Magnolia Wellness Center: Hoyer Lift Fall Causes Head Injury - MO
Federal inspectors classified the incident as causing actual harm. The resident was transported by ambulance to the hospital, where a CT scan confirmed a laceration to the head.
The fall happened during a transfer. Two certified nursing assistants, identified in inspection records as CNA B and CNA D, were attempting to lift the resident using a Hoyer lift when the straps broke. The resident dropped to the floor.
What happened next is where the accounts diverge.
RN A arrived and found the resident on the floor. While on the phone with the Director of Nursing, RN A asked who was in the room. CNA D said it was CNA B and himself or herself, explaining it was CNA B's assignment. That answer, given while the DON was still on the line, put two people in the room at the time of the fall.
Then CNA D changed the story. In a written account, CNA D said he or she was not in the room.
CNA C, who came to the room after the fall, told inspectors he or she was not present when it happened. But CNA C also said that when he or she arrived, CNA D was crouched beside the resident on the floor, placing a towel under the resident's head. CNA B had gone to get the nurse.
CNA C told inspectors he or she was "shocked" when CNA D changed the account, specifically because the original statement had been made while RN A was on the phone with the DON. CNA C said the pad was blue with different colored straps, but said he or she could not say whether CNA D had been in the room before the fall.
RN A, in her own account, said she did not see the Hoyer pad itself after the incident. She saw where the straps had broken.
The Director of Nursing told inspectors she received the call from RN A that morning and was told two staff members were in the room. She asked about injuries and was told the resident was bleeding from the head. She directed staff to call the doctor and 911. The resident was taken to the hospital. The DON said she believed the wrong type of pad may have caused the fall.
The Medical Director, interviewed the day inspectors arrived, said he expected staff to follow facility policy. He offered nothing further that inspectors recorded.
What the inspection report does not resolve is whether the straps broke because of the wrong pad, a worn pad, improper technique, or some combination. The DON raised the pad as a possible cause. Nobody on record confirmed it. RN A never located the pad after the fall. CNA D's shifting account left the question of how many people were managing the lift, and how, without a clean answer.
Hoyer lift transfers are among the higher-risk routines in a nursing home. The lifts require a sling and pad fitted to the resident, straps rated for the load, and staff trained in the equipment. When a strap fails during a transfer, a resident in mid-air has nothing to catch them.
This resident had nothing to catch them.
CNA C suggested that CNA D's reversal came from fear. "Maybe he/she was scared," CNA C told inspectors. Scared of what, exactly, the report does not say. Scared of being blamed for a fall that sent a resident to the hospital with a head wound. Scared of having been somewhere they weren't supposed to be, or of not having been somewhere they were supposed to be.
The resident was taken out by stretcher. The CT scan results came back. The DON learned about the laceration. The Medical Director said what he expected.
What the resident's family was told, and when, is not in the record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Wellness Center from 2025-10-24 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
MAGNOLIA WELLNESS CENTER in SAINT LOUIS, MO was cited for violations during a health inspection on October 24, 2025.
Federal inspectors classified the incident as causing actual harm.
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.