The resident, identified in inspection records as Resident 1, had fallen at the facility on June 2 at 11:10 p.m. Three weeks earlier, on May 11, they had fallen in the community, suffering severe injury that led to hospitalization and transfer to Terrace View.
Yet when staff completed a fall risk assessment, they recorded no falls for the resident.
The assessment also missed four medications that increase fall risk. Staff documented that Resident 1 took no high-risk medications, despite physician orders for a diuretic, an antihypertensive, a narcotic, and a sedative.
These errors combined to give the resident an artificially low fall risk score.
Federal inspectors reviewed the case during a complaint investigation completed October 29. They found that the facility's own policy, revised in October 2024, required staff to "identify specific risks and causes to try and prevent falls."
The resident was admitted to Terrace View after the community fall and discharged home on June 28. The unwitnessed facility fall occurred at 11:10 p.m. on June 2.
When inspectors interviewed Licensed Vocational Nurse 3 on October 29 at 6:40 a.m., the nurse verified the fall risk assessment contained "multiple inaccuracies." These included both the number of falls and the medications the resident was taking.
LVN 3 told inspectors that "the resident's fall risk score would have been higher if it had been scored accurately."
The Director of Nursing confirmed the same problems during a separate interview that afternoon at 2:45 p.m. The DON verified that the assessment contained multiple inaccuracies regarding both falls and medications.
"The DON stated the resident's fall risk score would be higher if it had been assessed and scored accurately," inspectors wrote.
The inspection focused on falls prevention after receiving a complaint. Inspectors sampled three residents who had experienced falls, finding the assessment failures affected one of the three.
Resident 1's community fall on May 11 was severe enough to require hospitalization before transfer to the nursing facility. Less than a month later, on June 2, they fell again while at Terrace View.
The medications missed in the assessment represent four different categories that increase fall risk. Diuretics can cause dehydration and dizziness. Antihypertensive medications can lead to drops in blood pressure when standing. Narcotics can cause drowsiness and confusion. Sedatives have calming or sleep-inducing effects that can impair balance and reaction time.
All four medication types were ordered by the resident's physician but ignored during the fall risk screening.
The fall risk assessment was completed early in the morning hours, at 4:41 a.m., according to inspection records. The timing suggests it may have been done during a night shift, when staffing is typically lighter.
Inspectors reviewed closed medical records for the resident, who had been discharged home nearly four months before the October inspection. The review began October 28, the day before the inspection concluded.
The facility's fall prevention policy, updated just a month before the inspection, emphasizes identifying specific risks and causes. But the assessment failures meant staff missed clear risk factors for a resident who had already demonstrated a pattern of falling.
The June 2 fall at the facility occurred late at night, when supervision is often reduced. Inspection records describe it as "unwitnessed," meaning no staff member saw what happened.
Federal regulations require nursing homes to maintain accident-free environments and provide adequate supervision to prevent accidents. The inaccurate fall risk assessment violated these requirements by failing to properly identify and address known risk factors.
When inspectors interviewed both the LVN and Director of Nursing, both immediately recognized the errors in the assessment. Neither offered an explanation for how such obvious mistakes occurred.
The resident's case illustrates how documentation failures can compromise safety. A higher fall risk score would have triggered additional precautions and monitoring. Instead, the artificially low score suggested the resident needed less protection than their history indicated.
The timing of events created a particularly concerning pattern. The resident fell in the community on May 11, was hospitalized, transferred to Terrace View, then fell again at the facility on June 2. Yet the fall risk assessment, completed sometime during this period, recorded zero falls.
The medication screening errors were equally significant. Each of the four missed medications affects balance, alertness, or blood pressure in ways that increase fall risk. Diuretics can cause frequent urination, leading to rushed trips to the bathroom. Blood pressure medications can cause dizziness when standing up. Pain medications and sedatives can impair judgment and coordination.
Missing all four medication categories in the screening suggests either inadequate training or insufficient attention to detail during the assessment process.
Inspectors found the deficiency created "minimal harm or potential for actual harm" affecting "few" residents. However, for Resident 1, the potential consequences were serious. Falls can cause fractures, head injuries, and other complications that are particularly dangerous for older adults.
The resident's discharge home on June 28 came about three and a half weeks after the facility fall. Whether the inaccurate assessment affected their care during those final weeks at Terrace View remains unclear from inspection records.
Both nursing staff members interviewed acknowledged that accurate scoring would have resulted in a higher fall risk designation. This suggests they understood the assessment criteria but failed to apply them correctly in this case.
The facility's October 2024 policy revision on fall prevention came just weeks before the inspection, indicating recent attention to the issue. Yet the assessment errors for Resident 1 occurred despite this updated guidance.
Resident 1's experience demonstrates how documentation failures can cascade into safety risks, leaving vulnerable residents without appropriate protections while creating the illusion of proper care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace View Care Center from 2025-10-29 including all violations, facility responses, and corrective action plans.