The incident happened in July 2010. The injured resident was found at the top of a stairwell the day before her accident. She was fitted with an electronic wristband that automatically locks exit doors as residents approach them. A mere eight hours later, the woman wheeled away from an activity in an area of the facility not equipped with the automatic locks and fell down seven concrete stairs. She reportedly was found lying at the bottom of the flight of stairs and most likely fractured two ribs in the fall.

While the nursing home facility disagreed with the state’s findings, it did take corrective measures.