Venetian Care & Rehab: Improper Transfer Injury - NJ
The June 8 incident at The Venetian Care & Rehabilitation Center involved a resident who had been living at the facility for over 10 years and required substantial assistance with transfers due to impairment on both sides of the lower extremities.
Certified nursing assistants found the resident sleeping in a chair during overnight care on June 9 and decided to move them to bed. According to the facility's investigation, one CNA held the resident by their pants on the right side while the second CNA held them by the pants on the left side.
The next morning, nursing staff discovered purplish discoloration extending from the resident's left inner thigh to the right posterior thigh. The primary nurse immediately called a physician about the bruising.
The facility's investigation concluded that the resident's thigh came into contact with the wheelchair armrest during positioning. But interviews with facility leadership revealed the transfer violated multiple safety protocols.
"The nursing assistants should not have held onto his/her pants to transfer into the bed and should have removed the armrest from the wheelchair which caused the bruise," the Director of Nursing told federal inspectors on August 18.
The Director of Rehabilitation confirmed the improper technique during a separate interview the following day. The armrest should have been removed from the wheelchair prior to the transfer, and staff should have used a gait belt instead of pulling on the resident's pants.
According to the nursing assistants' statements, they stood on opposite sides of the resident, put their arms under the person's armpits with one hand on their pants, then swung them over the wheelchair armrest into the bed.
The resident's care plan, dating back to 2015, specifically addressed transfer assistance. It noted the resident wanted to help with surface-to-surface transfers and required extensive assistance, with interventions including verbal cues to prompt cooperation during transfers.
A quarterly assessment from March revealed the resident scored three out of 15 on a cognitive screening test, indicating severe impairment. The same assessment documented the need for substantial to maximal assistance with chair and bed transfers.
Federal inspectors attempted to interview both nursing assistants involved in the incident but could not reach them. One assistant's voicemail was not set up, and the other did not return calls made on August 18.
The facility classified the injury as unknown origin and developed a plan to reinforce safe two-person transfer techniques for dependent residents. However, inspectors noted that the facility's transfer policy was requested from the administrator but not provided before the survey concluded.
This incident occurred more than a year after the resident's care plan was established, suggesting the proper transfer techniques outlined in facility protocols were not followed despite clear documentation of the resident's needs and limitations.
The bruising discovery prompted an immediate investigation, but the facility's own findings confirmed that basic safety measures - removing wheelchair armrests and using proper lifting equipment - were ignored during the transfer.
Residents with cognitive impairment and mobility limitations face particular vulnerability during transfers, as they cannot effectively communicate discomfort or advocate for proper handling techniques.
The resident had been admitted to the facility in April 2015, making this incident occur during their 10th year of residence. Despite the length of stay and documented care needs, the transfer resulted in preventable injury.
Federal regulations require nursing homes to maintain accident-free environments and provide adequate supervision to prevent injuries. The facility's own investigation acknowledged the transfer was performed improperly, with staff using the resident's clothing instead of appropriate equipment.
The Director of Nursing's interview revealed that facility leadership understood the correct transfer procedures but failed to ensure staff implementation. Removing wheelchair armrests and using gait belts are standard safety measures in long-term care settings.
Inspectors found this failure during a complaint investigation that reviewed three residents for potential abuse. The improper transfer technique increased the risk of injury for other residents requiring similar assistance.
The facility's investigation timeline showed nursing staff discovered the bruising on June 9, conducted employee interviews on June 10, and completed the injury investigation the same day. However, the fundamental safety violations that caused the injury remained unaddressed until federal inspection months later.
Staff statements during the investigation confirmed they lifted the resident by their pants and swung them over the wheelchair armrest - a technique that facility leadership acknowledged was inappropriate and dangerous.
The resident's decade-long stay at the facility, combined with documented cognitive impairment and transfer needs, should have ensured staff familiarity with proper handling techniques. Instead, the incident revealed gaps in basic safety protocol implementation.
Federal inspectors classified this as a violation affecting few residents with minimal harm or potential for actual harm. But the facility's own findings demonstrated that proper procedures could have prevented the injury entirely.
The investigation revealed that two experienced nursing assistants either ignored or were unaware of fundamental transfer safety requirements, raising questions about training and supervision adequacy at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Venetian Care & Rehabilitation Center, The from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
VENETIAN CARE & REHABILITATION CENTER, THE in SOUTH AMBOY, NJ was cited for violations during a health inspection on August 21, 2025.
Certified nursing assistants found the resident sleeping in a chair during overnight care on June 9 and decided to move them to bed.
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.