Resident #97 was completely dependent on staff and required assistance from two people for all activities, according to the resident's care plan and assessment records. But nursing staff ignored these requirements during an incident that resulted in actual harm, inspectors determined.
The violation occurred despite clear expectations from facility leadership about following care plans. The Director of Nursing told inspectors on December 22 that dependent care meant "the resident was not able to participate in assisting with their care." She stated it was her expectation that all staff followed resident care plan interventions.
The MDS/Care Plan Coordinator reinforced this during a December 19 interview, telling inspectors she expected staff to follow the care planned interventions based on Resident #97's documented needs.
LPN #09, who worked at the facility as needed, confirmed during questioning that the resident was dependent on staff and required total assistance for all care. However, the nurse stated they could not remember the specifics surrounding the incident involving Resident #97.
Federal inspectors cited the facility for failing to prevent accidents and provide adequate supervision, resulting in actual harm to the resident. The violation falls under regulations requiring nursing homes to ensure residents receive proper care and supervision to prevent accidents.
The facility's own fall prevention policy, revised in March 2018, required staff and physicians to identify interventions to prevent subsequent falls and address risks of significant consequences from falling. The policy specifically stated that based on assessment findings, pertinent interventions should be implemented.
Despite these written protocols and clear staff expectations, the facility failed to ensure Resident #97 received the required two-person assistance. The breakdown in following established care requirements led to the complaint investigation and subsequent citation for actual harm.
The facility is disputing the citation, according to inspection records. Federal inspectors investigated the incident under Complaint Number 2614070 and determined the facility was not in compliance with safety requirements.
The case highlights ongoing challenges nursing homes face in ensuring staff consistently follow individualized care plans, particularly for residents who require multiple workers for safe assistance. When facilities fail to implement their own documented safety protocols, vulnerable residents face increased risks of injury.
Resident #97's situation demonstrates the critical importance of care plan compliance for dependent residents who rely entirely on staff for their safety and wellbeing. The failure to provide required two-person assistance violated both the resident's individual care plan and the facility's own fall prevention policies.
The inspection findings show a disconnect between facility policies and actual practice, with nursing leadership clearly understanding requirements but staff failing to implement them consistently. This gap between expectation and execution resulted in preventable harm to a vulnerable resident who had no ability to protect themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arc At Cincinnati from 2025-12-23 including all violations, facility responses, and corrective action plans.