The April 10, 2025 incident at Wesley Pines Retirement Community involved Resident #5, who had a history of becoming combative during personal care. Nursing Assistant #2 was providing incontinence care before the evening meal when the resident became resistive.
NA #2 called for assistance over the radio. While waiting for help to arrive, she was able to calm the resident and resumed the care alone.
The resident was holding onto the bed frame during the procedure when he pulled himself off the bed. NA #2, who was standing behind him to clean his rectal area, could not hold onto him as he fell.
The resident suffered a soft tissue skin tear to his forehead that required treatment at the hospital emergency department. Medical staff cleaned the wound and applied steri-strips. A head CT scan showed no new injury, and imaging revealed no fractures. The resident returned to the nursing home the same day.
Nurse #6, who was familiar with the resident, told investigators she knew he became combative during personal care. Since his last fall, the facility had implemented a two-person assist policy for all his care, along with side rails on the bed for him to grab during procedures.
"The accident could have potentially been avoided had two staff members been in the room," Nurse #6 stated. She could not recall NA #2 asking for help on the night of the fall.
The Director of Nursing interviewed NA #2 the day after the incident. NA #2 explained that she had called for help when the resident became combative and agitated, but was able to calm him while waiting for assistance. She then resumed the incontinence care alone.
The DON determined there had been no deviation from proper practice because the resident was not classified as requiring a two-person assist for incontinence care prior to the April 10 fall. Nursing assistants were trained to turn residents on their side away from the caregiver according to facility procedures.
The DON noted that NA #2 had worked with the resident for many years and was usually able to calm him and provide incontinence care successfully. During this incident, NA #2 had calmed the resident before proceeding, but he then pulled himself off the bed.
The Administrator conducted a full investigation into the fall. NA #2 explained that it was dinnertime and she wanted to provide incontinence care before the evening meal was served. When the resident became resistive, she called for assistance over the radio, but resumed care after he calmed down while she waited.
The Administrator acknowledged the fall may have been prevented with another staff member on the opposite side of the bed or if the resident had quarter side rails to grab. However, the side rails had been removed during a previous safety assessment that determined they were unsafe because the resident was putting his arms through the bed rails.
The facility's response highlighted a contradiction in care protocols. While Nurse #6 indicated that two-person assistance had been implemented for all care following a previous fall, the DON maintained that incontinence care was not designated as requiring two staff members.
When the hospice provider and emergency management systems arrived at the facility, the resident was transported to the hospital. The Nurse Practitioner assessed him the following day and found he was at his baseline with no new issues or concerns.
The incident occurred during what should have been a routine care procedure, but revealed gaps in how the facility managed residents with behavioral challenges during personal care. The nursing assistant's decision to proceed alone after the resident calmed down, despite having called for backup, resulted in an injury that required emergency medical treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wesley Pines Retirement Community from 2026-01-30 including all violations, facility responses, and corrective action plans.