Two residents fell repeatedly without receiving required safety interventions. One resident fell four times between May and August. The other fell in July. Neither had their care plans updated with fall prevention measures afterward.
The facility's own written procedure, titled "Steps to Follow When a Fall Occurs," requires staff to hold immediate team meetings to determine interventions, establish new interventions, and place them on care plans. Inspectors found the facility failed to follow its own rules.
Resident #3 experienced the most falls. Clinical records show documented falls on May 17, May 21, August 23, and August 29. After each incident, staff failed to add new fall interventions to the resident's care plan.
Resident #2 fell on July 17. Like the other resident, no new fall interventions appeared on the care plan following the incident.
When inspectors interviewed the Director of Nursing on September 10 at 9:40 a.m., she acknowledged the requirement. "I know interventions need to be on the care plan, I get that, but sometimes we have other things," she said.
The nursing director could not provide evidence that fall-related interventions had been placed on either resident's care plan.
Federal inspectors reviewed clinical records on September 10 and found the care plan gaps. The facility's own documentation showed multiple falls for both residents, but no corresponding safety measures were implemented.
The inspection was conducted as a complaint investigation on September 11. Inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
During the inspection, administrators met with the Director of Nursing, regional director of clinical services, and vice president of operations. They were informed of the concerns but provided no additional information.
The facility's written fall procedure outlines specific steps staff must take after any resident falls. The document requires immediate team meetings with current staff to determine interventions to prevent further falls. It mandates establishing new interventions and placing them on care plans, then implementing those interventions.
None of these steps were followed for either resident who fell.
Resident #3's pattern was particularly concerning to inspectors. Four documented falls over a four-month period, with the most recent incidents occurring just six days apart in late August. Each fall represented an opportunity to implement safety measures that could have prevented subsequent incidents.
The nursing director's statement revealed awareness of regulatory requirements coupled with apparent disregard for following through. Her admission that other priorities took precedence over fall prevention planning highlighted systemic issues in care plan management.
Federal regulations require nursing homes to ensure areas are free from accident hazards and provide adequate supervision to prevent accidents. Care plans serve as the primary tool for documenting and implementing individualized interventions to keep residents safe.
Falls represent one of the most serious safety risks in nursing homes. When residents fall repeatedly without interventions, the risk of serious injury increases significantly with each incident.
The inspection found that Alleghany Health and Rehab had established appropriate written procedures for fall response but failed to implement them consistently. The gap between policy and practice left vulnerable residents without necessary protections.
Both residents who fell remained at risk for future incidents without proper interventions in place. The facility's failure to update care plans meant ongoing safety concerns were not being systematically addressed.
The September complaint investigation revealed broader issues with care plan management and staff follow-through on safety protocols. Despite having clear written procedures, the facility struggled to execute basic fall prevention requirements.
The nursing director's candid admission during the interview suggested that competing priorities regularly interfered with mandatory safety interventions. Her statement indicated that required fall prevention measures were viewed as optional rather than essential resident protections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alleghany Health and Rehab from 2025-09-11 including all violations, facility responses, and corrective action plans.