Waterview Pines: Wrong Sling Nearly Injures Residents - MN
The dangerous practice came to light when inspectors observed two nursing assistants preparing to transfer a resident on August 6. The woman was lying in bed with a toileting sling underneath her body. The assistants switched it out for a full body sling, explaining that staff on the previous shift had used the wrong equipment.
One nursing assistant told inspectors that the sling underneath the resident "was not the correct sling."
The distinction matters. Toileting slings have openings that allow residents to use the bathroom without removing the equipment. Full body slings provide complete support during transfers. Using the wrong type can cause residents to slip through openings and fall.
A registered nurse explained the assessment process during an interview the next day. Sling size and type depend on the resident's height and weight, she said. The type also depends on whether the resident is continent.
More critically, she said a toileting sling should not be used if residents have physical limitations like amputations or if they are agitated and could slip through the equipment.
Yet the nurse defended using a toileting sling for another resident whose lift form indicated she was "unable to follow simple instructions and was not cooperative with transfers." The nurse said the toileting sling was still appropriate because the resident used the toilet.
The contradiction highlighted the confusion among staff about proper sling selection. Residents who cannot follow instructions during transfers face higher risks of falling through equipment designed with openings.
Federal inspectors determined the immediate jeopardy began on August 1, suggesting the dangerous practice had been ongoing for nearly a week before discovery.
The facility's own policy emphasized that mechanical lift equipment should be used "in all circumstances when lifting/moving residents except when manual assistance is deemed absolutely necessary." The policy, dated March 2020, stated that all resident care should be provided "in a safe, appropriate and timely manner in accordance with the residents plan of care."
But staff were not following those guidelines. The wrong sling selections violated both safety protocols and individual care plans that specify appropriate equipment for each resident.
Transfer accidents can cause serious injuries in nursing home residents. Hip fractures, head injuries, and other trauma from falls during mechanical lifts often require hospitalization and can be life-threatening for elderly residents with multiple health conditions.
The registered nurse told inspectors that slings are supposed to be assessed on admission, quarterly, and whenever a resident's condition changes. But the ongoing use of wrong equipment suggested those assessments were either not happening or not being properly communicated to staff.
The immediate jeopardy designation means inspectors found conditions that posed serious risk of injury or death to residents. Such findings can trigger federal funding cuts and facility closure if not promptly corrected.
Waterview Pines moved quickly to address the violations. The facility removed the immediate jeopardy status on August 8 by implementing what inspectors called "a systemic plan."
The corrective actions included developing a system to determine appropriate sling sizes and types based on resident needs and manufacturer guidelines. The facility assessed all residents who required assistive devices to ensure correct equipment was being used.
Staff received education about the new procedures and where to find information about proper slings for each resident. The facility also developed new procedures specifically related to assessing resident sling use.
All staff responsible for transferring residents were educated about the policies and changes before their next shifts began.
The swift response suggested the facility recognized the severity of the safety breach. Wrong sling selection represents a basic failure in resident care that could have resulted in serious injuries.
The inspection focused on three residents specifically mentioned in the violation. Each required different equipment based on their individual conditions and abilities.
The nursing assistants who discovered the wrong sling on August 6 appeared to understand proper protocols, immediately recognizing the equipment mismatch and correcting it. Their actions likely prevented a potential fall.
But the fact that previous shift staff had placed the wrong sling suggests broader training gaps or communication failures about resident-specific equipment needs.
Mechanical lifts and slings are essential safety equipment in nursing homes where many residents cannot transfer independently. Proper selection and use prevent both resident injuries and staff back injuries from manual lifting.
The violation occurred during a complaint inspection, meaning someone had reported concerns about the facility to state health officials. Federal inspectors arrived to investigate specific allegations about care quality or safety.
The immediate jeopardy finding indicates the problems were more serious than initially reported. What began as a complaint investigation revealed systemic failures in transfer safety that put multiple residents at risk.
The facility's quick implementation of corrective measures and staff education suggests management took the violations seriously. But the incident raises questions about how long residents had been transferred with inappropriate equipment before the dangerous practice was discovered.
For families with loved ones at Waterview Pines, the violation highlights the importance of asking specific questions about transfer procedures and equipment selection during care plan meetings.
The registered nurse's comment that toileting slings were appropriate for residents who "still used the toilet" despite being unable to follow transfer instructions reveals concerning gaps in safety understanding among clinical staff.
Residents who cannot follow instructions during transfers need maximum support and security. Using equipment with openings creates unnecessary risks that proper full body slings would eliminate.
The August inspection found that basic safety protocols were not being followed consistently, putting vulnerable residents in danger during routine daily care.
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.
The dangerous practice came to light when inspectors observed two nursing assistants preparing to transfer a resident on August 6.
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.