Rivers Edge Nursing: Unsafe Hoyer Lift Transfers - WI
The resident, who has spina bifida and requires total assistance for transfers, told inspectors during an August complaint investigation that "sometimes only 1 CNA uses the Hoyer lift with her and this happens on PM shift." She added that she knows there are supposed to be two people when using the lift.
CNA C, who usually works the evening shift, confirmed the violation when interviewed by inspectors. Asked whether he uses one or two staff with the Hoyer lift, he said there's not always enough staff. "He tries to have 2 people with a Hoyer transfer, tries to get help but can't, and sometimes he uses it alone," according to the inspection report.
The nursing assistant told inspectors his decision depends on the resident. "We can use it with one or two," he said. When asked which residents he transfers alone, he specifically named the resident with spina bifida.
Rivers Edge policy states clearly that all mechanical lifts require two staff members. The facility's Transfer Status policy, updated in January, aims to "ensure safe, consistent, and resident-centered transfer practices for all long-term care residents, minimizing risk of injury to residents, staff, and visitors."
The resident's care plan specifically requires "Hoyer to Broda chair, ensure patient and staff safety. 2 assist." This intervention was initiated in December and revised as recently as May.
The resident was admitted with multiple complex conditions including spina bifida, Type 2 diabetes, asthma, chronic heart failure, and cardiomyopathy. Her care plan notes physical functioning deficits related to mobility impairment, muscle weakness, traumatic brain injury, obesity, and a history of falls. Staff assessments indicate her memory is intact.
According to her most recent assessment, she requires total dependence on staff for toileting, showering, and transfers. The care plan intervention requiring two-person Hoyer transfers has been in place since December 2024.
Both the Director of Nursing and Nursing Home Administrator told inspectors they expected staff to follow facility policies. DON B said she expected staff to follow the transfer policy requiring two staff members for Hoyer lifts and to follow resident care plans.
NHA A confirmed that staff should always follow facility policies regarding safe transfers. She stated that Hoyer transfers "should always have two staff members to assist."
The violation occurred despite clear documentation in multiple facility records. The resident's comprehensive care plan, initiated in September 2021 and updated multiple times, specifically addresses her mobility limitations and transfer requirements.
The nursing assistant's admission that he determines transfer procedures based on his own judgment contradicts both facility policy and the resident's individualized care plan. His statement that transfer requirements depend on the resident suggests a pattern of policy violations rather than an isolated incident.
The resident's awareness that two staff members should be present indicates she understands proper safety procedures. Her concern about single-person transfers suggests she may feel unsafe during these procedures.
Hoyer lifts are mechanical devices designed to safely transfer residents who cannot support their own weight. The equipment requires proper training and typically involves one staff member operating the lift while another provides support and ensures resident safety throughout the transfer process.
The facility's own policy acknowledges that proper transfer procedures minimize injury risk to residents, staff, and visitors. Single-person mechanical lift transfers increase the risk of resident falls, improper positioning, and staff injury from attempting to manage both the equipment and resident simultaneously.
The inspection found that Rivers Edge failed to ensure adequate supervision to prevent accidents for this resident. The violation was classified as having potential for minimal harm affecting few residents.
The resident's multiple medical conditions, including heart failure and a history of falls, make safe transfer procedures particularly critical. Her spina bifida diagnosis indicates she likely has limited mobility and sensation, potentially increasing injury risk from improper transfers.
CNA C's statement that he "tries to get help but can't" suggests ongoing staffing challenges that may compromise resident safety. However, facility administrators' expectations that policies be followed indicate management was unaware of the violations or had not addressed staffing concerns that prevented compliance.
The inspection occurred following a complaint, suggesting someone reported concerns about transfer safety at the facility. The specific nature of the complaint and its source were not detailed in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rivers Edge Nursing and Rehab from 2025-08-25 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
Rivers Edge Nursing and Rehab in Muscoda, WI was cited for violations during a health inspection on August 25, 2025.
CNA C, who usually works the evening shift, confirmed the violation when interviewed by inspectors.
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.