DEMOTTE, IN - Federal inspectors cited Oak Grove Christian Retirement Village for safety violations after an agency nursing assistant improperly transferred a dependent resident, causing fractures to her leg and ribs, and staff left a high-fall-risk resident unattended in a bathroom where she fell and required staples for a head wound.
Manual Transfer Causes Multiple Fractures
The most serious incident involved a resident with moderate cognitive impairment who required mechanical lift assistance for all transfers according to her care plan. On March 10, 2025, an agency certified nursing assistant manually lifted the resident from her bed to a wheelchair, despite clear instructions requiring a mechanical lift and two-person assistance.
The resident's care plan, updated in January 2025, explicitly stated that a mechanical lift must be used for all transfers with two staff members present. Her CNA care card from March 7 reinforced these requirements, noting she was completely dependent for care and transfers.
When the day shift arrived at 6:00 AM, staff discovered significant bruising and swelling on the resident's right shin. The resident showed visible signs of pain, wincing when the area was touched. Emergency X-rays revealed an acute spiral fracture of the proximal tibia, and additional imaging at the hospital showed multiple left lower rib fractures.
Medical analysis indicates spiral fractures typically result from twisting forces applied to bones, often occurring during improper lifting or transfers. The fracture pattern suggested the resident's leg was subjected to rotational stress during the manual transfer, causing the bone to break in a characteristic spiral pattern.
Agency Worker Admits to Improper Technique
In written statements obtained during the facility's investigation, the agency nursing assistant initially claimed he found the resident with her legs hanging off the bed. However, in a subsequent email, he admitted to manually transferring her by placing "an arm under both her legs and the other arm under her back" to lift her into the wheelchair.
The worker had placed the mechanical lift pad on the wheelchair before the transfer, indicating he was aware of the requirement but chose not to use the equipment. Facility records show he had completed orientation training in November 2024 and had worked at the facility multiple times.
High-Risk Resident Left Unattended, Falls
A second violation involved a resident with severe cognitive impairment who had been assessed as high risk for falls. Her care card prominently displayed "FALL RISK" in red capital letters, and her care plan required assistance for bathroom transfers.
On April 28, 2025, at approximately 5:10 AM, a nursing assistant left the resident alone in the bathroom while retrieving socks from the dresser. The resident attempted to stand from the toilet independently and fell, sustaining a 3-centimeter head laceration that required five staples to close.
Falls among cognitively impaired nursing home residents pose significant risks for serious injury, particularly head trauma that can lead to brain bleeding or other complications. Residents with severe cognitive deficits often lack the judgment to recognize their physical limitations and may attempt unsafe activities when left unsupervised.
Supervision Protocol Failures
The facility's investigation revealed conflicting accounts about the bathroom incident. While the nursing assistant's written statement claimed she only "turned her back for a couple of seconds," interviews with management indicated she had actually left the bathroom area entirely to retrieve clothing items.
The resident's fall assessment from January showed multiple risk factors including disorientation, previous falls, chair-bound status, and medications that could contribute to falls. Despite these documented risks, supervision protocols were not followed.
Inadequate Post-Injury Monitoring
Following the transfer injury incident, nursing staff failed to complete required assessments of the resident's condition. After the resident returned from the hospital with an immobilizer on her fractured leg, nurses documented minimal information about her status. From March 11-13, nursing notes showed virtually no assessment of the fracture site or the resident's pain levels.
Proper post-injury monitoring requires regular assessment of circulation, sensation, and movement in affected limbs, particularly with immobilization devices that can cause circulation problems if not properly monitored.
The resident required increased narcotic pain medication after initial treatments proved ineffective, with documentation showing she was "grimacing anytime the leg was moved" and appeared to be in distress.
Facility Response and Requirements
The facility implemented corrective measures including requirements that high-fall-risk residents not be left unattended in bathrooms and that needed clothing items be placed within reach before care begins. However, the violations highlight systemic issues with staff training and supervision of care protocols.
Federal regulations require nursing homes to maintain accident-free environments and provide adequate supervision to prevent foreseeable injuries. The incidents represent failures in both staff training and adherence to individualized care plans designed to protect vulnerable residents.
The inspection was conducted as part of a complaint investigation, with both violations receiving citations under federal nursing home safety standards. Facilities must submit correction plans to continue participating in Medicare and Medicaid programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Grove Christian Retirement Village from 2025-05-07 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.