Resident 9 sat on the edge of their bed without a call light within reach on November 14. No fall mats flanked either side of the bed. No wheelchair sat in the room. No quarter bilateral enabler bars were attached to the bed.
The resident's care plan required all of those protections.
Staff 30, an agency certified nursing assistant, checked the Kardex during shift change that morning. The quick reference tool still showed Resident 9 needed moderate assistance from one person with transfers and walking. It specified the resident should have a wheelchair, floor mats on both sides of the bed, and enabler bars attached to the bed.
None of those safety measures were in place.
"She/he did not need assistance walking in their room," Resident 9 told inspectors. The resident explained they didn't use the call light because their roommate would call staff or find someone when help was needed.
For over four hours that day, from 8:38 AM through 12:45 PM, the call light remained out of reach. Inspectors found it stuck behind the bedside table and draped over the roommate's bed.
Staff 25, a certified nursing assistant, said Resident 9 "got up on her/his own, did not ask for assistance, and, since moving rooms, was independent with walking with a walker." She recalled the resident had fall mats at the beginning of admission but couldn't remember when they were removed.
She confirmed the call light wasn't within reach and found it attached to the roommate's bed.
Staff 31, another CNA, said the resident's abilities "fluctuated depending on the day, but she/he was mostly independent." When Resident 9 needed the bathroom, they went alone. The resident only asked for help when unable to do something independently.
The disconnect between what staff observed and what the care plan required created dangerous gaps in safety protocols.
Staff 4, a licensed practical nurse and resident care manager, confirmed during multiple interviews that the current care plan "was not accurate for all care needs and was not updated related to falls." The plan was last reviewed on November 10 and 11, but never revised after the October 23 fall.
"I expected the care plan to be updated regularly with changes and with quarterly assessments," Staff 4 said. She confirmed Resident 9 currently required hands-on assistance with transfers, contradicting staff observations of independence.
The fall mats, wheelchair, and quarter bilateral enabler bars were never removed from the care plan when they were discontinued from actual use.
Staff 14 responded to calls for help from Resident 9's roommate on October 23, the day of the fall. At that time, the resident "would walk and toilet on her/his own, but staff encouraged her/him to call for assist." The CNA said the resident wasn't impulsive, restless, or displaying behavioral issues during the fall.
He didn't recall what the Kardex stated but acknowledged "the expectation would have been to follow the Kardex/care plan."
Staff 2, the director of nursing services, and Staff 6, an assistant RN consultant, confirmed during a joint interview that Resident 9 required moderate assistance with transfers and ambulation at the time of the October fall. Both acknowledged the care plan was never updated with new fall prevention interventions.
"I expected staff to follow and implement the care plan," Staff 2 said. She confirmed they removed the fall mats but couldn't specify when. They discussed implementing new interventions but never changed the written care plan.
The nursing home's own policies created a system where staff removed safety equipment, observed increased independence, yet continued operating under outdated care requirements that no longer matched the resident's actual needs or room setup.
Staff 4 expected other employees to notify the resident care manager when care plans needed updates. But the communication never happened after the October fall, leaving Resident 9 in a room configured differently than their official care requirements specified.
The inspection found the facility failed to ensure the resident's care plan accurately reflected their current condition and needs, particularly regarding fall risk and required safety interventions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Post Acute from 2025-11-17 including all violations, facility responses, and corrective action plans.