The August 26 fall at Imboden Creek Senior Living involved a resident whose medical records show fractures, chronic pain from trauma, and unsteadiness on her feet. Her care plan documented impaired decision-making, memory loss, and a history of falling. She required a chair alarm due to impulsivity.
Licensed Practical Nurse V3 discovered the resident around 2:15 PM while walking by her room after hearing yelling. The resident was sitting on her buttocks directly in front of her wheelchair with visible bruises on her right temple, right arm, and left forearm.
"It looked like that's what she was trying to do," said LPN V4, describing how the resident appeared to have been attempting to transfer herself from the wheelchair. When staff asked what happened, the resident couldn't remember.
V4 performed an assessment and took vital signs, writing the information on a piece of paper for another nurse, V7. But V4 never documented the assessment, vital signs, or any details about the fall in the resident's medical record.
More critically, nobody called the family.
"I know I am supposed to call the family and tell the Administrator," V4 told inspectors. She said she assumed V7 would handle those notifications, but V7 never even went to the resident's room to check on her condition.
The Administrator confirmed during interviews that the family was never notified about the incident. This violated the facility's own policy, which requires staff to document the date and time when a resident's family member is notified of an accident.
The resident's medical history made the communication failure particularly concerning. Her diagnoses included a pelvic fracture, chronic pain from trauma, and multiple mobility issues. A fall risk evaluation from June documented that she was at risk due to intermittent confusion, being chair-bound, and requiring assistive devices.
Her care plan specifically noted impaired cognitive function, impaired thought processes, long-term and short-term memory loss, and decreased mobility. The chair alarm was installed because of her impulsivity - exactly the kind of behavior that led to this incident.
Federal regulations require nursing homes to immediately notify residents' families of situations that affect the resident, including injuries and accidents. The rule exists because families need to know when their loved ones are hurt so they can make informed decisions about care and potentially seek additional medical attention.
In this case, the breakdown occurred at multiple levels. The nurse who found the resident didn't make the required notifications. The nurse who conducted the assessment didn't document it or contact anyone. The supervising nurse who was supposed to receive the vital signs never checked on the resident.
The facility's policy, last revised in July 2017, clearly directs staff to document when family members are notified of accidents. But eight years later, staff either didn't know the policy or chose not to follow it.
The incident represents exactly the kind of communication failure that federal oversight is designed to prevent. When nursing home residents fall and sustain injuries, especially those with cognitive impairments who cannot advocate for themselves, families serve as crucial monitors of their care.
Without notification, this resident's family had no way to know she had fallen, suffered head and arm bruises, or might need additional medical evaluation. They couldn't ask questions about how the fall happened, whether preventive measures were adequate, or if the injury required follow-up care.
The Administrator's admission that the family was never contacted came more than a week after the incident, during the September inspection. By then, any opportunity for the family to seek immediate medical attention or adjust the resident's care plan had long passed.
For a resident already documented as having impaired decision-making and memory loss, family notification becomes even more critical. She couldn't remember what happened during the fall, making family advocacy essential for ensuring proper care.
The facility's failure violated not just federal regulations but basic principles of transparency and family involvement in nursing home care. When residents are hurt, families deserve to know immediately, not discover it weeks later during a government inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Imboden Creek Senior Living from 2025-09-05 including all violations, facility responses, and corrective action plans.