Clovernook Health Care And Rehabilitation Center

Based on medical record review, review of an incident report, staff interviews, and policy review, the facility failed to ensure residents were free from avoidable accidents during transfers with a mechanical (Hoyer) lift.

This affected one (#6) out of three residents reviewed for accidents.

The facility census was 110.Findings include:

Review of the medical record for Resident #6 revealed an admission date of 10/23/23.

Diagnoses included unspecified sequelae of cerebral infarction, unspecified protein-calorie malnutrition, anxiety disorder, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, congestive heart failure, peripheral vascular disease, hyperlipidemia, major depressive disorder, pseudobulbar affect, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.

Review of the annual Minimum Data Set (MDS) assessment, dated 09/08/25, revealed Resident #6 had severely impaired cognition. Resident #6 was assessed to require substantial/maximal assistance for upper body dressing, and was dependent for eating, oral hygiene, toileting, bathing, lower body dressing, personal hygiene, bed mobility, and transfer.

Review of the plan of care initiated on 11/16/23 revealed Resident #6 had an activity of daily living self-care performance deficit related to hemiplegia and was at risk for decline in physical function.

Interventions included use of a Hoyer lift with the assistance of two staff for transfers.

Review of the active physician orders revealed an order dated 06/18/25 for Resident #6 to be transferred using a Hoyer lift with two-person assistance for all transfers.

Review of the incident report dated 09/11/25 revealed Resident #6 was noted to have an area on the lower left side of her mouth that was discolored and swollen.

The investigation indicated staff were transferring Resident #6 with a Hoyer lift and the sling bar hit Resident #6's face when staff were moving her into bed.

The incident report revealed Resident #6 did not show any signs or symptoms of discomfort and did not require any medical intervention.

Interview on 09/22/25 at 10:54 A.M. with Certified Nursing Assistant (CNA) #264 verified was one of the CNA's transferring Resident #6 with the Hoyer lift the incident happened on 09/11/25. CNA #264 stated she did not actually notice the Hoyer lift bar hit Resident #6 during the lift. CNA #264 confirmed staff are to ensure the Hoyer lift sling bars do not hit the residents during the Hoyer lift transfer.Interview on 09/22/25 at 11:16 A.M. with Licensed Practical Nurse (LPN) Unit Manager #2 revealed Resident #6 had bruising and swelling to her lip and chin following a Hoyer lift transfer on 09/11/25. LPN Unit Manager #2 confirmed there were two CNA's present during the Hoyer lift transfer. LPN Unit Manager #2 stated the injury occurred during a transfer with the Hoyer lift when the bar swung back and hit Resident #6's chin.

LPN Unit Manager #2 confirmed staff are to ensure the Hoyer lift sling bars do not hit the residents during the Hoyer lift transfer.

Review of the facility policy titled Using a Mechanical Lifting Machine, revised 07/2017, revealed staff were to stop the lowering once the resident's weight was released and ensure that the sling bar does not hit the resident.This deficiency represents non-compliance investigated under Complaint Number 2617865.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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