The resident fell on August 28, August 29, September 8, twice on September 13, September 22, and September 27. Federal inspectors found no documentation that staff put any fall prevention measures in place after any of these incidents.
The facility's own Fall Prevention and Management policy, last reviewed in April, required staff to investigate causal factors after each fall and revise the resident's care plan with new interventions. None of this happened.
The resident required substantial assistance with basic activities. According to federal assessment records from August, they had severe cognitive impairment, limited range of motion on one side of their body, needed help with toileting, and required substantial assistance with dressing and hygiene. Their diagnoses included non-Alzheimer's dementia, anxiety, and depression.
Their care plan from September showed they needed one staff member's help for walking, getting in and out of bed, transfers, and toileting. The plan listed only basic fall interventions: encourage participation in exercise activities, ensure appropriate footwear, and monitor for changes in gait and balance.
But even these minimal measures weren't updated or expanded after the falls began.
The first fall occurred at 8:00 PM on August 28. The next night, at 7:45 PM, they fell again. Ten days later, at 10:45 PM on September 8, another fall. Five days after that, they fell twice on September 13, once at 8:00 PM.
The falls continued. September 22 at 8:45 PM. September 27 at 7:30 PM.
Each time, staff filled out a SAFE Resident Event form documenting the fall. Each time, the form showed no intervention to prevent future falls had been implemented.
The facility's policy outlined specific steps staff should take after every fall. A nurse was supposed to observe the resident and perform a full-body exam. If no serious injury occurred, staff should use a total body lift to transfer the resident off the floor. Once stable, staff were required to investigate what caused the fall.
The policy mandated that staff communicate about the fall during shift changes and daily meetings. Most importantly, it required reviewing and revising the resident's care plan with new interventions to prevent future falls.
Federal regulations require nursing homes to ensure their environments are free from accident hazards and provide adequate supervision to prevent accidents. The facility failed on both counts for this resident.
During a September 29 interview, the Director of Nursing confirmed that interventions to prevent future falls were not implemented after any of the six documented falls. The nursing director acknowledged that the care plan should have been updated after each incident.
The resident's vulnerability made the facility's inaction particularly concerning. People with severe cognitive impairment face elevated fall risks due to confusion, impaired judgment, and difficulty following safety instructions. Their limited range of motion on one side further compromised their stability and mobility.
Good Samaritan Society-Bloomfield houses 35 residents. Federal inspectors reviewed three residents' records as part of their complaint investigation and found this pattern of neglect affected multiple people.
The facility's policy emphasized using "a proactive approach before a fall occurred," including screening to identify risk factors and implementing appropriate interventions. For this resident, staff took no proactive steps despite mounting evidence of fall risk.
Each fall represented a missed opportunity to reassess and strengthen prevention strategies. Staff could have increased supervision during evening hours when most falls occurred. They could have evaluated environmental hazards in the resident's room or along frequently traveled paths. They could have reviewed medications that might affect balance or cognition.
Instead, they documented each fall and moved on.
The pattern suggests systemic problems beyond individual oversights. Six separate falls over 30 days, with six separate opportunities to implement prevention measures, and six separate failures to act on the facility's own policy requirements.
The Director of Nursing's admission that interventions weren't implemented and care plans weren't updated confirms that staff understood their obligations but failed to meet them. This wasn't confusion about policy requirements or documentation procedures.
It was a month-long failure to protect a vulnerable resident who kept falling while staff watched and recorded but never acted to prevent the next incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Bloomfield from 2025-11-18 including all violations, facility responses, and corrective action plans.
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