The October incident at Accura Healthcare of Carroll left the resident lying on her stomach, complaining of ankle and toe pain, before staff used a mechanical lift to move her to a wheelchair. Hours later, worsening ankle pain sent her to the hospital for X-rays.
The resident required assistance from two staff members at all times for care-related activities, according to facility records reviewed by federal inspectors. But on the morning of the fall, only one certified nursing assistant was helping with the transfer.
Staff A, the lone aide present, told inspectors she was assisting the resident when "she had a jerky moment and fell." The aide immediately radioed for help, bringing additional staff members to the room where they found the resident face-down on the floor.
Licensed Practical Nurse Staff D, who responded to the radio call, said the resident gave conflicting accounts of what happened. "Resident #1 stated she slipped out of bed first, and then stated that she had a jerky moment and fell," the nurse told inspectors.
The resident initially complained only of ankle and toe pain while lying on the floor. Staff D assessed her while she remained face-down, then helped other staff members roll her onto her back for a more thorough evaluation.
"Resident #1 did not complain of pain once staff rolled her to her back," Staff D said. The resident had normal range of motion with no facial grimacing, according to the nurse's assessment.
Four staff members then used a full-body mechanical lift with a sling to transfer the resident to her motorized wheelchair, per her request not to return to bed. The resident was wearing shoes at the time of the fall, multiple staff members confirmed.
Staff D noted the resident's obesity and lymphedema made it difficult to detect swelling or bruising immediately after the incident. The resident "stated she was okay until later in the afternoon," when her ankle pain intensified.
The worsening symptoms prompted Staff D to send the resident to the hospital for X-rays that afternoon.
CNA Staff C, who arrived after the initial response, helped obtain the mechanical lift equipment. She found the resident still lying face-down with "a couple of nurses and CNAs already present in the room."
Multiple staff members confirmed the resident normally required assistance from one person with a gait belt and four-wheeled walker for transfers. But facility records showed she needed two staff members present at all times for any care-related activities due to what the inspection report described as "false allegations."
Staff B, another responder, emphasized that the resident "always has her shoes on before a transfer" and confirmed the two-person requirement for all care activities.
The facility's comprehensive care plan, dated April 2025, required interdisciplinary team review and revision after each assessment. Federal inspectors found the violation represented minimal harm or potential for actual harm affecting few residents.
The incident highlighted gaps between written safety protocols and actual practice at the 120-bed facility. While staff responded quickly once the fall occurred, the initial violation of the two-person rule created the conditions that led to the resident's injury and subsequent hospitalization.
Staff interviews revealed consistent details about the response: the resident's face-down position, her initial complaints of toe and ankle pain, and the eventual need for mechanical lift assistance. But none addressed why only one aide was present for the original transfer attempt.
The resident's conflicting explanations - first saying she slipped from bed, then describing a "jerky moment" - suggested confusion about the exact sequence of events. Her delayed pain response, with ankle discomfort worsening hours after the fall, ultimately required medical evaluation beyond what facility staff could provide.
Federal inspectors documented the violation as part of a complaint investigation completed in October 2025, finding the facility failed to ensure adequate supervision during resident transfers as required by its own care planning protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Accura Healthcare of Carroll from 2025-10-15 including all violations, facility responses, and corrective action plans.