Azria Health Park Place: Lift Transfer Safety Failures - IA
The September 2025 inspection, triggered by a complaint, captured the transfer on observation. A nursing assistant identified in the report as Staff E operated the mechanical lift with the leg bar kept together, rather than spread open, as the resident was raised from a wheelchair and moved toward a bed. When the lift hit cords beneath the bed during the transfer, Staff E told another nursing assistant to pull the cords out of the way, then continued lowering the resident into bed.
The manufacturer's instructions for the Protekt 600, one of the lifts in use at the facility, are direct: during lifting or lowering, whenever possible, keep the base of the lift in the widest position. The manual for the Hoyer HPL500, another lift at the facility, states the leg bar can be opened to navigate around armchairs, wheelchairs, and other furniture. A third lift manual, for the Linak Medline-Careline, instructs users to assure free space for movement in both directions to avoid a blockade.
None of that guidance had made it into the facility's own training materials. An undated Resident Lift and Transfer Safety Observation Form used at the facility listed steps like locking the wheelchair and bed before a transfer, but contained no steps specific to operating a mechanical lift. The facility's Safe Lifting and Movement of Residents policy, last revised in July 2017, said staff responsible for direct resident care would be trained in the safe and proper use of mechanical lifting devices. It did not say how.
The Regional Nurse, interviewed the morning of September 10th, said the spread bar needed to be out whenever a resident was transferred from one surface to another. She also said the facility had been planning to do survey preparation but had not conducted any competency audits, including for transfers.
The Director of Nursing told inspectors the following day that the facility's policy contained no information on whether the bars should be in or out during a transfer. She said she thought it depended on where the lift was being used and where the resident was going. She noted the resident rooms were small and the lift had to fit in whatever space was available. She said she expected staff to follow the manufacturer's instructions.
Those two answers, from the facility's top two nursing leaders, pointed in different directions. The Regional Nurse said the bar should always be out during a transfer. The Director of Nursing said it depended on the room.
By the exit conference that afternoon, the President of Operations had arrived at a third answer. The mechanical lifts at the facility, she said, did not require the legs to be out during a transfer at all. The spreader bar should be opened only to get around furniture or a wheelchair.
That answer also conflicts with the Protekt 600 manual, which says to keep the base in the widest position during lifting or lowering whenever possible, not only when navigating around obstacles.
The violation was cited at a level of minimal harm or potential for actual harm. A resident was in the sling during the transfer described in the report. The Protekt 600 manual contains one instruction that requires no interpretation: do not roll casters over any object while the resident is in the sling. During this transfer, the lift hit cords under the bed while the resident was suspended in it.
No one interviewed during the inspection described what the resident experienced during the transfer, or whether anyone asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Azria Health Park Place from 2025-09-11 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 29, 2026 · Our methodology
Azria Health Park Place in Des Moines, IA was cited for violations during a health inspection on September 11, 2025.
The September 2025 inspection, triggered by a complaint, captured the transfer on observation.
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.