The September 11 incident at Clovernook Health Care and Rehabilitation Center involved Resident #6, a woman with severe cognitive impairment who requires maximum assistance for nearly all daily activities. She had been living at the facility since October 2023 following a cerebral infarction that left her with paralysis affecting both sides of her body.
The resident depends entirely on staff for eating, bathing, toileting, and moving from bed to wheelchair. Physician orders specifically required two staff members to operate the Hoyer lift during all transfers, a mechanical device designed to safely move patients who cannot support their own weight.
Two certified nursing assistants were transferring the resident into bed when the Hoyer lift's metal sling bar hit her face. The impact caused visible discoloration and swelling on the lower left side of her mouth, along with bruising to her lip and chin.
Neither assistant noticed the strike during the transfer.
CNA #264, one of the staff members operating the lift that day, told inspectors she "did not actually notice the Hoyer lift bar hit Resident #6 during the lift." The injury was discovered only later, when other staff observed the facial swelling and discoloration.
Licensed Practical Nurse Unit Manager #2 confirmed the details during interviews with state inspectors. The manager explained that "the injury occurred during a transfer with the Hoyer lift when the bar swung back and hit Resident #6's chin."
The resident showed no signs of discomfort following the incident and required no medical intervention, according to the facility's incident report. However, the injury remained visible days later when inspectors arrived to investigate a complaint.
Facility policy explicitly addresses this type of accident. The nursing home's mechanical lifting procedures, last updated in July 2017, instruct staff to "stop the lowering once the resident's weight was released and ensure that the sling bar does not hit the resident."
Both staff members interviewed confirmed they understood this safety requirement. CNA #264 acknowledged that "staff are to ensure the Hoyer lift sling bars do not hit the residents during the Hoyer lift transfer." The unit manager made an identical statement to inspectors.
The resident's medical condition makes her particularly vulnerable to injury. Her diagnoses include the aftermath of cerebral infarction, malnutrition, anxiety disorder, congestive heart failure, and major depressive disorder. The stroke left her with hemiplegia affecting both her dominant right side and non-dominant left side, requiring complete dependence on staff for mobility.
Her cognitive impairment is rated as severe, meaning she likely cannot communicate pain or distress effectively. The facility's assessment from September 8 documented that she requires substantial to maximal assistance for upper body dressing and complete dependence for all other personal care activities.
The care plan established in November 2023 specifically identified her risk for decline in physical function and mandated two-person assistance for all Hoyer lift transfers. These precautions were designed to prevent exactly the type of accident that occurred.
Hoyer lifts are standard equipment in nursing homes for transferring residents who cannot move independently. The devices use a fabric sling to support the resident's body weight while a mechanical arm raises and lowers them. When operated correctly, the metal sling bar should remain clear of the resident throughout the transfer process.
The failure to notice the impact raises additional concerns about staff attention during transfers. Federal inspectors noted this represents a broader pattern of inadequate supervision during potentially hazardous procedures involving vulnerable residents.
State health department investigators reviewed the case as part of complaint number 2617865. The facility's 110 residents include many with similar mobility limitations who depend on mechanical lifts for safe transfers.
The resident continues to live at Clovernook, where staff must now demonstrate they can operate lifting equipment without striking the people they're supposed to be helping move safely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clovernook Health Care and Rehabilitation Center from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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