Thornapple Manor: Resident Fracture, Delayed Report - MI
CNA U was helping Resident #102 use the commode on August 17 when she "lowered" the resident to the bathroom floor. The aide was using a gait belt as required, but she was working alone. The resident's care plan had been updated six days earlier to specify "two assist with gait belt to stand at grab bar in bathroom while commode is placed behind her."
LPN K found the resident lying on her right side on the bathroom floor at 9:34 PM. The CNA was sitting on the floor with the resident, who had a pillow under her head. When the nurse asked if she had fallen, the resident said no. When asked if she was hurt, she said she wasn't.
The resident was helped back into her wheelchair using her gait belt, with another staff member positioning the chair underneath her. Staff then moved her to bed using a pivot disc.
Nobody filed an incident report.
The facility's policy requires completing an incident report "on the shift in which the accident/incident occurred" whenever "a resident falls or sustains an injury." The report must include the resident's recollection, witness statements, the nurse's assessment, and corrective actions to prevent recurrence.
LPN K didn't create the incident report until after Resident #102's fracture was discovered. The inspection report doesn't specify when the fracture was found or how much time passed.
The facility's own policy defines care guides as "quick reference tools" that should be "easily located and used by staff to assist the resident with their direct care needs." These guides are based on individualized care plans developed by residents and their care teams.
CNA U had access to Resident #102's updated care plan. The two-person transfer requirement had been in place for six days when she decided to work alone.
Federal inspectors found the facility had violated transfer protocols and incident reporting requirements. The violations caused "actual harm" to the resident, though inspectors classified it as affecting "few" residents.
The facility implemented corrective measures after the violation. Staff received education on checking care guides before providing assistance. Nursing staff got additional training on the importance of following care guide requirements before delivering any care.
Management also changed how care plan updates are communicated to nursing staff, using a "huddle board" system. The incident reporting policy was updated with a clearer definition of what constitutes a fall, and nurses received training on when reports must be completed.
The facility demonstrated it was monitoring the corrective actions and maintaining compliance by September 3.
But for Resident #102, the policy changes came too late. The resident who needed two people for safe transfers was handled by one aide, ended up on a bathroom floor, and suffered a fracture that went unreported until someone finally noticed the injury.
The inspection report doesn't identify what type of fracture the resident sustained, where it occurred, or what medical treatment was required. It also doesn't explain why the incident report was delayed or who eventually discovered the injury.
CNA U told LPN K that the resident "did not fall" and that she had "lowered her down to the floor." The distinction apparently mattered to staff at the time, but not to federal inspectors who found the facility failed to follow the resident's care plan and failed to report the incident promptly.
The resident had been assessed immediately after being found on the floor. No pain was noted. When asked directly about hitting her head, she said no. When asked if she was hurt, she said she wasn't.
Those assessments proved incomplete. Somewhere between the bathroom floor and the eventual discovery of her fracture, Resident #102's condition became clear. By then, the incident report that should have been filed immediately was finally created, documenting an event that had already caused actual harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Thornapple Manor from 2025-09-04 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
Thornapple Manor in Hastings, MI was cited for violations during a health inspection on September 4, 2025.
CNA U was helping Resident #102 use the commode on August 17 when she "lowered" the resident to the bathroom floor.
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.