Abington Manor: Broken Arm After Wrong Transfer Method - PA
The resident, identified in inspection records only as Resident 3, had a care plan that was specific: any transfer required a mechanical lift, and it required two staff members to do it. That plan existed for a reason. The aide, identified as Employee 1, did not follow it. The result was a mid-humerus fracture, a break in the upper arm bone, documented as a serious physical injury.
The nursing home administrator and the director of nursing both confirmed to inspectors that the failure to follow the care plan caused the fracture. That is not a disputed finding. The facility's own leadership acknowledged it directly.
Employee 1 was terminated.
The violation was cited under the federal abuse and neglect framework at the level of actual harm, meaning inspectors determined a real injury occurred to a real person, not a theoretical risk. The citation, tagged F0600, covers neglect, which under federal standards includes the failure to provide goods and services that prevent physical harm. Skipping a required two-person mechanical lift for a resident whose care plan demands exactly that qualifies.
The inspection was triggered by a complaint, not a routine survey. Someone reported what happened at Abington Manor. Inspectors came and found that the report was substantiated.
What the care plan required was not complicated. Mechanical lifts exist in nursing homes because some residents cannot bear weight, cannot assist with transfers, or have conditions that make manual handling dangerous. When a facility writes into a resident's care plan that a lift is required along with two staff, that instruction is built from an assessment of that specific person's body and needs. It is not a suggestion. Employee 1 either did not check the care plan, did not check the Kardex, which is the quick-reference nursing summary that mirrors care plan instructions, or checked and ignored what was there.
The facility said in its corrective action plan that it cannot retroactively fix what happened to Resident 3. That is accurate. A broken humerus cannot be un-broken.
What the facility could do, and said it did, was move quickly after the injury came to light. A full audit of resident transfer statuses across the entire building was completed on July 29, 2025, checking whether care plans and Kardex entries matched and were current. Education for nursing staff began the same day, covering the correct use of lift slings, how to read the Kardex, and the facility's own policies on abuse and neglect. The training ran July 29, 30, and 31. Any nurse who had not completed the education by 11 p.m. on July 31 was barred from working until they did.
Transfer observations were conducted with staff on each unit. Daily audits on every shift were scheduled for a week, with random weekly audits to follow after that. Results went to an emergency quality assurance meeting, an ad hoc session of the Quality Assurance Performance Improvement Committee convened specifically to review what had happened and what the facility was doing about it.
The facility's compliance date was set at July 31, 2025. Inspectors, reviewing all of this during the August 20 visit, cited the violation as past non-compliance, meaning the deficient practice had occurred and the facility had since taken corrective steps that inspectors verified as implemented.
That designation matters, but it does not change what happened to Resident 3.
A mid-humerus fracture is a break in the shaft of the upper arm, the long bone running between the shoulder and the elbow. In older adults, this type of fracture can involve significant pain, weeks of immobilization, and limitations in daily function that may be permanent depending on the person's baseline health and the severity of the break. For a nursing home resident who already required a mechanical lift for transfers, meaning someone whose mobility was already compromised enough to warrant that level of assistance, a fracture of the upper arm introduces new complications into an already difficult physical situation.
The inspection report does not describe Resident 3's age, diagnosis, or what their recovery looked like. It does not say whether they were in pain, whether they required surgery, or whether they were able to return to their prior level of function. Those details are not in the public record. What is in the public record is that a person living at Abington Manor, a person whose care plan was written to protect them from exactly this kind of injury, was hurt because one employee did not follow that plan.
The facility's response, the termination, the audits, the emergency training, the shift-by-shift observations, suggests that leadership understood the seriousness of what occurred. The administrator and director of nursing did not minimize it when speaking to inspectors. They confirmed the causal link between the aide's actions and the fracture without qualification.
But the corrective action plan also reveals something about what preceded the injury. The education provided after the fracture covered not just lift technique but also how to correctly read the Kardex, the basic reference document that every nursing aide is expected to consult before moving a resident. The fact that post-incident training had to include Kardex review as a topic suggests that checking the Kardex before a transfer was not a universal habit among staff before Resident 3's arm was broken.
The audit of transfer statuses across the building, completed the same day education began, was described as verifying that care plans and Kardex entries were up to date and correct. A facility-wide audit of that kind, conducted in the immediate aftermath of one resident's injury, implies that the problem inspectors found was not assumed to be isolated to a single employee's single act.
Abington Manor is a licensed nursing facility in Clarks Summit, in Lackawanna County in northeastern Pennsylvania. The complaint that triggered this inspection was filed before the August 20 visit. The investigation substantiated the violation. The harm was real.
Resident 3 has a broken arm that happened because the person responsible for moving them safely did not use the equipment and the help that were specifically required. The care plan said two people and a mechanical lift. There was one person and no lift. The bone broke.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Abington Manor from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 15, 2026 · Our methodology
ABINGTON MANOR in Clarks Summit, PA was cited for violations during a health inspection on August 20, 2025.
That plan existed for a reason.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.