The incident at Village Creek Rehabilitation and Nursing Center occurred on August 11, when a certified nursing assistant identified as CNA A was providing perineal care to Resident #1. Despite facility policies requiring two-person assistance for high-risk residents, the assistant worked alone.
The resident fell from the bed during the care. Hospital evaluation found no injuries, but federal inspectors determined the failure placed the resident in immediate jeopardy — the most serious category of nursing home violations.
The facility's own Safe Handling and Moving Protocol policy, dated July 18, 2018, required staff to "ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident."
The policy specifically outlined "expectations of assessment and communication" and required that "the charge nurse will notify current floor staff providing care" about accurate assistance levels through the Electronic Health Record system. It also addressed "bariatric needs" for obese residents.
CNA A had been suspended pending investigation immediately after the fall. The facility obtained statements from the assistant and completed a full investigation the same day.
Federal inspectors found the violation represented past noncompliance that had been corrected before their November inspection. The administrator was notified on November 19 at 2:00 p.m. that inspectors had identified the immediate jeopardy situation from three months earlier.
The facility responded immediately on August 11 with multiple corrective actions. Resident #1 received a complete head-to-toe assessment and was interviewed about the fall. Staff ordered X-rays per physician orders and notified both family members and the attending physician.
Risk management completed documentation of the incident. The facility notified police and the ombudsman as required by state law.
The resident's care plan and Kardex were updated immediately to specify two-person assistance for both perineal care and bed mobility. The facility then conducted a comprehensive audit of care plans and Kardex records for all residents requiring transfer assistance.
Staff completed immediate in-service training on August 11 covering neglect prevention, safe perineal care and bed mobility for high-risk residents, and proper Kardex utilization. All training included comprehension quizzes that staff were required to pass.
The training sessions covered "Abuse, Neglect, and Resident Rights," "Training on Neglect and Prevention Response," "Safe Peri-Care and Bed Mobility for High-Risk Residents," and "Abuse, Neglect, and Drill Evaluation." CNA A's signature appeared on all completed training documents.
The facility initiated ongoing monitoring for seven days following the incident, followed by weekly checks for four weeks. Staff completed spot checks and took corrective actions when needed.
During their November inspection, federal surveyors interviewed staff across all shifts from November 19 through November 21. They spoke with CNA A, multiple licensed vocational nurses identified as LVN B through LVN J, several certified nursing assistants, a medication aide, the administrator, and the director of nursing.
All interviewed staff demonstrated they knew where to find information about how residents should be transferred and their required level of bed mobility assistance. Staff were able to verbalize understanding of the information provided in the training sessions.
Inspectors reviewed the facility's complete Provider Report documentation, which included statements from both the resident and staff, X-ray results, risk management documentation, comprehension quizzes, all completed in-service materials, life satisfaction rounds documentation, and proof of police and ombudsman notification.
The file also contained complete audit documentation of Kardex records, care plans, and MDS assessments — the comprehensive evaluations nursing homes use to determine resident care needs.
Federal surveyors conducted random reviews of four residents' records, including Resident #1, between November 18 and November 21. They found no inconsistencies between the MDS assessments, care plans, and Kardex records.
On November 19 at 1:34 p.m., inspectors observed CNA K and LVN J providing perineal care and bed mobility assistance. They found no violations during this observation.
The inspection report noted that transfer assistance requirements did not match up properly before the August incident, leading to the resident's fall. The facility had since retrained staff on proper procedures.
Inspectors wrote that "the possible outcome for a resident that was not transferred properly could be a fall or injury to the resident." The facility's policy required staff to ensure accurate communication about assistance levels to prevent exactly this type of incident.
The immediate jeopardy finding began on August 11, 2025, and was removed the same day after the facility's corrective actions. Federal inspectors classified this as past noncompliance that had been resolved before their investigation began.
The November inspection was conducted in response to a complaint. Federal surveyors spent three days at the facility, from November 19 through November 21, reviewing the August incident and current practices.
Village Creek's response demonstrated the facility had taken the violation seriously, implementing comprehensive staff training, policy updates, and ongoing monitoring to prevent similar incidents. The immediate corrective actions and sustained follow-up monitoring showed recognition of the serious safety risk the fall had represented.
The case illustrates how quickly nursing home incidents can escalate to immediate jeopardy status when basic safety protocols fail. A single assistant working alone instead of following two-person assistance requirements created a situation federal regulators determined could have resulted in serious injury or death.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village Creek Rehabilitation and Nursing Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
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