The September 7 incident at Clark-Lindsey Village involved a resident who requires maximum assistance with all daily activities and is completely dependent on staff for eating, hygiene, toileting, and mobility. Two certified nursing assistants were transporting her from the toilet back to her bed using a total body mechanical lift when she continued having a bowel movement.
The resident was positioned incorrectly in the sling and "screaming in pain" about a foot away from the toilet when one nursing assistant pushed a small garbage can underneath her, according to her power of attorney who witnessed the incident.
The family member immediately contacted the interim director of nurses with multiple concerns about the staff's treatment of the resident. She specifically requested that the two nursing assistants involved in the incident not provide care for the resident again.
Both assistants continued providing care after September 7.
When the power of attorney informed the interim director that both staff members were still caring for the resident, the nursing director responded that it was acceptable because they were not the resident's "primary CNAs."
The family member asked to speak with someone else about the ongoing care concerns and what she described as staff "neglecting" the resident. The interim director told her that no one else would be able to do anything.
Federal inspectors discovered the facility had no grievance log or grievance reports. The interim director of nurses told inspectors during their October entrance conference that the facility had not received any family concerns or grievances for the past three months.
The administrator in training learned about the family's concerns on September 7 but took no action. She told inspectors the interim director of nurses informed her she was "taking care of that situation" and nothing else needed to be discussed or elevated to a grievance report.
The interim director of nurses acknowledged working "closely" with the resident's power of attorney on multiple concerns about lack of care. But she never reported the family's complaints to the facility's grievance officer because she "did not think the concerns needed to rise to the level of a grievance."
The facility's grievance officer had no knowledge of the incident or the family's ongoing complaints when inspectors interviewed her in October. She confirmed that grievances can be brought forward by residents, resident representatives, staff, visitors, or anyone with a concern.
The grievance officer stated the family's concerns would "rise to the level of a grievance" and should have been reported to her.
Federal regulations require nursing homes to honor residents' rights to voice grievances without discrimination or reprisal. Facilities must establish grievance policies and make prompt efforts to resolve complaints.
Clark-Lindsey Village's own policy, dated October 19, 2022, states that residents have the right to voice grievances without fear of discrimination or reprisal. The policy specifically notes that voicing grievances "is not limited to a formal, written grievance process but may include a resident's verbalized complaint to facility staff."
The resident at the center of the incident is moderately cognitively impaired according to her most recent assessment. She requires maximum assistance from staff for personal hygiene and is completely dependent on staff for assistance with eating, oral hygiene, toileting, showering, dressing, bed mobility, and transfers.
The inspection found Clark-Lindsey Village failed to document, follow up, and resolve grievances for the resident. Inspectors reviewed grievance handling for eight residents and found deficiencies in one case.
The facility's failure to properly handle the family's complaints violated federal standards designed to protect residents from retaliation and ensure their concerns receive appropriate attention from nursing home management.
The September incident highlighted broader concerns about staff training and supervision in the facility's handling of residents who require mechanical assistance for mobility and toileting. The resident's complete dependence on staff for all activities of daily living made proper positioning in the lift critical for her safety and dignity.
The power of attorney's multiple conversations and emails with the interim director of nurses demonstrated persistent advocacy for better care. Her specific request to remove the two nursing assistants from her family member's care represented a reasonable accommodation request that the facility ignored.
The interim director's dismissal of the family's concerns as not rising to the level of a grievance contradicted both federal regulations and the facility's own written policies. Her statement that no one else could help the family violated residents' rights to escalate concerns through proper channels.
The administrator in training's passive response to learning about the incident on September 7 represented a failure of leadership oversight. Her acceptance of the interim director's assurance that the situation was being handled without verifying appropriate grievance procedures contributed to the regulatory violation.
The grievance officer's complete lack of awareness about the ongoing situation revealed systematic breakdown in the facility's complaint handling process. Her assessment that the concerns should have been reported as a formal grievance validated the family's persistence in seeking resolution.
The incident occurred during what the interim director described as a three-month period without any family concerns or grievances, suggesting either unusual quiet at the facility or systematic failure to recognize and document complaints properly.
The resident's positioning in the mechanical lift sling that caused her to scream in pain raised questions about staff competency and training in safe patient handling procedures. The decision to use a garbage can rather than properly repositioning the resident or returning her to the toilet demonstrated poor judgment and lack of dignity in care.
The family member's witness account of the incident provided detailed documentation of staff actions that compromised both the resident's physical safety and personal dignity during a vulnerable moment requiring assistance with intimate care needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clark-lindsey Village from 2025-10-15 including all violations, facility responses, and corrective action plans.