worked the night of April 3, 2025, and was assigned to Resident 1. A certified nursing assistant reported to her that the resident was on the floor, though the LVN could not recall which aide made the report.
"I did not have the time to do frequent visual checks on Resident 1," the LVN told federal inspectors during an August 27 interview.
The resident's care plan specifically required monitoring every hour for increased supervision. The LVN acknowledged this requirement during her interview with inspectors.
"If the resident was a fall risk, the resident should have been checked frequently," she said, recognizing the standard she had failed to meet.
A registered nurse at the facility explained the basic safety protocol to inspectors on April 2. When a resident was high risk for falls, the resident should be seen frequently to ensure safety, she said. A care plan for falls should be developed and interventions should be followed.
The Director of Nursing reinforced this standard during his August 28 interview. When a resident was a fall risk, frequent visual checks should have been done, he told inspectors.
Federal inspectors reviewed the facility's Fall Prevention Program policy, revised December 28, 2023. The policy states that each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.
The policy defines a fall as an event in which an individual unintentionally comes to rest on the ground, floor, or other level. The event may be presumed when a resident is found on the floor or ground.
Upon admission, nurses must complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse and interdisciplinary team must initiate interventions on the resident's care plan, in accordance with the resident's level of risk.
For at-risk residents, the policy requires additional interventions as directed by the resident's assessment, including increased frequency of rounds and a sitter if indicated.
Despite these clear protocols, Resident 1 ended up on the floor while under the care of a nurse who admitted she couldn't provide the required supervision.
The LVN's admission reveals a gap between the facility's written policies and actual staffing capabilities. While the facility's Fall Prevention Program mandates frequent checks for high-risk residents, the nurse responsible for Resident 1 stated plainly that time constraints prevented her from following the care plan.
The case illustrates how staffing limitations can compromise resident safety even when facilities have appropriate policies in place. The resident's care plan called for hourly monitoring specifically because of fall risk, yet the assigned nurse couldn't provide that level of supervision.
The incident occurred despite multiple layers of oversight built into the facility's system. The fall risk assessment, individualized care plan, and policy requirements all pointed toward the need for frequent monitoring. The breakdown came at the point of actual care delivery.
Federal inspectors found the violation represented minimal harm or potential for actual harm, affecting few residents. However, the case demonstrates how resource constraints can undermine safety protocols designed to protect vulnerable residents.
The facility's policy acknowledges that falls may be presumed when a resident is found on the floor or ground. In this case, that presumption applied to Resident 1, whose required hourly checks might have prevented the incident.
The Director of Nursing's acknowledgment that frequent visual checks should have been done for fall-risk residents contrasts sharply with the LVN's admission that she lacked time to provide such monitoring. This disconnect between management expectations and frontline reality left Resident 1 without the protection her care plan required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Community Care and Rehabilitation Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
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