That reasoning allowed the facility to skip required medical assessments, family notifications, and physician alerts after at least two incidents involving Resident 8 in September 2025.
The 84-bed facility failed to complete neurological checks, pain assessments, skin examinations, or 72-hour monitoring protocols after the resident was found on the ground September 14 and again September 16. Staff also didn't notify the resident's doctor or family about either incident.
During interviews with federal inspectors, multiple nurses confirmed the facility's systematic failure to follow post-fall procedures. RN 2 acknowledged that completing post-fall documentation was "important to check if there were any changes in the resident's condition," yet verified none of the required assessments had been done.
RN 3 reviewed Resident 8's medical record and found the progress note from September 14 showed "no neurological assessments, assessments for the skin, pain, and fall risk, and 72-hour post fall monitoring and documentation completed after the resident's fall incidents."
The facility's approach became clear during interviews with the director of nursing. She initially told inspectors that Resident 8's falls "were considered a behavior" and that "when Resident 8 was found on the floor, it was not considered a fall because it was a behavior."
She distinguished between what she saw as actual falls versus behavioral incidents. "A fall was when a resident tripped and fell," she explained to inspectors.
But when pressed the following day about her professional definition of a fall, the director changed her answer entirely. "Anything when the part of the body is touching the ground, it's a fall," she admitted. Asked directly if Resident 8's incidents should be considered falls, she answered yes.
RN 1 offered a different explanation for the missing documentation. She claimed the required assessments "were still done" but weren't documented because staff "monitored him every day." However, when shown the resident's behavior monitoring record, inspectors found it was incomplete.
The facility had convened a team meeting in May 2025 to address Resident 8's pattern of getting up unassisted. The plan called for monitoring and recording how often this behavior occurred each shift. But this behavioral approach meant skipping medical protocols required after falls.
LVN 2 described learning about a second incident on September 16 during shift change. She was told "Resident 2 sustained skin tears due to a fall" but said she "was not aware of the specifics of the fall." She documented her skin assessment findings but confirmed "there was no documentation, including the COC (change of condition), IDT, post fall monitoring, and post fall assessments done addressing the resident's fall."
When asked if assessments and documentation should have been completed, LVN 2 answered yes.
The director of nursing's own review of Resident 8's medical record confirmed the violations. She verified that after the September 14 incident, there was no change-of-condition documentation, no team notes, no neurological checks, no pain or skin assessments, no post-fall risk evaluation, no family notification, no physician alert, and no 72-hour monitoring.
For the September 16 incident, she found even less documentation. The medical record showed no progress notes, no change-of-condition documentation, no team consultation, no neurological assessment, no pain evaluation, no post-fall assessment, no family notification, and no 72-hour monitoring.
The facility's policy of treating falls as behavioral incidents rather than medical events meant Resident 8 received no systematic evaluation for potential injuries, complications, or changes in condition after being found on the ground twice within three days.
Federal regulations require nursing homes to assess residents immediately after falls and monitor them for 72 hours to detect delayed complications like internal bleeding or brain injuries that might not be immediately apparent.
Resident 8's case illustrates how administrative decisions about terminology can directly impact resident safety. By classifying falls as behavior rather than medical events, the facility avoided triggering the comprehensive assessment and monitoring protocols designed to protect vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Ridge Post Acute from 2025-09-25 including all violations, facility responses, and corrective action plans.