Resident #1 fractured his right femur sometime around September 29th. The break went undetected until weeks later, when medical records revealed a trochanteric fracture requiring treatment.
Two certified nursing assistants were transferring the resident from his wheelchair into a shower chair that day. CNA B had turned to pick up a soap bottle when she heard a hit. When she looked back, Resident #1 was on the floor.
"CNA B stated she and CNA A lifted Resident #1 off the floor and placed him back into the shower chair," according to the inspection report from federal investigators who interviewed staff this month.
The two aides told completely different stories about what happened next.
CNA A said the resident never fell. CNA B said he did fall to the floor. The Director of Nursing and Administrator had to choose which account to believe for their internal investigation.
They picked the wrong one.
During a November 4th interview, the Director of Nursing explained her reasoning. She said CNA A stated there was no fall, while CNA B said yes, there was a fall. "The DON stated the investigation moved forward with CNA A's statement that it was not a fall."
The DON told investigators she couldn't confirm how Resident #1 sustained his fracture. She said CNA B received additional training on abuse, neglect and fall prevention after giving her statement. But she admitted being "unaware as to why CNA B's statement that Resident #1 had sustained a fall was not investigated."
The Administrator offered a more revealing explanation for his decision-making process.
"The Administrator stated he was not able to determine whether Resident #1 had sustained a fall or not," investigators documented. He acknowledged receiving both conflicting accounts from the nursing assistants.
His solution was to punt the investigation to state regulators.
"The Administrator stated he opted to follow through with the investigation using CNA A's statement that Resident #1 had not fallen and let State tell him what really happened."
When pressed about why he didn't investigate CNA B's fall report, the Administrator said "he just wasn't sure." He told investigators "he did not know how Resident #1 sustained the fracture since CNA A had stated he had not fallen."
CNA B stood by her account when investigators interviewed her again the following day. She defined a fall simply: "when a resident is on the floor." She insisted she wasn't lying about what she witnessed.
"CNA B stated she had no reason to lie," according to the inspection report.
The facility's own policies required immediate investigation of suspected incidents. The nursing home's Abuse, Neglect and Exploitation policy, dated July 11th, states clearly: "An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur."
The policy defines an "Alleged Violation" as any situation "observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if verified, could be indication of noncompliance with the Federal requirements."
CNA B's report that Resident #1 fell to the floor during care qualified as exactly this type of incident requiring immediate investigation.
Instead, administrators dismissed her account in favor of the aide who claimed nothing happened.
The Director of Nursing told investigators that Resident #1 experienced "a light syncope episode" on the day of the incident. Syncope refers to temporary loss of consciousness caused by decreased blood flow to the brain. This medical detail emerged during the facility's belated investigation, but investigators found no evidence it influenced the original decision to ignore CNA B's fall report.
The fractured femur wasn't discovered until medical records later revealed the injury. Trochanteric fractures occur at the upper portion of the thighbone, near the hip joint. These breaks commonly result from falls in elderly residents, particularly during transfers or mobility assistance.
Federal investigators classified this as a violation of resident protection requirements. The facility failed to properly investigate a reported fall that resulted in serious injury to a resident.
The Administrator's approach of "letting State tell him what really happened" represented an abdication of his responsibility to protect residents under his care. Federal regulations require nursing homes to investigate suspected incidents immediately, not defer to outside agencies while residents potentially remain at risk.
CNA B's willingness to report what she witnessed, even when contradicted by her colleague, demonstrated the kind of transparency essential for resident safety. Her account proved accurate when the fracture was eventually discovered.
The facility's decision to provide additional training to CNA B, rather than investigating her concerns, sent a troubling message to staff about reporting incidents. Workers might reasonably conclude that speaking up about resident falls could result in remedial training rather than proper investigation.
This case illustrates how administrative failures can compound the harm from care incidents. The original fall may have been accidental, but the decision to ignore credible witness testimony about what happened represented a systemic breakdown in resident protection.
The Administrator's admission that he "just wasn't sure" which aide to believe reveals the inadequacy of the facility's investigation procedures. When staff provide conflicting accounts of potential resident harm, proper protocol demands thorough investigation of both versions, not arbitrary selection of the more convenient story.
Resident #1's fracture went untreated for weeks because administrators chose to believe the aide who said nothing happened, despite clear evidence from medical records that something serious had occurred.
The nursing home's own policy required immediate investigation of CNA B's fall report. The Administrator's decision to instead "let State tell him what really happened" violated this requirement and left Resident #1 without proper medical evaluation following his injury.
CNA B maintained she had no reason to lie about witnessing the resident fall to the floor. Her account proved consistent across multiple interviews with investigators, while the facility's handling of her report demonstrated systematic failures in incident response and resident protection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windsor Nursing and Rehabilitation Center of Mcall from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
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