Resident #120 at Teays Valley Center scored 15 on his fall risk evaluation upon admission in September 2024. The assessment noted he had fallen twice in the previous three months and remained "disoriented x 3 at all times," meaning he was confused about person, place and time.
The evaluation documented additional risk factors that elevated his fall danger. He was chairbound but continent. He had one to two predisposing diseases. His condition had changed within the previous 14 days. He was prescribed medications that could increase his fall risk.
Despite this comprehensive assessment identifying multiple fall hazards, the facility created no interventions to address them.
On October 6, 2024, Resident #120 fell.
The facility's incident reports confirmed the fall occurred. Only then, on October 7 — the day after the fall — did staff finally add fall risk interventions to his care plan.
Federal inspectors discovered the gap during a complaint investigation on October 21, 2025. They reviewed Resident #120's care planning documents and found the facility had failed to develop person-centered interventions to address his documented fall risks.
The facility's Director of Nursing acknowledged to inspectors that they had not addressed Resident #120's fall risk in his care plan when interviewed about the violation.
Fall risk assessments are designed to prevent exactly what happened to Resident #120. The evaluation process identifies residents most likely to fall and triggers specific interventions — bed alarms, frequent checks, physical therapy, medication reviews, or environmental modifications.
Resident #120's assessment revealed he met multiple criteria placing him in the highest risk category. His disorientation meant he couldn't reliably judge distances or remember safety precautions. His recent falls indicated a pattern of instability. His medications carried additional fall warnings.
The facility documented all these risks upon his admission. They assigned him a fall risk score of 15, well above thresholds that typically trigger immediate interventions at most nursing homes.
Yet his care plan contained no fall prevention strategies for weeks.
The October 6 fall was entirely predictable based on his assessment. A resident with his risk profile — chairbound, disoriented, medication-affected, with a recent fall history — represents exactly the type of case that comprehensive care planning is designed to prevent.
Federal regulations require nursing homes to develop care plans that address all of a resident's identified needs. The plans must include specific, measurable interventions with clear timetables for implementation.
For fall-risk residents, this typically means immediate safety measures. Common interventions include positioning beds at the lowest setting, ensuring call lights are within reach, providing non-slip socks, scheduling frequent safety rounds, and reviewing medications that affect balance or cognition.
None of these protections were in place for Resident #120 during his first weeks at the facility.
The timing of the care plan update reveals the reactive nature of the facility's approach. Adding fall interventions on October 7, immediately after the October 6 incident, demonstrates that staff understood what needed to be done. They simply hadn't done it.
This pattern — comprehensive assessment followed by inadequate care planning — undermines the entire resident safety system. Facilities conduct detailed evaluations specifically to identify risks before they result in harm.
When those assessments sit unused, residents like #120 experience preventable injuries.
The inspection found that Teays Valley Center, which houses 115 residents, failed to ensure person-centered comprehensive care planning for at least one of thirteen residents reviewed during the investigation.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The classification suggests the problem was caught before more serious injuries occurred.
But for Resident #120, the facility's failure meant weeks of unnecessary fall risk while disoriented and vulnerable in an unfamiliar environment.
His October 6 fall stands as a direct consequence of care planning that existed on paper but not in practice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Teays Valley Center from 2025-10-21 including all violations, facility responses, and corrective action plans.