The incident occurred on September 5, when nursing assistants used a mechanical lift to transfer Resident #1. After the transfer, she experienced significant knee pain and became unable to move from her wheelchair.
Nursing Assistant #2 told inspectors the resident "was having pain with transfer and not wanting to use the lift." Despite the resident's distress, staff never contacted the facility physician that evening.
The resident spent the night in pain, unable to get out of her wheelchair. When morning came, she called 911 herself to get to the hospital.
Hospital x-rays revealed a fracture in her knee.
Nurse #1, who was on duty that evening, told inspectors she "did not think to call the physician" about the resident's condition. The nurse acknowledged that facility policy required physician notification when residents experienced pain or functional decline.
The facility's medical director, interviewed by inspectors, said staff should have called him immediately. "If a resident was having a decrease in function this was something that needed to be conveyed to the physician," he explained.
He emphasized the urgency of the situation: "If the decrease in function and pain resulted in a resident being stuck in the wheelchair then there would have been a more urgent need to communicate with the physician about that."
Had he been notified, the physician said his response would have depended on the degree of pain. "Potentially they could have done x-rays at the facility, or he may have instructed the staff to send the resident out to the hospital."
The nursing assistant who performed the transfer told inspectors he "should have been called at that point." He also acknowledged that "the physician should also have been called if the resident was having pain after the transfer and wanting to go to the hospital."
When administrators interviewed the resident the week following the incident, she initially complained that the injury happened during the transfer. However, when she returned to the facility on September 24, her account had changed.
The Administrator and Director of Nursing said the resident told them on September 24 that "she had been experiencing knee pain for several weeks and she had pain all the time." She reportedly said "the pain following the transfer was no different than what she had been experiencing for the past few weeks prior to the transfer."
The resident also told administrators "she never asked Nurse #1 to send her to the hospital" and that "she had gotten worked up because the staff did not know what to do on the evening of September 5 to help her."
Administrators claimed Nursing Assistant #2 "had never reported a problem to them that the resident had been requesting to go to the hospital and that the nurse did not call the doctor before the resident called 911."
The facility's medical director offered another explanation for the fracture, suggesting it "could have occurred prior to the resident being at the facility and not identified on the x-ray films of August 22 when the resident felt a pop while at home."
However, the inspection found that regardless of when the fracture occurred, staff failed to follow proper procedures when the resident experienced pain and functional decline on September 5.
The resident had been unable to transfer from her wheelchair for the entire night, a significant change in her condition that warranted immediate physician notification under facility policy.
Federal inspectors cited the facility for failing to ensure that residents received proper medical care and that physicians were promptly notified of changes in residents' conditions.
The violation was classified as minimal harm with few residents affected, but highlighted gaps in communication protocols that could affect other residents' access to timely medical intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Emerald Health & Rehab Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
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