HOUSTON, TX - Federal inspectors cited Seven Acres Jewish Senior Care Services for serious safety violations including improper use of mechanical lifts that injured a resident and a security failure that allowed a cognitively impaired resident to wander into the parking lot unattended.
Improper Transfer Equipment Results in Resident Injury
The most serious violation involved a certified nursing assistant (CNA) using the wrong type of mechanical lift to transfer a resident, directly contradicting the care plan and resulting in injury. Resident #35 required a Hoyer lift for all transfers according to their individualized care plan, but CNA A used a standing lift instead after receiving a request from a family member.
The incident occurred in February 2025 when the CNA disregarded established protocols. The care plan specifically mandated use of a full-body mechanical Hoyer lift for Resident #35's transfers, but the employee chose to accommodate the family's preference for a standing lift. This decision violated multiple safety protocols and led to the resident sustaining an injury during the transfer.
Medical protocols for mechanical lifts exist to prevent exactly this type of incident. Full-body mechanical lifts like Hoyer lifts are prescribed for residents who lack the physical stability, strength, or cognitive ability to safely use standing lifts. These devices completely support the resident's weight and provide maximum safety during transfers from beds to wheelchairs or other surfaces.
Standing lifts, by contrast, require residents to bear some of their own weight and maintain balance during the transfer process. When used on residents who require full-body support, standing lifts create significant risk for falls, muscle strain, and other injuries.
The facility's investigation revealed this was not an isolated incident. Multiple staff members admitted to using the standing lift for Resident #35 at the family's request, despite being trained on proper transfer procedures. This pattern of behavior indicates a systemic failure to enforce care plan protocols when faced with family preferences.
Cognitive Assessment Contradicts Transfer Method
A physical therapy evaluation completed on May 2, 2025, confirmed that Resident #35 continued to require a full-body mechanical lift for all transfers. The assessment revealed the resident could not maintain static sitting balance on the edge of a bed for more than 30 seconds, making use of a standing lift medically inappropriate and dangerous.
This finding validates the original care plan requirements and demonstrates why medical professionals had prescribed the Hoyer lift. Residents who cannot maintain basic sitting balance lack the core strength and stability necessary to safely use standing transfer equipment.
The therapy evaluation also explicitly stated that a stand-up lift was not recommended for this resident. This professional assessment provided additional evidence that the CNA's decision to use the standing lift violated established medical protocols designed to ensure resident safety.
Security Breach Allows Vulnerable Resident to Leave Facility
In a separate incident, the facility failed to prevent a resident with severe cognitive impairment from leaving the building unattended. Resident #1, described as having a BIMs score of 4 indicating severe cognitive impairment, was found sitting in her wheelchair in the facility's parking lot on March 25, 2025.
Security camera footage revealed the sequence of events that led to this dangerous situation. At 8:35 PM, Resident #1 followed another family member out of the facility's main doors. The security guard on duty failed to prevent her exit, despite protocols requiring monitoring of residents with cognitive impairments.
The resident remained unsupervised in the parking lot for several minutes before another family member discovered her and returned her to the facility. During this time, she faced multiple risks including potential injury from falling out of her wheelchair, exposure to vehicle traffic, and vulnerability to outside threats.
Staff interviews revealed the significant dangers this incident created. As one CNA noted, the risks included the possibility that "the resident could fall out of her wheelchair, or someone could harm her." Another staff member emphasized that "it was not safe for a resident with cognition concerns to leave because they could get injured, or someone could harm them."
Industry Standards for Cognitive Impairment Security
Nursing homes must maintain specialized security protocols for residents with dementia and other cognitive impairments. These residents often experience disorientation, confusion about their location, and impaired judgment about safety risks. Standard practice requires multiple layers of protection including trained security personnel, door alarms, and monitoring systems.
The facility's own policy on "Wandering and Elopement of Residents" identified residents with dementia and Alzheimer's disease as being at potential risk for wandering behavior. However, Resident #1's elopement risk assessment completed just one day before the incident indicated she was not considered high risk and had not displayed abnormal behaviors or exit-seeking tendencies.
This assessment appears to have been inadequate given the resident's severe cognitive impairment score and subsequent behavior. Standard clinical practice suggests that residents with BIMs scores of 4 require heightened supervision regardless of their recent behavioral patterns, as cognitive impairment can lead to unpredictable actions.
Facility Response and Corrective Actions
Following the transfer injury incident, the facility terminated CNA A on February 18, 2025, and implemented facility-wide corrective measures. All nursing staff received re-education on following care plans despite family requests and completed competency assessments on proper lift usage.
The facility also conducted audits of all residents requiring mechanical lifts and updated their transfer assignment tracking systems. New policies required therapy evaluations for all new admissions to determine appropriate transfer methods, with care plans and assignment sheets updated immediately upon evaluation completion.
After the elopement incident, the facility in-serviced all staff on elopement procedures and terminated the security guard who was on duty. Additional security staff received education on elopement protocols before being allowed to work at the facility.
A Wander Guard was placed on Resident #1's wheelchair following the incident, though it was later removed after monitoring indicated the resident was no longer exhibiting exit-seeking behaviors.
Additional Issues Identified
The inspection also documented concerns about the facility's risk assessment procedures. Resident #1's elopement risk evaluation failed to account for the unpredictable nature of severe cognitive impairment, rating her as low risk just one day before she left the facility unattended.
The investigation revealed gaps in staff compliance with established protocols, as multiple employees admitted to deviating from care plans when requested by family members. This pattern suggests the need for stronger emphasis on professional medical judgment over family preferences when safety is at stake.
Record-keeping issues were also noted, as progress notes did not initially document all instances of improper lift usage, indicating potential gaps in incident reporting and documentation systems.
The Centers for Medicare & Medicaid Services classified these violations as causing immediate jeopardy to resident health and safety, though the facility is disputing this determination. Inspectors noted that while corrective actions were implemented, the facility remained out of compliance due to the need to evaluate the effectiveness of the new systems over time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seven Acres Jewish Senior Care Services, Inc from 2025-05-04 including all violations, facility responses, and corrective action plans.
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