The resident expressed her fears during a doctor visit on January 6 at 10:46 p.m., three days before another reported fall. According to the physician's progress note, "she expressed that she is very anxious about being in the facility because when they transferred her this morning she was dropped from the bed. She states that she is scared of falling again."
On January 9, the resident allegedly fell again. But when federal inspectors arrived three weeks later, they discovered the facility had failed to conduct any investigation into either incident.
The Director of Nursing told inspectors she had assumed the January 9 fall occurred in the shower room, stating "the patient did not fall in her room, and she thought the patient fell in the shower room." However, no documentation existed to support this assumption or any investigative effort.
Inspectors found no interdisciplinary team meeting notes or investigation records in the resident's progress notes covering the period from January 5 through January 27. The facility's own administrator acknowledged during a January 30 interview that "the facility protocol if someone alleges a fall, we investigate it."
When inspectors requested documentation of the investigation on January 30, the facility was unable to provide any records showing they had investigated the resident's fall on January 9.
The facility's written policy, dated 2017 and titled "Accidents and Incidents-Investigating and Reporting," explicitly requires investigation of all incidents. The policy states that "all accidents or incidents involving residents occurring on our premises shall be investigated and reported to the administrator."
According to the policy, "the nurse supervisor/charge nurse and/or the department director shall promptly initiate an investigation of the accident or incident." The policy also mandates that investigation reports include specific data, including "the date and time the accident or incident took place."
None of this happened.
The resident's January 6 physician visit revealed the psychological impact of being dropped during the transfer. Her documented anxiety about being in the facility and explicit fear of falling again should have triggered heightened attention to any subsequent fall reports.
Instead, when she allegedly fell three days later, staff made assumptions about where it occurred without conducting the investigation their own policies required. The Director of Nursing's statement that she "thought" the patient fell in the shower room demonstrated the kind of speculation that proper investigation procedures are designed to prevent.
The facility's failure to investigate extends beyond policy violations. Without proper investigation, administrators cannot identify whether staff training issues contributed to the initial drop during transfer, whether environmental hazards increased fall risk, or whether the resident's documented anxiety affected her mobility and safety.
The resident's physician note from January 6 captures the human cost of the facility's failures. A person recovering in what should be a safe environment instead expressed fear about her basic care, telling her doctor she was scared of experiencing another fall after being dropped during a routine transfer.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the facility's systematic failure to follow its own investigation protocols suggests broader problems with incident response and resident safety oversight.
The inspection occurred on January 30, more than three weeks after the January 9 fall allegation. During that entire period, no investigation had been initiated, no root cause analysis conducted, and no corrective measures implemented to address either the original transfer incident that left the resident fearful or the subsequent fall allegation.
For the resident who told her doctor she was "scared of falling again," the facility's investigation failure meant her fears went unaddressed and the circumstances that caused her anxiety remained unexamined.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sacramento Post-acute from 2026-01-30 including all violations, facility responses, and corrective action plans.