The September 8 incident at Linn Manor Care Center began when two certified nursing assistants found Resident #1 in his bathroom during their 6 a.m. rounds. Staff E asked if he needed help, but he declined assistance. Both workers reminded him to use his call light when finished, then left him sitting alone on the toilet to continue their rounds.
Staff D discovered the resident on the floor between his bed and bathroom around the same time, his wheelchair beside him with wheels locked. The resident had no shoes on his feet.
"This was the worst pain he had ever had," the resident told staff, rating his hip pain as 10 out of 10. Emergency room doctors confirmed a left hip fracture requiring surgical repair.
The fall occurred despite a clear intervention put in place just 24 hours earlier. After Resident #1 fell from his wheelchair on September 7, the Director of Nursing issued specific instructions that staff "do not leave unattended in his room in the wheelchair."
But when inspectors interviewed the DON on October 15, she admitted she "failed to know the difference from leaving him in the w/c or on the toilet in his room unattended." She acknowledged that when staff found the resident on the toilet on September 8, "the staff should not have left him on the toilet."
The confusion over basic safety protocols extended throughout the nursing staff. Licensed Practical Nurse Staff F said that after the September 7 fall, "she wouldn't have left him sitting on the toilet." Staff D, the nursing assistant who found the resident on the floor, was emphatic: "He would never leave Resident #1 on the toilet alone."
Yet that's exactly what happened.
Resident #1 had a documented history of falls and risky transfers. Licensed Practical Nurse Staff H reported the resident "had several falls they were due to him getting up from the wheelchair" and said he had seen the resident "attempt to get out to the wheelchair a few times."
Staff A confirmed the resident "attempted to self transfer before" and described their system for monitoring him: a touch call light placed next to him in bed "so they would know if he was getting up the light would come on."
The facility's investigation revealed staff had checked on the resident in his bathroom shortly before the fall and reminded him to use his call light when finished. But crucially, "none of the staff assisted Resident #1 off the toilet."
The investigation concluded the resident "took himself to the bathroom and fell attempting to go back to his bed from his wheelchair."
During interviews with inspectors, the nursing assistants revealed the breakdown in communication that led to the resident being left alone. Staff A reported she "failed to help him into the bathroom" and "left him with Staff E to care for him." Staff D, meanwhile, said he "failed to know Resident #1 was out of bed before finding him on the floor."
The DON's confusion about the previous day's safety directive proved particularly troubling. She admitted she "failed to know staff used the do not leave unattended intervention on the fall from the w/c in Jun 25, 2025" – indicating this wasn't the first time such an order had been issued for this resident.
The facility's own fall prevention policy acknowledges that "over 40% of nursing home residents fall each year" and that "five percent of these falls can result in a serious injury." The policy lists previous falls and problems with mobility as key risk factors and directs staff to "identify the possible reason for the fall and make appropriate changes to the plan of care."
Staff E's account revealed the casual nature of the decision to leave the resident unattended. During her interview, she described finding the resident on the toilet during rounds with Staff A, asking if he needed help, being declined, and then simply walking away to finish their duties down the hall.
The resident returned from the hospital three days later with a surgically repaired hip fracture, facing the long recovery that follows such injuries in elderly patients.
The incident highlights how quickly safety interventions can fail when staff don't understand or follow basic protocols. A resident identified as high-risk for falls, with explicit orders not to be left alone, was abandoned on a toilet by workers who later claimed they would never do such a thing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Linn Manor Care Center from 2025-10-16 including all violations, facility responses, and corrective action plans.