The November 7 incident at Cass County Senior Living & Rehabilitation involved a resident with left-side paralysis from a traumatic brain hemorrhage. Both staff members failed to position her affected arm safely before the transfer, despite knowing she had limited control over the limb.
The resident, identified in inspection records as R1, requires assistance from one staff member for transfers due to upper body impairment on one side. Her care plan specifically notes diagnoses including hemiplegia affecting her left dominant side, muscle weakness, and dizziness.
Certified nursing assistant V11 wrote in the facility's injury report that she and licensed practical nurse V12 "had placed (R1) on the commode. As we assisted her off the commode we did not realize (R2's) left arm had slipped under the armrest of the commode and as we lifted her, her arm stayed under the rail causing skin tears."
The resident's care plan, dated October 11, 2025, documented existing skin integrity problems. She already had two skin tears to her left forearm area and required protective arm covering "at all times due to risk of skin injury related to left side hemiplegia."
During a November 24 interview with federal inspectors, nursing assistant V11 described the transfer gone wrong. "When (R1) had her injury to her left arm I was assisting her along with a nurse (V12), to get transferred from the commode to her chair," V11 stated. "(R2's) arm that is weaker, was under the commode rest and it got caught as we went to stand her."
The nursing assistant acknowledged they "realized it right away, but she did have a flap of skin that tore during the transfer." V11 confirmed the resident "had less control over that arm and needed staff to ensure it was in a safe position to avoid it being injured during a transfer."
The facility's own policy on safe lifting and movement, dated July 2017, requires staff to use "appropriate techniques and devices to lift and move residents to reduce the risk of injury where possible." The policy states that "resident safety, dignity, self-initiated movement during transfer, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents."
Both staff members violated this policy by failing to account for the resident's paralyzed arm during the transfer. The injury occurred despite the resident's care plan explicitly warning of skin tear risks and requiring protective covering due to her left-side paralysis.
The resident's medical history made her particularly vulnerable to transfer injuries. Her minimum data set assessment from October 16 documented that she requires assistance from one staff member for transfers and has upper body impairment on one side. Her care plan notes multiple conditions affecting mobility, including traumatic hemorrhage of the right cerebrum without loss of consciousness.
Federal inspectors cited the facility for failing to ensure residents are transferred safely to prevent accident injuries. The violation affected few residents but represented minimal harm or potential for actual harm, according to the inspection report.
The incident highlights the critical importance of proper transfer techniques for residents with paralysis or weakness. Staff must position affected limbs safely before beginning any transfer to prevent entrapment under equipment or furniture.
The nursing assistant's admission that the resident "needed staff to ensure it was in a safe position to avoid it being injured during a transfer" underscores that both workers understood the precautions required but failed to take them.
The facility has experienced similar skin integrity issues with this resident before. Her care plan documented "actual alteration in skin integrity" with skin tears to her left forearm area, requiring constant protective covering since October 14.
The November inspection occurred in response to a complaint about the facility's care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cass County Senior Living & Rehabilitation LLC from 2025-11-26 including all violations, facility responses, and corrective action plans.