Presidential Oaks: Daily Care Failures Found - NH
The resident suffered a spiral fracture of the left tibia.
Physical therapist Staff A and physical therapist Staff E documented their first safety warning on August 15. Their treatment note stated that staff was "using various techniques including bear hugging pt which is unsafe for both pt and staff." They recommended a mechanical lift called a hoyer and notified the unit manager that the patient should use one.
Two weeks later, nothing had changed.
On August 29, Staff A wrote another treatment note: "pt is essentially D [dependent] for xfers [transfers]. Does not participate in xfers, unable to bear weight through LE [lower extremities]. Again recommend pt be a hoyer for pt and staff safety." The therapist notified nursing again.
On September 12, Staff A and Staff E documented a third warning to nursing staff that a hoyer lift should be used.
The warnings went unheeded. Licensed nursing assistant Staff C performed a dangerous one-person stand-pivot transfer on the resident after lunch on September 20, lifting the patient from wheelchair to bed without mechanical assistance. The resident said "Ow" during the transfer and again during incontinence care later. Staff C notified the nurse about the resident's pain complaints.
The next morning, September 21, the resident remained in bed due to pain complaints and was observed holding their left leg. The resident continued holding the leg during incontinence care that day.
On September 22, nursing assistants reported that the resident appeared to be in pain with swelling and redness in the left lower extremity. A nursing progress note documented the examination findings: "a reddened area just above the ankle on the left leg, the area was warm, red, and tender to the touch." The resident also had swelling of the lower left leg and foot.
An x-ray revealed a spiral fracture of the mid to distal left tibial diaphysis. The radiology report described it as a "minimally displaced spiral oblique fracture."
Staff C told inspectors they had understood the resident could be transferred by stand-pivot method, with a mechanical lift available if needed. The nursing assistant had cared for the resident on both September 20 and 21, performing the dangerous transfer that preceded the injury discovery.
The facility's own care plan, revised on September 16, specified that the resident required "2 staff hoyer transfer assist to move between surfaces as necessary." This revision came after the physical therapists' repeated warnings but six days before Staff C performed the one-person stand-pivot transfer.
Physical therapy assistant Staff A confirmed to inspectors that they had been providing therapy to the resident and that mechanical lift transfers were necessary for both the resident's and staff's safety. Staff A said they had communicated the transfer requirements verbally to nursing staff since August 15.
The resident was completely dependent for transfers, unable to bear weight through their lower extremities or participate in the movement process. Despite this total dependence and the clear safety warnings, staff continued manual lifting techniques that put both resident and caregiver at risk.
The spiral fracture pattern is consistent with twisting forces applied to the bone during improper handling. Such fractures in elderly patients can result from the rotational stress of unsafe transfer techniques, particularly when a dependent resident cannot assist with positioning or weight-bearing.
Federal inspectors determined the facility failed to implement interventions that addressed the resident's assessed transfer limitations, despite having clear documentation of those needs from qualified therapy staff. The violation carried a minimal harm designation, though the resident sustained an actual injury requiring medical intervention.
The month-long gap between the first safety warning and the resident's injury illustrates how communication failures between departments can directly impact patient safety. Physical therapy staff had identified the risk, documented it multiple times, and notified nursing management, but the dangerous practices continued until the predictable injury occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Presidential Oaks from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PRESIDENTIAL OAKS in CONCORD, NH was cited for violations during a health inspection on November 18, 2025.
The resident suffered a spiral fracture of the left tibia.
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.