The LVN told inspectors on September 22 that when residents were admitted to the 507 West Ave facility, the process included instructions on how to transfer each person safely. She said Resident #2 required transfers using a mechanical lift, but acknowledged she had never actually transferred that resident herself.
Despite having access to care plans and the ability to make adjustments when needed, the nurse couldn't identify who held direct responsibility for the documents that govern resident safety procedures.
When inspectors asked about potential consequences of not following transfer protocols outlined in care plans, the LVN said injury was possible.
The facility's own baseline care policy, dated May 2022, requires staff to implement care plans within 48 hours of admission "to ensure continuity of care and communication, prevent adverse events, and inform the resident and or responsible party of the initial care and services."
According to the policy, baseline care plans must address initial goals based on admission orders, physician orders, dietary requirements, therapy services, social services, and PASRR recommendations.
The inspection was conducted in response to a complaint and found the facility violated federal regulations requiring comprehensive care plans that prevent accidents and maintain resident safety during transfers.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents.
The deficiency centered on the facility's failure to ensure residents were transferred according to their individualized care plans, creating unnecessary injury risks during routine care procedures.
Staff interviews revealed gaps in understanding basic care plan responsibilities, despite policies requiring comprehensive planning within two days of each resident's arrival.
The LVN's admission that she could modify care plans but didn't know who created them highlighted systemic issues with accountability for resident safety protocols.
Mechanical lift transfers require specific training and adherence to individualized procedures based on each resident's physical condition and mobility limitations. When staff deviate from established care plans, residents face increased risks of falls, improper positioning, and equipment-related injuries.
The facility's policy emphasizes preventing adverse events through proper care planning and communication, but the inspection found staff couldn't identify who held responsibility for ensuring these critical safety documents were properly maintained and followed.
The November 21 inspection focused specifically on transfer safety protocols after complaints were filed regarding care plan compliance at the Schulenburg facility.
Inspectors found that while the facility had written policies requiring baseline care plans within 48 hours, staff understanding of care plan responsibilities remained unclear, creating potential safety gaps for residents requiring mechanical assistance with transfers.
The LVN interviewed admitted she had never transferred Resident #2, despite being responsible for understanding and potentially modifying that person's care plan requirements.
This disconnect between policy and practice raised concerns about whether other staff members were following individualized transfer protocols for residents requiring mechanical lifts and specialized positioning assistance.
Federal regulations require nursing homes to develop comprehensive care plans that address each resident's specific needs and prevent accidents during routine care activities like transfers between beds, wheelchairs, and other locations within the facility.
When asked directly about the consequences of not following care plans during transfers, the LVN acknowledged that resident injury was a possible outcome, demonstrating awareness of the risks while revealing gaps in implementation.
The facility's May 2022 policy specifically aims to prevent adverse events through proper care planning, but the inspection found staff couldn't clearly identify who bore responsibility for ensuring these safety measures were properly executed.
Inspectors documented the violation under federal regulation F 0655, which requires facilities to provide care and services to prevent accidents and maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
The inspection report indicates the deficiency affected few residents but created minimal harm or potential for actual harm through inadequate adherence to individualized transfer safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At the Oak from 2025-11-21 including all violations, facility responses, and corrective action plans.