The resident's daughter had wheeled her into the room at Highland Ridge Care Center around 6:45 pm, turned on the TV, and left. What happened next involved at least four staff members who each assumed someone else would handle the situation.
Staff D, a certified medication assistant, knew the resident was in her room and "was not to be in her room by herself in the wheelchair because she would get up and fall." But he left to continue passing medications.
Staff M, a nursing assistant working the evening shift, was asked to check on the resident. She found her sitting in the wheelchair in her room, exactly where she wasn't supposed to be alone. Staff M "assumed that Staff N or Staff D would take care of her and returned to her assigned unit."
Nobody took care of her.
Staff M heard over the radio shortly after that the resident was on the floor. When she returned to the room, she found the resident with other staff and a nurse. The resident "yelled out in pain when she was turned on her side for the mechanical lift sling to be placed under her."
Staff M couldn't remember if the resident was moving her legs.
The medical director, who was on vacation during the incident, later reviewed the situation. He explained that nurses should call the emergency room if there's a significant change in condition, increased pain, no movement of an extremity, or if family disagrees with nursing recommendations. "There is staff on call 24/7 there for anything serious," he said.
But no one called a physician immediately after the fall. Staff O, who was working that evening, told the resident's daughter she should monitor her mother but "did not call and report to a physician" and instead "placed a report on the physician clip board."
The facility held an interdisciplinary team meeting two days later to review what went wrong. Their root cause analysis determined "the resident had self-transferred from her wheelchair to bed and lost balance." The intervention they established was "to avoid leaving the resident in her wheelchair unattended in her room."
That was exactly what multiple staff members already knew before the fall happened.
The resident was eventually transferred to a hospital for further evaluation. The facility's investigation remained ongoing at the time of the federal inspection in November.
Federal inspectors found the incident violated regulations requiring nursing homes to ensure each resident receives adequate supervision and assistance to prevent accidents. The violation caused actual harm to the resident.
Highland Ridge Care Center's own fall prevention policy, dated 2021, makes the clinical coordinator responsible for supervising personnel in delivering safe care and collaborating with the interdisciplinary team to prevent falls. The policy states that care plans should indicate resident-specific interventions to prevent falls, and nurses should notify 911, the primary physician, and nurse practitioner based on initial evaluation.
Staff D later told investigators that when he responded to the radio call for assistance, other staff and the nurse were already present and "stated they did not need his assistance and no one requested for him to give prn pain medication" to the resident.
The facility's assessment revealed that staffing levels are evaluated to determine capability for admitting additional patients, and admissions may be held based on staff levels or if staff aren't trained for specific care needs. Staff members are instructed not to perform tasks they don't feel competent to perform.
But competence wasn't the issue on October 26th. Multiple staff members knew exactly what they were supposed to do. They knew the resident couldn't be left alone in her wheelchair in her room because she would try to get up and fall.
They walked away anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Ridge Care Center, LLC from 2025-11-19 including all violations, facility responses, and corrective action plans.
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