The first resident was found on the floor and later developed blood in his catheter bag. The second resident fell and expressed severe hip pain, requiring immediate hospitalization. Both incidents occurred without staff present to witness what happened.
Federal inspectors found the facility's response violated its own written policies on investigating potential abuse, neglect, and injuries of unknown origin.
The facility's written policy states clearly: "If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law."
But that didn't happen.
The Director of Nursing told inspectors on October 21, 2025, that unwitnessed falls were discussed with the Administrator to determine if investigation and self-reporting were necessary. In both cases involving these residents, "the instances of Residents #1 and #2 were not required to be self-reported in their opinions."
Resident #1's case raised particular concerns. Staff found him on the floor after an unwitnessed fall. Initial assessment showed no obvious injury or trauma to his catheter. However, during follow-up checks, staff discovered blood in his catheter bag and sent him to the hospital.
The DON stated that Resident #1 was hospitalized "due to the blood seen in the catheter bag during follow-up checks as the follow-up checks were not remarkable for any injury because of the fall."
She added that "the assessment of Resident #1 when he was found on the floor did not indicate any dislodging or trauma to the catheter."
Yet the facility made no connection between the fall and the subsequent bleeding that required hospitalization.
Resident #2's situation was more immediately serious. After being found on the floor, she expressed severe hip pain and was sent to the hospital right away.
The DON described her interactions with both residents as limited. She said she "had limited interactions with Resident #1 during his stay at the facility and did not notice anything remarkable with his memory or ability mentally." For Resident #2, interactions "were brief and the resident was able to respond appropriately to general inquiries, however, did not have in-depth interactions with her."
Staff interviews revealed they understood the basic protocols for responding to falls. CNA C told inspectors that unwitnessed falls should be reported to nurses immediately, along with any changes in condition like blood in a catheter bag. The CNA stated that suspicions of abuse, neglect, or exploitation, including unexplained injuries, should be reported immediately to the facility's abuse coordinator, who was the Administrator.
LVN D explained the proper response when finding a resident on the ground: ensure the resident's safety, call for help, assess whether they could move their extremities, and call the doctor for orders if the resident experienced pain, or call 911 immediately if pain was severe.
The LVN said all unwitnessed falls and injuries of unknown origin were to be reported to the DON and Administrator immediately "so they could determine if an investigation needed to happen."
The DON described similar expectations, saying staff should call for a nurse when finding a fallen resident, assess the person, and try to identify what caused the fall through resident reports or environmental factors. If no pain was expressed, staff would help the resident to bed and monitor for delayed injuries.
But the facility's written policy goes further than these general protocols. It requires immediate reporting to multiple authorities when injuries of unknown origin occur.
The policy specifies that reports must go to "the state licensing/certification agency responsible for surveying/licensing the facility," "the resident's attending physician," and "the facility medical director."
The policy defines "immediately" as "within two hours of an allegation involving abuse or result in serious bodily injury."
Neither resident's case was reported as required.
The DON told inspectors she was responsible for reporting incidents of abuse, neglect, exploitation, and injuries of unknown origin, with the Administrator reporting in her absence. Yet both administrators concluded these unwitnessed falls with subsequent medical complications didn't warrant investigation or reporting.
The contradiction between written policy and actual practice formed the basis for the federal citation. Inspectors found the facility failed to ensure incidents were reported and investigated according to its own procedures.
Both residents required hospital treatment after their falls. One developed bleeding that wasn't initially apparent. The other experienced severe enough pain to require immediate emergency care.
The facility's decision not to investigate left fundamental questions unanswered. What caused these residents to fall? Were environmental hazards involved? Did medical conditions contribute? Could similar incidents be prevented?
Federal regulations require nursing homes to investigate unexplained injuries to protect residents and identify systemic problems. The facility's own policy acknowledged this responsibility but wasn't followed when it mattered.
The DON stated she believed "the appropriate interventions were in place for both Residents #1 and #2 at the time of their unwitnessed falls." However, those interventions didn't include the investigations and reports required by facility policy and federal regulations.
Staff demonstrated knowledge of basic fall response procedures during interviews. They knew to assess residents, call for help, contact doctors when needed, and report incidents up the chain of command.
But knowledge of procedures proved insufficient when administrators decided investigation wasn't necessary despite clear policy requirements.
The cases illustrate a gap between written policies and actual implementation. Facilities may have comprehensive procedures on paper, but those procedures only protect residents when consistently followed.
Both residents experienced medical complications after their falls that required hospital treatment. Without proper investigation, the facility missed opportunities to identify contributing factors and implement prevention measures.
The blood in Resident #1's catheter bag raised particular questions about the connection between his fall and subsequent medical issues. The DON insisted initial assessment showed no catheter trauma, but the timeline suggests the fall may have caused internal injuries not immediately visible.
Resident #2's severe hip pain requiring immediate hospitalization indicated significant injury from her unwitnessed fall. Such injuries typically warrant investigation to determine cause and prevent recurrence.
The facility's administrators made judgments about reporting requirements that contradicted their own written policies. Those decisions left residents without the protections federal regulations and facility procedures were designed to provide.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Legacy Midtown Park from 2025-11-19 including all violations, facility responses, and corrective action plans.