The incident occurred at St Annes Nursing Center on October 9, 2025, around 6:00 AM as staff prepared Resident #1 for dialysis. Staff G, a certified nursing assistant, had the patient in the wheelchair when they began complaining of right leg pain.
Because the resident was wearing pants, the aide could not see their legs but administered Tylenol for the pain. The resident left for dialysis as scheduled.
Staff J, a registered nurse, reported the change in condition and ordered a stat X-ray. The resident was subsequently hospitalized, where orthopedic specialists evaluated the injury and decided against surgery. The patient initially received a splint, which was later replaced with a cast.
The resident cannot receive therapy due to the cast and limited movement from the injury.
Federal inspectors found the facility violated regulations requiring residents to be free from abuse and neglect. The investigation revealed staff failed to follow the nursing home's own mandatory lift policy during the transfer.
St Annes Nursing Center maintains detailed policies requiring mechanical lifting equipment for specific residents. The facility's patient lift policy, effective April 6, 2005, states that "all resident transfers/lifting is done safely and appropriately to protect the employee and patient from injury."
The policy designates mechanical lifting devices as "MANDATORY for use in moving the patient, due to their inability to assist effectively and safely during transfers." Patients requiring mechanical lifts are identified in the facility's electronic medical records system.
"Failure to follow the guidelines established by this policy will result in disciplinary action being taken," according to the facility's written procedures.
The policy emphasizes that injuries from improper patient transfers "directly affects the quality of life for our staff members and patients." It requires healthcare professionals to "practice safe lifting, transporting and proper body mechanics at all times."
Throughout the facility, certain patients have been determined to require assistance for all moves. The mechanical lifting requirement exists "for the protection of the staff member as well as the patient."
The nursing home operates under Catholic Health Systems and maintains comprehensive abuse prevention policies dating to December 3, 2004. These policies state that "residents have the right to be free from mental, physical, sexual, and verbal abuse, neglect, misappropriation of resident's property, corporal punishment, involuntary seclusion and exploitation."
The facility pledges to "protect residents from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, consultants, other residents, staff of other agencies serving the residents, visitors, friends, family members or legal guardians, or other individuals."
Under state law, the policy mandates that "any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency and necessary corrective action will be implemented."
The facility commits to "implement processes for screening and training employees on protection of neglect, mistreatment and misappropriation of property."
Federal inspectors classified the violation as causing "actual harm" to residents during their November 13, 2025 complaint investigation. The deficiency affected "few" residents according to the inspection report.
The incident highlights the consequences when nursing home staff ignore mandatory safety protocols designed to prevent resident injuries. Mechanical lifts serve as critical protection for vulnerable patients who cannot safely assist during transfers.
The resident's injury occurred during a routine morning transfer before dialysis, a procedure that likely happens multiple times per week. The aide's decision to proceed without mechanical assistance despite facility requirements directly contradicted established safety measures.
Staff G administered pain medication but continued with the scheduled dialysis appointment rather than immediately investigating the source of the resident's complaints. The injury only became apparent after the resident returned from dialysis and received medical evaluation.
The timing of the incident, occurring early in the morning shift, suggests potential staffing or equipment availability issues that may have influenced the aide's decision to bypass required lifting procedures.
The resident's ongoing inability to receive therapy represents continuing consequences from the initial transfer injury. Physical therapy often plays a crucial role in maintaining mobility and preventing further complications for nursing home residents.
Orthopedic specialists' decision against surgery indicates the severity of the fracture may have been significant enough to require careful evaluation of treatment options. The progression from splint to cast suggests the injury required extended immobilization for proper healing.
The facility's location at 11855 Quail Roost Drive in Miami serves a population that often includes residents with complex medical needs requiring dialysis and other specialized treatments. These patients frequently depend on staff assistance for basic mobility and transfers.
Federal regulations require nursing homes to ensure adequate staffing and proper equipment use to prevent resident injuries. The mechanical lift policy at St Annes represents industry standard practices for protecting vulnerable patients during transfers.
The resident now faces an uncertain recovery period, unable to participate in rehabilitation therapy that could help maintain their functional abilities and independence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Annes Nursing Center, St Annes Residence Inc from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for St Annes Nursing Center, St Annes Residence Inc
- Browse all FL nursing home inspections