Resident 12 threw himself back and to the left while wound care staff were treating him on October 16, landing on his left side with his right leg still secured in the lift straps. Staff had to release the strap before they could finish their wound assessment.
The resident called out for his mother while lying on the floor but showed no signs of pain or injury, according to inspection records. CNA 283 cleaned and re-dressed his wound after he was helped back into his wheelchair.
Nobody made the required notifications.
Licensed Practical Nurse 270 told inspectors she came into the room when CNA 283 requested help transferring the resident back to his chair "after he had a behavior and was lowered to the ground." She found him lying on the floor "anxiously fidgeting," which she described as normal behavior for him.
The nurse explained that the resident "had gotten his arm out and under the sling which had been supporting him in the lift" and was caught and lowered while his legs remained secured. She admitted she never notified the resident's family or hospice provider about what happened.
RN 238 was in the room with the wound care team when the incident occurred. She confirmed the resident got his arm under the lift support sling and was lowered to the ground, then "threw himself to the side before they were able to get his legs unstrapped."
The registered nurse told inspectors that LPN 270 "would have made notifications to the family, physician, and hospice" but verified she had not made any notifications regarding the incident.
Hospice RN 312 confirmed the facility never contacted the hospice provider about what happened to their patient.
The facility's own policies required immediate action that never came. According to the January 2023 policy on notifications, staff must notify the resident, physician, and resident representative when there is an accident or significant change in status.
The facility's accident policy, revised in May 2024, specifically addresses falls and requires staff to assess for injuries, notify the physician, provide necessary treatment, and notify the resident representative.
Foundation Park Care Center defines a fall as "unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming force." Under this definition, being lowered to the floor from a mechanical lift would qualify.
The inspection found the facility failed to follow its own notification procedures, leaving the resident's family and medical team unaware of an incident that left him on the floor with his leg still trapped in equipment.
Federal inspectors cited the facility for failing to ensure residents receive proper supervision and assistive devices, and for not making required notifications when accidents occur. The violation was classified as causing minimal harm or potential for actual harm to few residents.
The resident's hospice status indicates he was receiving end-of-life care, making communication with his medical providers and family particularly crucial for coordinating his treatment and keeping loved ones informed about his condition and care.
The October incident highlighted gaps in the facility's communication protocols, particularly around mechanical lift safety and incident reporting. Staff members interviewed by inspectors each assumed someone else would handle the required notifications, but no one actually made the calls.
The resident spent an unknown amount of time on the floor while staff worked to free his trapped leg and complete their wound care assessment, an experience that could have been traumatic even for someone showing no obvious signs of distress.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Foundation Park Care Center from 2025-11-25 including all violations, facility responses, and corrective action plans.