In a community like Mount Vernon—where many residents move between rooms, common areas, dining spaces, therapy areas, and hallways—falls can occur during high-traffic moments:
- After meals or during medication distribution/rounds
- Transfer times (bed-to-chair, chair-to-toilet)
- Transport to therapy or back from activities
- Evenings and shift changes, when staffing coverage may be thinner
When falls occur in these windows, the question isn’t “was the resident clumsy?” It’s whether the facility had the right fall-prevention plan in place for that resident—and whether staff followed it.


