Resident 2 fell from his wheelchair on September 30, 2025, sliding slowly to the floor despite having his brakes locked. The incident prompted a care plan meeting two days later where staff decided he needed a therapy evaluation, a dropped wheelchair seat to prevent sliding, and non-skid material in his chair.
None of these interventions happened.
The resident fell again, this time fracturing his hip and requiring hospitalization for surgery. He returned to the facility on October 13 with a restorative nursing plan, but still without the wheelchair modifications that might have prevented his injury.
LVN C, who witnessed the first fall, told inspectors on October 22 that the resident had locked his brakes and slid in slow motion to the floor. She was surprised he fractured his hip from what appeared to be a soft fall. The licensed nurse said she never saw the resident in a wheelchair with the drop seat or non-skid material that the care team had decided he needed.
The facility's own policy requires staff to develop and implement comprehensive care plans with measurable objectives and timeframes to meet residents' medical and nursing needs. The policy states that care plans should help residents attain or maintain their highest practical quality of life.
But multiple staff members acknowledged the breakdown in following through on the safety plan.
The MDS Coordinator admitted during her October 22 interview that she was unsure how she missed adding the care plan interventions for the therapy evaluation and dropped seat. She said she was also uncertain why the non-skid material intervention was not carried out, adding that it was the job of the entire facility to read care plans and carry out the interventions.
The Director of Nursing offered a different explanation. She told inspectors that Resident 2 was private pay and had no funding for therapy services. She said therapy would have evaluated him and dropped his seat if it was safe, and would have provided the non-skid material, but because he was not evaluated before his hospitalization, he never received these safety measures.
The DON said a restorative nursing plan was finally written for the resident when he returned from hip surgery on October 13. But by then, the damage was done.
The Administrator acknowledged the importance of following interventions decided by the interdisciplinary team, telling inspectors that interventions are put in place to keep residents healthy and safe. He confirmed that the care plan meeting occurred on October 2, following the fall that injured the resident.
The Administrator said therapy was supposed to evaluate the resident for safety in his wheelchair, but this never happened because he was private pay and the cost needed family approval. When the resident eventually went to the hospital for hip surgery, therapy did evaluate him for a restorative program upon his return, but not for the dropped seat or non-skid material that had been identified as necessary weeks earlier.
The inspection found that the facility's failure to implement the agreed-upon safety interventions could have resulted in further injury to residents from additional falls. Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting some residents.
The case illustrates how administrative barriers and communication breakdowns can leave vulnerable residents at risk. Despite having a clear safety plan developed by the care team, the facility allowed nearly two weeks to pass without implementing basic wheelchair modifications that might have prevented a serious injury.
Resident 2's experience highlights the gap between care planning and execution at Marshall Manor West. Staff identified the problem, developed solutions, but failed to follow through. The resident paid the price with a fractured hip and surgery that could have been avoided.
The facility's comprehensive care planning policy promises to help residents maintain their highest practical quality of life. For Resident 2, that promise went unfulfilled as he slid from his wheelchair a second time, this time with consequences that required surgical intervention and extended hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Marshall Manor West from 2025-10-22 including all violations, facility responses, and corrective action plans.