The October 21, 2024 incident left the non-English speaking resident with matching wounds measuring 2.5 inches by 1.65 inches on both forearms when Hospitality Aide #12 attempted to help them stand from a chair to use the bathroom.
Through an interpreter, the resident told staff the injuries occurred while "being assisted by a staff member to get out of the chair to go to the bathroom." But hospitality aides at the facility are banned from touching residents under any circumstances.
LPN Staff #9 discovered the injuries at 4:30 PM that day when she was called to the resident's room. She found two large skin tears on both of the resident's forearms and immediately got an interpreter to communicate with the patient.
The LPN confronted Hospitality Aide #12 about the incident. "She informed Hospitality Aide #12 that he should not have touched the resident, obtained a statement from him then reported the incident to her supervisor," according to the inspection report.
Hospitality Aide #12 confirmed in a written statement dated October 20 that "the resident sustained skin tears when he assisted them to get up from the chair."
The facility's own job description for hospitality aides, revised in December 2022, explicitly states that "PCAs are not permitted to perform direct patient care, even if supervised." Their duties are limited to greeting residents, filling water pitchers, and answering call lights.
Director of Nursing initially told inspectors she was "unfamiliar with the incident" when interviewed on October 6, 2025. But she later located investigative files and confirmed the violations.
The resident's family filed a complaint stating they were never notified of the injuries. When they discovered the wounds and asked for an explanation, "the facility gave four different versions of the incident."
LPN Staff #9 had attempted to reach the resident's representative on October 20, leaving a message asking them to call back the facility. But the family's complaint indicates they never received proper notification about their loved one's injuries.
The inspection revealed multiple documentation failures beyond the improper care. LPN Staff #9 admitted she never measured the skin tears, despite facility protocol requiring precise documentation of wounds. Her nursing notes failed to record the size of the injuries that family members later described as substantial.
The facility's response included providing additional training to hospitality aides "emphasizing boundaries of their responsibilities to ensure patient safety and proper care." But the training occurred only after the resident was injured by staff performing duties they were never qualified to handle.
Resident #19 had been admitted to Layhill Nursing with multiple conditions including shortness of breath, dementia, and osteoarthritis of the right shoulder. The dementia diagnosis made the resident particularly vulnerable to confusion and unable to advocate for proper care.
Federal inspectors determined the facility "failed to keep a resident free from accidents and hazards by failing to provide a qualified caregiver to assist the resident." The violation affected few residents but created minimal harm or potential for actual harm.
The case illustrates how facilities can put vulnerable residents at risk when unqualified staff exceed their authorized duties. Hospitality aides are specifically prohibited from direct patient care precisely because they lack the training to safely assist residents with mobility and personal needs.
The resident required physician notification and medical treatment for the lacerations caused by the unauthorized assistance. The injuries occurred during what should have been a routine request for bathroom assistance.
When the Director of Nursing reviewed the facility's investigative documents, she confirmed the inspector's findings that an unqualified worker had injured a resident while performing duties outside their scope of practice.
The incident remained unresolved in terms of family notification, with the resident's representative filing a formal complaint about both the injuries and the facility's failure to properly inform them of what happened to their loved one.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Layhill Nursing and Rehabilitation Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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