Waterview Pines: Wrong Sling Causes Resident Fall - MN
The incident at Waterview Pines occurred when the nursing assistant selected a toileting sling instead of the full body sling specified in the resident's care plan. The resident, identified as R1, put her arms through the sling openings during the transfer from wheelchair to bed, compromising the lift's safety and causing both women to fall.
During an interview on August 7, the nursing assistant explained what happened during the transfer. She said R1 had been "confused and tired" and was resting her hands on her lap when she put her arms inside the sling. The aide said she watched R1 put her arms through the openings and told her to keep her arms outside the sling.
"She tried to catch R1 when she fell and they both fell," according to the inspection report.
The resident landed on the floor at the end of the bed, despite a floor mat positioned between the bed and wheelchair. The wheelchair had been positioned parallel to the bed during the attempted transfer.
The nursing assistant told inspectors she had used the correct sling size and confirmed she used a toileting sling. However, R1's care plan specifically directed staff to use a full body sling for all transfers except when using the toilet.
A rehabilitation aide interviewed during the inspection explained the critical difference between sling types. The aide said toileting slings have more open area than full body slings, making size selection much more important for safety. With toileting slings, residents must have the cognitive and physical ability to keep their arms outside the sling during transfers.
The rehabilitation aide stated that if a resident cannot keep their arms outside the sling, a toileting sling would not be recommended for that person. The aide explained that when the appropriate sling is used during transfer, a fall from the mechanical lift should not occur.
The incident represents a clear deviation from the resident's established care plan. Care plans in nursing homes specify which equipment and techniques should be used for each resident based on their individual needs, cognitive abilities, and physical limitations.
R1's care plan designated a full body sling for transfers, indicating that staff had previously assessed her as needing the more secure sling type. Full body slings provide more comprehensive support and have fewer openings where confused residents might place their arms.
The nursing assistant's decision to use a toileting sling instead directly contradicted these care plan instructions. The toileting sling's design, with larger openings to accommodate bathroom needs, created the exact scenario the rehabilitation aide described as dangerous for residents who cannot reliably keep their arms positioned correctly.
The fall occurred despite the nursing assistant's awareness of the problem. She observed R1 putting her arms through the sling and attempted to correct the resident's positioning by telling her to keep her arms outside. However, this verbal instruction proved insufficient for a resident described as "confused and tired."
The incident highlights the importance of following individualized care plans rather than making independent equipment decisions. Each resident's care plan reflects assessments of their cognitive abilities, physical limitations, and safety needs. When staff deviate from these plans, residents face increased injury risks.
Mechanical lifts are designed as safety devices to prevent injuries during transfers of residents who cannot move independently. When used with appropriate slings and proper technique, they significantly reduce fall risks for both residents and staff. However, using incorrect equipment or techniques can transform these safety devices into hazards.
The rehabilitation aide's comments underscore how equipment selection must match resident capabilities. For residents with cognitive impairments or physical limitations that prevent them from following positioning instructions, toileting slings present unacceptable risks during transfers.
Waterview Pines' policy on abuse prohibition and vulnerable adults, dated April 2025, requires immediate investigation of incidents. The policy states that staff must take immediate action to prevent further problems while investigations proceed. Investigations should include interviews with staff, residents, and witnesses to determine what happened.
The policy also mandates corrective action based on investigation findings, which may include procedure changes, additional training, staff discipline, or discharge. However, the inspection report does not indicate what corrective measures, if any, the facility implemented following this incident.
The fall represents what inspectors classified as minimal harm or potential for actual harm affecting few residents. This classification suggests the immediate physical injuries were limited, though the incident revealed systemic problems with care plan adherence and equipment selection.
Both the resident and nursing assistant fell to the floor during the incident. The aide's attempt to catch the falling resident, while well-intentioned, resulted in both women being injured when the transfer went wrong. This outcome demonstrates how equipment failures can create cascading safety problems.
The incident occurred during what should have been a routine transfer from wheelchair to bed. Such transfers happen multiple times daily in nursing homes, making proper technique and equipment selection critical for resident and staff safety. When procedures fail, the consequences affect everyone involved.
The inspection found that facility staff failed to follow the resident's individualized care plan, which specifically required a full body sling for transfers. This deviation from established protocols directly contributed to the fall and injuries. The resident's confusion and fatigue, noted by the nursing assistant, made strict adherence to the care plan even more important.
R1's attempt to position her hands on her lap during the transfer shows how cognitive limitations can interfere with safe lift operations. The care plan's requirement for a full body sling likely reflected previous assessments of her ability to follow positioning instructions during transfers.
The nursing assistant's recognition that she used the wrong sling type, combined with her observation of R1 putting arms through the openings, suggests awareness of the developing problem. However, continuing the transfer rather than stopping to use the correct equipment led directly to the fall.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
The Waterview Pines LLC in VIRGINIA, MN was cited for violations during a health inspection on August 12, 2025.
During an interview on August 7, the nursing assistant explained what happened during the transfer.
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.