Resident #2 required partial to moderate assistance for transfers and had fallen before arriving at the facility. The resident's admission assessment on September 17 triggered a care area assessment for falls, which should have prompted staff to develop a specific fall risk care plan.
No care plan was created.
The first fall happened the next day. A nursing progress note from September 18 at 8:04 am documented that Resident #2 was "found on the floor in room with no apparent injury."
Two weeks later, the resident fell again. The October 2 nursing note at 3:30 pm recorded a "witnessed fall with no injury noted."
The next day brought a third fall. The October 3 note at 7:00 pm documented another "witnessed fall in room with no injury noted."
Federal inspectors interviewed the MDS Nurse on October 8, who confirmed that no fall risk care plan existed for Resident #2. She acknowledged she should have developed the plan when completing the admission assessment and care area review.
"She must have missed it," the MDS Nurse told inspectors.
The facility's Interim Director of Nursing explained that an interdisciplinary team met weekly to discuss each resident and ensure care plans reflected their needs. But the MDS Nurse responsible for creating fall risk care plans was not attending these weekly meetings.
"The care plan should have been updated during the weekly IDT meeting by the MDS Nurse," the Interim Director of Nursing told inspectors on October 8. She confirmed the MDS Nurse was absent from the meetings designed to ensure residents' care plans matched their actual needs.
The Administrator confirmed during her October 8 interview that the MDS Nurse was responsible for developing Resident #2's fall risk care plan.
Fall prevention represents a critical safety measure for nursing home residents, particularly those with cognitive impairment who may not recognize hazards or remember safety instructions. Federal regulations require facilities to assess fall risk and implement specific interventions to prevent injuries.
Resident #2's case illustrates how administrative gaps can leave vulnerable residents without basic protections. The admission assessment correctly identified fall risk and triggered the requirement for a care plan. The system broke down at the implementation stage.
The timing proved particularly concerning. Resident #2 fell the day after admission, then twice more within two weeks. Each incident was documented in nursing notes, yet no care plan materialized to address the obvious pattern.
The MDS Nurse's absence from weekly interdisciplinary team meetings meant the staff member responsible for fall risk assessments was not participating in discussions about resident care needs. This created a communication gap that left Resident #2 without appropriate interventions.
While none of the three falls resulted in apparent injury, the pattern demonstrated the facility's failure to implement required safety measures for a resident already identified as high-risk for falling.
The inspection found the facility violated federal requirements for comprehensive care planning. Regulations mandate that nursing homes develop care plans addressing each resident's specific needs and risks, including fall prevention for those identified as vulnerable.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The finding resulted from a complaint investigation conducted on November 17.
The case highlights how seemingly minor administrative oversights can compromise resident safety. A care plan might have included interventions such as increased supervision, environmental modifications, or assistive devices to reduce fall risk.
Instead, Resident #2 experienced three falls in two weeks while staff documented each incident without implementing the prevention measures required by the initial assessment.
The MDS Nurse's admission that she "must have missed it" underscores the human element in nursing home safety failures. Individual oversights, compounded by system gaps like missing key staff from interdisciplinary meetings, can leave residents vulnerable to preventable harm.
For Resident #2, the consequence was three falls within 16 days of admission, each documented but none prevented by the care plan that should have been in place from day one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Davis Health and Wellness Center At Cambridge Vill from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Davis Health and Wellness Center At Cambridge Vill
- Browse all NC nursing home inspections