The resident, who suffered a right leg fracture during a staff-assisted transfer in July, told inspectors at Heartland Nursing & Rehab that she now requires a full mechanical lift for all transfers because she cannot use her legs to walk. Her care plan, updated October 16, specifically requires a mechanical aid sling and full mechanical lift for transfers.
But on October 19, when the full mechanical lift on her hallway stopped working, certified nursing assistant V7 used a sit-to-stand lift instead. The resident described her fear during the transfer to inspectors the next day.
"Yesterday the full mechanical lift wasn't working so the Certified Nursing Assistant used the sit to stand mechanical lift to transfer me from the wheelchair into bed," the resident told inspectors on October 20. "During the transfer, I said Dear Jesus please don't let me fall."
The nursing assistant confirmed the equipment failure and the improper transfer when questioned by inspectors. V7 stated that sometimes one of the full mechanical lifts doesn't work, and on October 19 "the lift on R3's hallway wouldn't go up."
V7 put in a work order request but acknowledged that maintenance staff aren't in the facility on Sundays. Despite knowing the resident transfers with a full mechanical lift, V7 proceeded with the sit-to-stand lift transfer.
The resident's medical records document a nondisplaced comminuted fracture of the shaft of her right femur, with routine healing noted as of July 23. Her Minimum Data Set assessment shows she is cognitively intact but completely dependent on staff for transfers.
Physical Therapy Assistant and Director of Rehab V13 told inspectors that while the resident continues physical and occupational therapy and can perform stand pivot transfers with contact guard and minimal assistance during therapy sessions, "floor staff should use a full mechanical lift for R3's transfers."
V13 was clear about the equipment restriction: the resident "has not been approved to use the sit to stand lift."
The discrepancy between therapy capabilities and nursing care requirements created confusion among staff. The nursing assistant told inspectors that therapy staff had been working with the resident on two-assist transfers to the commode, suggesting some staff believed the resident's transfer status had changed.
MDS and Care Plan Coordinator V8 confirmed the resident's current transfer status requires a full mechanical lift and acknowledged the confusion. V8 stated she "needs to check with therapy on R3's transfer status since therapy staff have been working with R3 to stand and use the commode."
However, V8 admitted she "has not received any recommendations from therapy to change R3's transfer status."
The facility's own policy, dated July 2017, requires nursing staff and rehabilitation staff to jointly assess each resident's transfer assistance needs on an ongoing basis, with transfer needs documented in the care plan. The policy mandates that these assessments be conducted "in conjunction" between departments.
The inspection revealed a breakdown in this coordination system. While therapy staff worked with the resident on standing and pivot transfers during scheduled sessions, the nursing staff continued operating under care plan instructions requiring full mechanical lift assistance for all transfers.
The resident's experience illustrates the vulnerability of nursing home residents when equipment fails and communication breaks down between departments. Her July fracture occurred during a staff-assisted transfer, making the October incident particularly concerning.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But for the resident involved, the fear was immediate and real as she found herself being transferred with inappropriate equipment while praying not to fall.
The inspection found that Heartland Nursing & Rehab failed to properly transfer the resident, violating federal requirements to ensure nursing home areas remain free from accident hazards and provide adequate supervision to prevent accidents.
The facility's plan to correct this deficiency was not available at the time of the inspection report, though federal regulations require nursing homes to submit correction plans to maintain program participation.
The resident remains dependent on staff for all transfers, sitting in her wheelchair on a full mechanical lift sling when inspectors observed her on October 20, a day after fearing she might fall during an improper transfer with broken equipment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heartland Nursing & Rehab from 2025-10-20 including all violations, facility responses, and corrective action plans.