Waterview Pines: Lift Fall Not Reported to State - MN
The resident, identified in inspection records as R1, had lived at The Waterview Pines LLC since June 2023. She had dementia with behavioral disturbance, back pain, chronic pain, and spinal stenosis. Her care plan was specific about how she was to be moved: a toileting sling when she was on the toilet, and a full body split-leg sling for every other transfer.
On August 1, 2025, a nursing assistant was moving R1. She did not use the full body sling. She used the toileting sling.
R1 fell through it and hit her head on the floor.
The facility's own incident review, dated the same day, documented what happened. The administrator knew. The director of nursing knew. And when a state inspector sat down with both of them on August 6, the administrator explained why no one had called the state agency: the care plan had been followed during the transfer.
It had not been followed. The care plan required the full body sling for that transfer. The toileting sling was for toilet use only. Those are not the same thing.
The ceiling lift company's representative, identified in the inspection report as R-A, was interviewed the following morning. R-A said that when a resident falls from a lift during a transfer, something went wrong with the way the sling was used or applied. R-A said the toileting sling requires the resident to keep her arms outside it at all times. R-A said sling size matters more with the toileting sling because there is more open area for a person to slip through. And R-A said something that cuts directly to what happened to R1: if a resident does not have the cognitive or physical ability to keep her arms outside the sling, the toileting sling would not be recommended.
R1 had dementia with behavioral disturbance. Her care plan already documented an alteration in cognition.
R-A's conclusion was unambiguous. If the right sling had been used for the right resident, a fall from the lift should not have happened.
The nursing assistant, identified as NA-A, gave her account the same morning. Her version of events differed from the administrator's in one significant detail: she said she was transferring R1 from a wheelchair to the bed, not from the bathroom. The administrator had described R1 falling from a bathroom transfer. The incident review said bathroom to bed. NA-A said wheelchair to bed.
Whatever the starting point, NA-A described watching R1 put her arms inside the sling during the transfer. R1 was confused. She was tired. Her hands had been resting in her lap. NA-A said she told R1 to keep her arms outside the sling. R1 did not, or could not. NA-A said she tried to catch her when she began to fall. They both went down. A floor mat had been positioned between the bed and the wheelchair. R1 landed on the floor at the end of the bed, not on the mat.
NA-A said she had used the correct sling size. She said she had used the toileting sling.
That last statement is where the care plan becomes the story. R1's care plan did not authorize the toileting sling for a wheelchair-to-bed transfer. It authorized the full body split-leg sling. NA-A used the toileting sling anyway, for a transfer that the care plan explicitly assigned to a different sling entirely.
The lift company's representative had already explained what the toileting sling demands of a user: arms out, always, throughout the transfer. It is a design requirement, not a preference. And R1's own documented condition, dementia with behavioral disturbance and an alteration in cognition, is precisely the profile R-A described when saying the toileting sling would not be recommended.
The facility's own abuse and neglect policy, dated April 2025, defines neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The same policy states that suspected neglect must be reported to the state agency within two hours.
The fall happened August 1. The state inspector arrived August 6. No report had been made.
The administrator's explanation, that the care plan had been followed, was the facility's entire justification for staying silent. The inspection record does not reflect any acknowledgment from the administrator that the wrong sling had been used. The administrator said the care plan had been followed. The care plan said full body sling. The nursing assistant used the toileting sling. Those two facts do not coexist.
Inspectors cited the facility for failing to report an allegation of neglect to the state agency. The violation was tagged at a level of minimal harm or potential for actual harm, affecting few residents. One resident was reviewed for mechanical lift use. That resident is the one who fell.
What the inspection record does not contain is any account of what R1 experienced after she hit the floor, or what treatment she received, or what her condition was in the days that followed. She has dementia. She could not have understood why she was suddenly falling, or why the floor came up to meet her, or why the person trying to help her fell too. The record does not say whether she was injured beyond the fall itself.
The ceiling lift representative's words are worth sitting with. If the sling used during the transfer was appropriate for the resident, a fall from the lift should not have happened.
The sling was not appropriate for the resident. The resident's care plan had already made that determination, months before August 1, when someone wrote down: full body split-leg sling, all other transfers. The plan existed because someone had assessed R1 and concluded she needed that level of support. That assessment was not wrong. The fall confirmed it.
The Waterview Pines is located at 1201 8th Street South in Virginia, Minnesota.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Waterview Pines LLC from 2025-08-12 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.
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Last verified: November 3, 2026 · Our methodology
THE WATERVIEW PINES LLC in VIRGINIA, MN was cited for violations during a health inspection on August 12, 2025.
The resident, identified in inspection records as R1, had lived at The Waterview Pines LLC since June 2023.
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.