Renaissance Rehabilitation and Nursing Care Center operated without any registered nurses from 7 AM July 19 until 7 AM July 20, federal inspectors found during a November complaint investigation. During those 24 hours, staff discovered Resident #4 on the floor with blood coming from their nostril.
Two licensed practical nurses lifted the resident from the floor and transferred them to bed. No registered nurse assessed the resident before the move, despite facility requirements for RN evaluation after falls.
The facility's own policy required 72-hour monitoring for signs of injury including bruising, pain, swelling and changes in mental status or behavior. No documentation exists showing this monitoring occurred.
Certified Nurse Aide #11 found the resident on the floor and immediately told Licensed Practical Nurse #12 about the discovery. "They knew they could not move the resident," the aide told inspectors in November. The resident was transferred back to bed by LPN #12 and LPN Supervisor #8. "There were no other nurses that came to see the resident," the aide said.
The facility's staffing records show three LPNs covered the second floor that day. LPN #12 worked 7 AM to 7 PM, LPN #13 worked 7 AM to 2 PM, and LPN #14 worked 7 PM to 11 PM. LPN Supervisor #8 worked the overnight shift from 7 PM July 19 to 7 AM July 20.
Licensed Practical Nurse #12 told inspectors the standard process was to call the Director of Nursing after falls. But they could not recall speaking with the director about Resident #4's fall. "They often communicated with the Director of Nursing via text," inspectors noted. The LPN said they had not seen the director come to the facility to assess residents after falls.
LPN Supervisor #8, who was working during the fall, confirmed the protocol required calling the Director of Nursing, Medical Director, and corporate nurse for after-hours falls. "Many times there were no registered nurses working at the facility when residents had falls," they told inspectors. They could not remember a registered nurse being in the building to conduct an assessment when Resident #4 fell.
The Director of Nursing initially told inspectors on October 29 that they served as backup when no registered nurses were in the building. But they did not come to the facility to assess residents. "Instead the nurses called them with problems, and they provide guidance and support over the phone," according to the inspection report.
The director said they did not write notes after speaking to nurses about incidents. They claimed they were not aware of Resident #4's July 19 fall until July 21 - two days later.
During a follow-up interview the next day, the Director of Nursing changed their account. They now remembered being notified by the nurse about the fall. But they still had not written any assessment or notes. "They had a lot of things on their mind," they told inspectors.
No nursing progress notes exist from July 19 through July 29 documenting any registered nurse assessment of Resident #4 following the fall. The resident's physician and family were notified at 6 PM on July 19, but the required 72-hour post-fall monitoring was never documented or implemented.
The facility failed to provide the immediate registered nurse assessment required by federal regulations when a resident suffers a fall with injury. The bloody nose constituted evidence of trauma that should have triggered comprehensive evaluation for potential head injury, broken bones, or other complications.
Renaissance Rehabilitation's practice of operating without registered nurses on duty left residents vulnerable during medical emergencies. Licensed practical nurses lack the advanced training and scope of practice needed to conduct thorough post-fall assessments, particularly when head injuries or internal bleeding might be present.
The Director of Nursing told staff during an in-service meeting that they needed to call about falls in the facility. But the director's own admission of not writing notes or assessments, combined with their initial failure to remember being notified, suggests systemic gaps in fall response protocols.
Resident #4's case illustrates the human cost of inadequate nursing coverage. A person who suffered a traumatic fall with visible bleeding received no registered nurse evaluation, no documented monitoring for complications, and no treatment for their bloody nose beyond being lifted off the floor and placed in bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Renaissance Rehabilitation and Nursing Care Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
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