The resident, identified as R3 in inspection documents, was documented as having cognitive impairment severe enough that they couldn't complete basic mental status testing. Their care plan from October 30 classified them as an "elopement risk/wanderer" who was "disoriented to place and has impaired safety awareness."
The falls occurred on November 20 around 6:00 AM. But the sequence of events that night revealed a breakdown in supervision that administrators said should never have happened.
Certified nurse assistant V18 was stationed outside the resident's room that night. During her lunch break sometime in the middle of the night, another aide discovered the resident on the floor. V18 returned from break to learn about the first fall from V19, a fellow aide.
Around 4:30 AM, V18 helped the resident off the floor and took them to the bathroom, then left them sitting on the edge of their bed. An hour and a half later, during change-of-shift rounds at 6:00 AM, the resident was found on the floor again next to their bed.
V19 reported the second fall to V7, the registered nurse on duty. But instead of rushing to assess the fallen resident, V7 told V19 to "leave R3 and the floor," according to the aide's account. V7 never went to the resident's room to check on them after either fall.
The registered nurse later explained her inaction by citing information from the previous shift. V8, a licensed practical nurse, had told V7 during shift report that this resident "would sometimes put herself on the floor and that it would not be considered a fall."
That interpretation contradicted the facility's own policy, which defines a fall as any event where someone "unintentionally comes to rest on the ground, floor, or other level" and specifically states that such events "can occur anywhere" and may be "witnessed, reported, or presumed when a resident is found on the floor."
V7 acknowledged making "a mistake in not documenting the unwitnessed fall." The failure to document meant there was no official record of either incident, despite the resident's documented fall risk and cognitive impairment.
The resident's October 23 care plan had already identified them as at risk for falls due to "dementia, side effects of medication and a terminal condition." Their admission assessment confirmed they were at risk for falls. The facility's policy required individualized interventions based on risk level, including increased monitoring, assistive devices, or constant supervision when indicated.
Administrator V1 said the expectation was clear: staff "should have partnered with their coworkers to keep a close eye on R3 to prevent falls and keep R3 safe and comfortable."
But that partnership failed. One aide went to lunch without ensuring coverage. Another aide found the resident on the floor and reported it up the chain. The registered nurse dismissed the incident without assessment and failed to document it entirely.
The facility's fall prevention policy outlines specific interventions for high-risk residents: increased frequency of rounds, sitters when indicated, low beds, alternate call systems, and scheduled toileting assistance. None of these safeguards prevented the resident from falling twice in the span of two hours.
The inspection found the facility failed to provide adequate supervision for this cognitively impaired resident, who was left alone despite being classified as both a fall risk and a wandering risk. The resident's terminal condition and medication side effects only heightened the danger of unsupervised time.
Federal inspectors cited the facility for failing to ensure the nursing home area was free from accident hazards and for not providing adequate supervision to prevent accidents. The violation affected few residents but represented a fundamental breakdown in basic safety protocols for the facility's most vulnerable patients.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Loft Rehab & Nursing of Normal from 2025-12-01 including all violations, facility responses, and corrective action plans.