The Administrator admitted she "had missed it" during an October 28 interview with federal inspectors, taking "full responsibility for not investigating and reporting the incident in the 2 hours or 24 hours' time frame."
Resident #2 was discovered on the floor of her room around dinnertime, lying on her left side near the door with blood streaming from a forehead wound. LVN B, the nurse working that shift, heard the resident yelling from her room.
"The bed was in the lowest position, and she heard her yelling and when she got to the room the resident was at the door on the floor on her left side and bleeding," according to the inspection report.
The resident had sustained a skin tear with blood and hematoma to her forehead. The nurse immediately checked vital signs, called the doctor and 911, then cleaned the wound before the resident was transported to the nearest hospital by ambulance.
The resident returned from the hospital the same day with no stitches, continued bleeding, or fractures. But the fall was never properly investigated.
The facility's own Abuse Prohibition Policy, dated June 2, 2025, explicitly requires investigations of suspected neglect and injuries of unknown source. The policy states that the Abuse Coordinator must report allegations involving serious bodily injury within two hours, and all other incidents within 24 hours.
"The facility will thoroughly investigate all alleged violations and take appropriate actions," the policy reads. "Investigations will be prompt, comprehensive and responsive."
None of that happened.
The Director of Nursing initially told inspectors that when incidents were reported to her, she would inform the Administrator, who would then investigate and report to the state. She said unwitnessed falls should be investigated and reported if there were injuries and if the resident couldn't explain what caused the fall.
But during her October 28 interview, the Administrator contradicted this account entirely. She said the incident was never investigated or reported within the required timeframe.
"She said the day they told her about the incident she had intended to investigate and report it but did not get a chance," inspectors wrote. "She said she had missed it."
The Administrator explained that nursing issues would typically be reported to the Director of Nursing or charge nurse, who would then inform her about incidents involving abuse, neglect, or exploitation. She acknowledged being informed about Resident #2's fall.
"She said she was informed about Resident #2's fall and had got written up because it was not investigated and reported within the reporting time frame," according to the inspection.
The Administrator promised inspectors she would "ensure that all incidents regarding abuse, neglect and exploitation would be investigated and reported in the timely reporting manner."
Federal regulations require nursing homes to have comprehensive abuse prevention programs that include screening, training, prevention, identification, investigation, protection, and reporting components. Bay Ridge's written policy appeared to meet these requirements on paper.
The policy designates a qualified staff member to oversee the abuse prohibition program and requires posting of abuse prohibition notices visible to residents, families, and staff. It mandates that the facility "will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations."
The policy specifically addresses injuries of unknown source, stating that the Abuse Coordinator will report such incidents within two hours if they involve serious bodily injury, or within 24 hours for other cases.
But policies mean nothing without implementation.
The fall occurred during dinnertime when Resident #2 was in bed with the bed in its lowest position. How she ended up on the floor near her door remains unexplained in the inspection report. LVN B's account suggests the resident may have gotten out of bed on her own, but the circumstances that led to her fall were never investigated.
The resident's ability to communicate about what happened isn't detailed in the inspection report, but the Director of Nursing had told inspectors that unwitnessed falls should be investigated when residents are unable to explain what caused them.
The incident represents exactly the type of situation federal regulations are designed to address. An unwitnessed fall resulting in injury to a vulnerable resident requires immediate investigation to determine whether neglect occurred and to prevent similar incidents.
The facility's failure to follow its own policies and federal requirements left critical questions unanswered. Was the resident properly supervised? Were safety measures adequate? Did staff respond appropriately before the fall occurred?
These questions remain unresolved because the Administrator "missed" conducting the required investigation.
The inspection found that Bay Ridge Healthcare Center failed to ensure that alleged violations of resident rights were thoroughly investigated, and that proper authorities were notified in accordance with federal regulations. The facility also failed to report the results of investigations to enforcement agencies as required by state law.
Federal inspectors determined the violation caused minimal harm or potential for actual harm to a few residents. But the systemic failure to investigate incidents as required by policy represents a breakdown in the facility's abuse prevention program.
The Administrator's admission that she simply "missed" investigating a resident's bloody fall highlights gaps in the facility's oversight systems. Her promise to ensure future compliance came only after federal inspectors discovered the violation during their complaint investigation.
Resident #2 returned from the hospital without serious injury, but her fall exposed serious deficiencies in Bay Ridge Healthcare Center's commitment to protecting vulnerable residents through proper investigation and reporting procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bay Ridge Healthcare Center from 2025-11-25 including all violations, facility responses, and corrective action plans.