Dinwiddie Health: Mechanical Lift Injury - VA
The incident at Dinwiddie Health and Rehab Center occurred on July 9, 2025, when CNAs attempted to move a resident using a U-shaped sling. Federal inspectors found that the nursing assistants had not crossed the sling straps between the resident's legs as required for safe operation.
The injured resident required immediate medical intervention. Facility staff implemented orders for a wrist splint, arm immobilization with a sling, ice and elevation treatments, pain management, and an orthopedic referral to address the shoulder and wrist trauma.
One of the CNAs involved in the accident went home after the incident, reportedly upset about what had happened.
Following the injury, facility administrators launched an immediate investigation. They removed the mechanical lift used in the accident from service and had maintenance inspect it, finding no mechanical malfunctions. Staff then inspected every mechanical lift in the building, discovering no equipment problems but removing five lift slings from use.
The facility conducted a re-enactment of the transfer with the same CNAs who had been involved in the original incident. This demonstration confirmed what investigators suspected: the lift sling straps had not been crossed as safety protocols required.
Administrators immediately provided education to the CNAs involved, focusing specifically on the procedure for crossing sling straps between residents' legs during transfers. The facility's director of nursing then expanded this training facility-wide.
Between July 10 and July 12, every CNA in the building underwent competency testing on proper mechanical lift use, sling strap positioning, and care plan procedures for transfers. Staff documented these sessions on forms titled "Skills Checklist Using a Mechanical Lift," with supervisors observing and signing off on each aide's demonstrated proficiency.
On July 16, the director of nursing conducted additional in-service education with all CNAs and nurses, reviewing residents' transfer status requirements and emphasizing the importance of following care plans and kardex documentation for proper transfer procedures.
The facility implemented ongoing monitoring beginning July 21, with the director of nursing or a designee conducting random observations of five mechanical lift transfers each week for four weeks. These findings were presented to the quality assurance committee, with weekly audits continuing throughout the correction period.
By August 5, the facility reported full compliance with the corrective measures. Audits conducted since that date showed staff were properly following lift procedures, including correct sling strap positioning. No additional falls or incidents involving mechanical lifts occurred after the August 5 correction date.
The facility did experience six resident falls between August 5 and the September inspection, but federal investigators found no deficiencies related to those incidents after reviewing the cases.
During the September 3 inspection, investigators observed a mechanical lift transfer involving a different resident. CNAs #2 and #3 demonstrated proper sling and strap positioning along with safe lift operation during the observed transfer, which used a U-shaped sling similar to the one involved in the July accident.
Inspectors interviewed twelve CNAs across different shifts about the education and competency training they had received. All staff members confirmed they had participated in the training and could verbalize the importance of crossing bottom straps when using U-shaped slings.
The facility's plan of correction was deemed acceptable and properly implemented. Federal inspectors found no ongoing compliance issues related to falls or accidents since the August 5 correction date.
Administrators, including the facility administrator, director of nursing, clinical service specialist, and director of quality assurance, reviewed the findings with inspectors on September 2 at 2:50 p.m. and again on September 3 at 11:40 a.m. No additional information was presented before the survey concluded.
The case was ultimately cited as past non-compliance, meaning the facility had successfully corrected the safety deficiencies that led to the resident's injuries. However, the incident highlighted how seemingly minor procedural oversights in nursing home care can result in serious harm to vulnerable residents who depend entirely on staff for safe assistance with basic daily activities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dinwiddie Health and Rehab Center from 2025-09-03 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
DINWIDDIE HEALTH AND REHAB CENTER in PETERSBURG, VA was cited for violations during a health inspection on September 3, 2025.
The incident at Dinwiddie Health and Rehab Center occurred on July 9, 2025, when CNAs attempted to move a resident using a U-shaped sling.
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.