The facility only filed the required report on September 11th after the resident's family raised concerns during a care conference. Staff had found the injury on September 4th.
Resident 44's injury came to light when two nursing assistants noticed blood on the person's arm following the mechanical lift transfer. When they rolled up the sleeve, they found what one assistant described as a large skin tear. The nursing assistants immediately informed the nurse on duty.
But the response unraveled from there.
CNA 99 told inspectors she saw no problems during the transfer and had no reason to believe the injury happened during the Hoyer procedure. She couldn't explain how the skin tear occurred. CNA 210 echoed those statements, saying there was no incident during the transfer that would have caused such a severe injury.
The nurse who received the initial report, RN 200, filled out an incident report but left blank the section asking what happened. She later told inspectors another staff member completed that section after the facility finished its investigation.
Hospice workers who examined the resident painted a starker picture. Two hospice staff members told inspectors this wasn't a simple skin tear at all, but a deep laceration that cut through the subcutaneous tissue beneath the skin.
The hospice team had not provided care to Resident 44 the morning of the transfer, before staff discovered the injury. They spoke with the resident's family and nursing home administrators on September 4th, the day the wound was found. At that time, hospice staff said, the cause remained under investigation and had not been determined.
The Director of Nursing learned about the injury the following day at a care conference with the resident's daughter on September 4th. But the facility's own policy required reporting allegations to the administrator and state agency within required timeframes.
That didn't happen.
The facility eventually settled on an explanation: they believed the resident was cut by a buckle on a Broda chair. The Director of Nursing and Regional Administrator told inspectors they felt confident in this determination based on their investigation, noting that Resident 44 had just been transferred using the Hoyer lift.
The Assistant Director of Nursing, identified as ADON 315, updated the incident report with this reasoning after the facility completed its investigation. She told inspectors they added the explanation because initially they didn't know how the injury occurred.
But the family wasn't satisfied with the facility's handling of the situation. They reported concerns to the nursing home during a care conference on September 11th. Only then did Willow Brook Christian Home report the injury to state agencies.
The delayed reporting violated the facility's own abuse, neglect and exploitation policy dated July 2025. That policy required the facility to report allegations to the administrator and state agency within required timeframes. It also mandated that the administrator follow up with state agencies with updates and report final findings within five days.
None of that happened according to the required timeline.
The Director of Nursing acknowledged to inspectors that if an injury's cause was unknown and staff observed it had occurred, it should be reported promptly so an investigation could begin immediately.
RN 200 faced disciplinary action for the delay in reporting the injury of unknown origin. The Director of Nursing confirmed the nurse received a written disciplinary action specifically due to the reporting delay.
The case highlighted gaps in the facility's incident response procedures. Despite having clear policies requiring timely reporting, staff failed to follow them. The injury remained unreported to state authorities for a full week while the facility conducted its internal investigation.
The nursing assistants who discovered the injury provided consistent accounts that nothing during the Hoyer transfer would have caused such severe tissue damage. Both CNAs expressed uncertainty about what could have caused the deep laceration.
The facility's explanation that a Broda chair buckle caused the injury came only after their investigation concluded. But hospice staff characterized the wound as more severe than facility staff initially described, calling it a deep laceration rather than a skin tear.
The discrepancy between the facility's initial description and the hospice assessment raised questions about whether staff fully understood the severity of Resident 44's injury when they first discovered it.
Federal inspectors investigated the case as part of a complaint filed under number 2627023. The inspection found the facility in violation of reporting requirements, with inspectors determining the delayed notification represented minimal harm or potential for actual harm affecting few residents.
The violation occurred despite the facility having written policies that clearly outlined reporting obligations. The policy required not just initial reporting within required timeframes, but also follow-up updates and final findings within five days.
Willow Brook Christian Home's handling of Resident 44's injury demonstrated how internal investigations can delay required reporting to state oversight agencies. The facility spent a week determining the cause of the injury before notifying authorities, only filing the required report after family members complained.
The resident's family ultimately drove the reporting timeline, not the facility's adherence to its own policies or federal requirements. Without their intervention at the September 11th care conference, it remains unclear when or if the facility would have filed the required state notification.
The case underscored the vulnerability of nursing home residents when facilities fail to follow established reporting procedures for unexplained injuries, particularly those severe enough to cut through multiple layers of tissue.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Brook Christian Home from 2025-12-23 including all violations, facility responses, and corrective action plans.