Resident 43 suffered the fracture on November 16 at 11:40 a.m. while staff assisted her with the mechanical device. The incident wasn't documented until 8:10 p.m. that same day.
Nobody filed the required incident report.
Federal inspectors discovered the violation the next day during a complaint investigation at Buckeye Care and Rehabilitation. The facility's Director of Nursing learned about the fracture on November 17 at 11:45 a.m., but as of 1:45 p.m. that afternoon, still hadn't filed a facility reported incident as required by federal regulations.
The nursing notes describing what happened weren't written by the two aides who provided the physical assistance. They were written by someone else, nine hours later.
When inspectors interviewed the Director of Nursing at 2:55 p.m. and again at 3:35 p.m. on November 17, she confirmed she knew about the fracture since late that morning. She said she immediately contacted the physician and received orders to send the resident to the emergency room for monitoring and observation.
But she confirmed she hadn't spoken with the two aides who were assisting Resident 43 during the transfer to determine what actually happened or whether they had used the sit-to-stand machine appropriately.
The Director of Nursing told inspectors she knew the injury occurred during what she considered a fall involving the sit-to-stand machine. When asked how she knew this, she said there was a nurse's note about the incident and she had spoken with Resident 43, who said she felt the injury occurred during the incident with the equipment.
The resident's own account was the primary source of information about how the fracture happened.
During the inspection, the Director of Nursing confirmed she was planning to interview the two aides later in the day. This was more than 24 hours after the incident occurred and only after federal inspectors began asking questions about what happened.
The facility's own policy requires immediate reporting of injuries of unknown origin. According to the September 2022 policy on "Reporting and Investigating Abuse, Neglect, Exploitation, or Misappropriation," all reports of abuse, neglect, exploitation, or theft are supposed to be reported to local, state, and federal agencies and thoroughly investigated by facility management.
The policy defines "immediately" as within two hours of an allegation involving abuse or result in serious bodily injury, or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
The administrator or individual making the allegation is supposed to immediately report their suspicion to the state licensing and certification agency responsible for surveying and licensing the facility.
None of this happened.
Inspectors found no facility reported incident filed between November 1 and November 17 regarding Resident 43's fracture. The facility was required to file this report but didn't, even after managers became aware of the broken hip.
The sit-to-stand machine incident raises questions about how the equipment was used and whether proper procedures were followed. These mechanical devices are designed to help residents move safely from sitting to standing positions, but they require proper training and technique to operate safely.
Without interviewing the two aides who were present, facility management had no way to determine if the equipment was used correctly or if the incident could have been prevented. The nine-hour delay in documentation also meant any immediate recollections of what happened weren't captured in real time.
The nursing notes that were eventually written came from someone who wasn't in the room during the incident. This creates a potential gap between what actually happened and what was documented in the resident's medical record.
Federal regulations require nursing homes to investigate incidents promptly and thoroughly. The facility's failure to interview key witnesses or file required reports suggests a breakdown in the incident response process that's supposed to protect residents and prevent similar injuries.
The Director of Nursing's reliance on the resident's own account of what happened, rather than witness statements from staff, represents a significant gap in the investigation. Residents who have just suffered injuries may not have clear recollections of exactly how an incident unfolded, especially if they experienced pain or confusion.
Buckeye Care is disputing the citation, according to federal inspection records.
The facility's policy clearly states that incidents should be thoroughly investigated by facility management, but the evidence suggests this didn't happen in Resident 43's case. The two people who were actually present during the incident remained uninterviewed even as the resident was sent to the emergency room for treatment.
The timing of the documentation also raises concerns about the facility's incident response protocols. A nine-hour delay between an incident and its documentation means crucial details could be lost or forgotten. Staff who witnessed the incident might have completed their shifts, gone home, or been assigned to different duties before anyone thought to get their account of what happened.
This delay also prevented the facility from conducting an immediate safety review to determine if similar incidents might be prevented. Without knowing exactly how the sit-to-stand machine was involved in the fracture, managers couldn't assess whether additional training was needed or if equipment modifications might be necessary.
The inspection revealed a pattern of delayed reporting and incomplete investigation that federal regulators say puts residents at risk. When facilities fail to properly document and investigate incidents, they lose opportunities to identify systemic problems and prevent future injuries.
Resident 43's hip fracture occurred during what should have been a routine assisted transfer. The fact that it resulted in a serious injury requiring emergency room treatment makes the facility's inadequate response particularly concerning.
The two aides who were present during the incident remain the only witnesses to what actually happened, yet they weren't interviewed until after federal inspectors arrived and began asking questions about the facility's incident reporting procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Buckeye Care and Rehabilitation from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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