Good Samaritan Villisca: Lift Transfer Safety Violation - IA
A September 2025 complaint inspection at Good Samaritan in Villisca found the facility failed to properly follow its own mechanical lift transfer procedures for residents who cannot bear their own weight, a violation that inspectors classified as carrying potential for actual harm.
The facility's Safe Resident Handling Program, last reviewed on July 7, 2025, spelled out the requirements in plain terms. Two staff members must be present when using a non-weight-bearing mechanical lift. Before the resident is moved away from any surface while suspended in the sling, staff are required to perform what the document calls a TIME OUT, a deliberate stop to confirm all straps are secured on both sides. No one turns their back on the resident. The team moves together.
On September 2, a staff member described the procedure to inspectors the same way: two people hook the sling to the lift, check that the loops match on both sides, call the time out, and then move the resident as a unit from one location to the next. The resident is never left alone while connected to the lift.
The Director of Nursing said the same thing at 3:45 that afternoon. Staff should use personal protective equipment for all direct care contact, including transfers and toileting. Two staff are expected any time the non-weight-bearing lift is in use.
The administrator said the same thing fifteen minutes later.
Everyone agreed on what was supposed to happen. The complaint inspection existed because it hadn't.
The violation was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. That classification sits near the lower end of the federal harm scale, but it describes a specific category of risk: something went wrong, or came close enough to wrong that a complaint was filed and investigators came.
Mechanical lift failures are among the more documented sources of serious injury in long-term care. A resident suspended in a sling between surfaces has no ability to catch themselves. A strap that isn't checked, a second staff member who isn't present, a moment when no one is watching — the margin between an uneventful transfer and a fall from height is exactly the kind of procedural redundancy the two-person rule and the TIME OUT are designed to preserve.
Good Samaritan's own resource packet understood this. The document wasn't a vague aspiration. It named the pause point explicitly, described what to verify before movement, and applied the two-staff requirement specifically to residents who need full weight-bearing support from the lift. The facility had reviewed that document less than two months before the inspection.
What the inspection record does not contain is an explanation for why the protocol wasn't followed, who was present or absent during the transfer in question, or what happened to the resident involved. The narrative is thin on those details. What it does contain is a clear picture of a gap between a written standard and what actually occurred, confirmed by the facility's own leadership on the day inspectors arrived.
The administrator and the Director of Nursing both acknowledged the standard without qualification. Neither offered an account of how it was missed.
The resident who was affected remained connected to the lift during toileting tasks, according to staff statements, which means the moment of risk was not a brief or incidental one. Toileting transfers with a mechanical lift involve moving a person who cannot support their own weight from a bed or chair, positioning them over a toilet, and returning them, all while managing the sling, the straps, and the lift itself. The TIME OUT protocol exists for exactly this kind of extended, multi-step transfer.
Whether the second staff member was absent, whether the time out was skipped, or whether straps were moved without the required check, the inspection record doesn't specify. It records only that the standard wasn't met, that the potential for harm was real, and that the people responsible for the facility confirmed, when asked, exactly what should have been done.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan - Villisca from 2025-09-03 including all violations, facility responses, and corrective action plans.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
Good Samaritan - Villisca in Villisca, IA was cited for violations during a health inspection on September 3, 2025.
The facility's Safe Resident Handling Program, last reviewed on July 7, 2025, spelled out the requirements in plain terms.
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.