Riverside Manor: Broken Arm After Ignored Lift Order - OH
The therapist had evaluated the resident on April 10 and recommended a Sara Steady or sit-to-stand mechanical lift for all transfers. Neither aide knew the order existed. There was no gait belt in the room. Nobody had one.
CNA #104, one of the two aides involved, described what happened when inspectors interviewed her on April 24. She and CNA #105 had hooked their arms under the resident's arms, one on each side, and began moving her. The resident had a history of not bending her legs or helping push up during transfers, and the aide said she had considered that a safety issue. When the resident's feet started sliding, she panicked and went dead weight. The two aides had to press down on her arms to keep her from falling.
They heard a pop. The resident was in pain and couldn't move her arm.
CNA #105 went to get the nurse. CNA #104 stayed with the resident until help arrived. The resident was taken to the recliner safely, but her right arm was fractured.
CNA #104 told inspectors she had received one-on-one training on using gait belts for all transfers. She confirmed that staff were supposed to follow therapy recommendations. When the surveyor showed her the physical therapy note from April 10, she read it and confirmed it had recommended a mechanical lift. She had never seen it before that moment.
The Physical Therapy Assistant and Rehabilitation Director, identified in the report as PTA #107, initially told inspectors the resident had been classified as a two-person assist with gait belt. Then the surveyor asked to see the actual PT notes. After reviewing them together, the PTA confirmed the notes said something different: a Sara Steady or sit-to-stand lift, not a two-person assist with gait belt. The PTA said she had not been aware of the physical therapist's April 10 recommendation until the inspection on April 24, two weeks after the fracture.
The PTA told inspectors the arm fracture could have been prevented if staff had used a gait belt during the April 12 transfer. She had conducted an in-service on gait belts the previous week, after the incident.
The Director of Nursing told inspectors she had not been aware that staff were ignoring the therapy recommendation until the day of the inspection. She said she had reached out to therapy on April 20, eight days after the fracture, and that staff had begun using the Sara Steady for transfers at that point.
Inspectors noted that Riverside Manor had no policy on transfers.
The physical therapist evaluated the resident on a Thursday. The recommendation sat in the chart. Two days later, on Saturday, two aides moved her the old way, without the equipment the therapist had specified, without a gait belt, without any apparent awareness that anything had changed. The resident's feet slid. She panicked. Her arm broke.
The facility's own rehabilitation director did not know what the facility's own physical therapist had written until a federal surveyor put the document in front of her.
The resident, whose name was not released in the inspection report, had wanted to remain as independent as possible during transfers, according to CNA #104. That detail appears once in the record and is not revisited. What the record does revisit, repeatedly, is the gap between what the therapist wrote on April 10 and what anyone at the facility knew about it on April 12, or April 20, or April 24.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverside Manor Nrsg & Rehab Ctr from 2026-04-24 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
RIVERSIDE MANOR NRSG & REHAB CTR in NEWCOMERSTOWN, OH was cited for violations during a health inspection on April 24, 2026.
The therapist had evaluated the resident on April 10 and recommended a Sara Steady or sit-to-stand mechanical lift for all transfers.
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.