The September 4 incident at Prairieview Lutheran Home involved a cognitively intact resident who required partial assistance for transfers and had fallen multiple times before. The resident's care plan specifically required staff to use a gait belt, grab bar, or walker during all transfers.
Nursing assistant V19 was helping the resident move from wheelchair to bed when the person let go of the bed rail to adjust their pants while standing. The resident's knees weakened and V19 assisted them to the floor.
No gait belt was used during the transfer.
"R7 went to grab the siderail on his bed, R7 let go with one of his hands to grab his pants while standing, R7 lost his balance and fell," V19 told inspectors on October 27. The assistant confirmed not using a gait belt despite the resident's care plan requiring one.
The resident sustained no injuries but told inspectors during the October visit about the recent fall with staff assistance. "A gait belt was not used during this transfer," the resident said.
Staff documented the fall in nursing notes but never completed an incident report or investigation packet. Director of Nursing V2 confirmed to inspectors that "the nurse documented R7's fall in the 9/4/25 nursing note but didn't complete an incident report" and "there was no fall investigation packet completed for this fall."
The facility's own policy requires staff to implement resident-centered fall prevention plans and monitor responses to interventions. The policy states that if residents continue to fall, "staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions."
None of that happened.
The resident's functional mobility assessment, completed by Licensed Practical Nurse V18, documented the person's transfer status as requiring one assist with a gait belt. V18 confirmed staff should also have the resident use grab bars in the bathroom, on the recliner, and on the bed, along with a wheeled walker.
Following the fall, nursing notes indicated the post-fall intervention would be to use two staff members for bed transfers instead of one. But without a proper investigation, staff couldn't determine whether the lack of safety equipment contributed to the incident or what other factors might prevent future falls.
The resident had experienced two or more falls without injury since their prior assessment, according to their Minimum Data Set. Their care plan, dated August 26, 2024, identified them as at risk for falls due to weakness and enrolled them in a transfer restorative program.
Federal regulations require nursing homes to ensure areas are free from accident hazards and provide adequate supervision to prevent accidents. The facility's failure to use required safety equipment during transfers and complete mandatory fall investigations violates those standards.
The accident investigation form from September 4 documented that V19 assisted the resident with the transfer and that the person's knees became weak, causing them to be lowered to the floor. But the form didn't record whether a gait belt was used, and no thorough investigation followed to determine root causes or prevent similar incidents.
During the October inspection, V19 provided additional details about the sequence of events, explaining the resident had been transferred from the bathroom to the wheelchair before the attempted bed transfer. The assistant described how the resident lost balance while trying to adjust their clothing during the standing portion of the transfer.
The resident's endurance and functional mobility assessment clearly established the safety requirements for transfers. V18, who completed that assessment, confirmed the resident needed one-person assistance with a gait belt and access to grab bars or walker during all transfers.
Without proper investigation and incident reporting, the facility missed opportunities to identify whether staff training, equipment availability, or care plan modifications could prevent future falls. The resident continues to require transfer assistance, but the September incident provided no learning opportunities for staff or safety improvements for the resident.
The inspection found the facility failed to safely transfer the resident and failed to investigate the resulting fall, despite having policies requiring both proper transfer techniques and thorough incident reviews.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prairieview Lutheran Home from 2025-11-05 including all violations, facility responses, and corrective action plans.