The violation occurred on October 2, 2025, at Advanced Health & Rehab Center of Garland, according to federal inspection records. The resident in question cannot transfer without a hydraulic lift due to his medical condition.
The facility's Director of Nursing confirmed during a November 7 interview that the solo operation was "not acceptable" and posed safety risks. She emphasized that assistance from two staff members was required for all hydraulic lift operations, including routine tasks like obtaining resident weights.
"It was not acceptable for CNA A to operate the hydraulic lift by herself, even if it was for obtaining resident weights," the Director of Nursing told inspectors. She stated that two-person assistance was mandatory for safety purposes.
The facility's own policy, revised as recently as September 13, 2024, explicitly addresses hydraulic lift operations. The policy states its purpose is "to enable to lift and move a resident safely."
A validation checklist for mechanical lifts, completed for the nursing assistant on October 8, 2025, clearly outlined the requirement. Under the section titled "Lifting the Resident," the checklist stated: "Must have two staff members when using the lift."
This means the nursing assistant received training on proper lift procedures just six days after the violation occurred.
The Director of Nursing revealed additional systemic failures during her interview with inspectors. She acknowledged that the resident should have had hydraulic lift and transfer care documented on his Comprehensive Care Plan, ensuring that anyone providing his care would understand proper transfer procedures.
"Anyone that takes care of him will know how to transfer him properly," she explained, noting this information should have been clearly documented in the resident's care plan.
The nursing director accepted ultimate responsibility for ensuring resident care needs were properly identified and documented in Comprehensive Care Plans. However, she noted that she was recently hired and promised to review the concern immediately.
The facility conducts skills checkoffs annually for nursing assistants, supplemented by mini skills refresher sessions throughout the year. The Assistant Director of Nursing typically handles the majority of nursing assistant education, according to the Director of Nursing.
Despite these training protocols, the October incident demonstrates a breakdown in both policy adherence and care plan documentation. The resident's transfer needs were not properly communicated to staff through his care plan, and the nursing assistant violated established safety procedures.
Hydraulic lifts are essential equipment for residents who cannot bear weight or assist with transfers. Operating these devices requires specific training and, according to this facility's policy, two-person teams to ensure resident and staff safety during transfers.
The violation was discovered during a complaint investigation conducted on November 26, 2025. Inspectors classified the incident as causing minimal harm or potential for actual harm, affecting few residents.
Record reviews confirmed that the nursing assistant in question was indeed working on October 2, 2025, when the solo lift operation occurred. The facility administrator provided staffing documentation that verified the nursing assistant's presence that day.
The incident highlights broader concerns about care plan accuracy and staff compliance with safety protocols. The resident's inability to transfer without mechanical assistance represents a significant care need that should have been prominently documented and communicated to all staff members.
The newly hired Director of Nursing's acknowledgment that she would "review this concern immediately" suggests the facility recognized both the policy violation and the documentation failures that contributed to the incident.
For residents requiring hydraulic lifts, proper operation is not merely a matter of convenience but of fundamental safety. These devices support individuals who cannot support their own body weight during transfers from beds to wheelchairs, toilets, or scales.
The October 2 incident occurred during what should have been a routine task - weighing the resident. Even for this seemingly simple procedure, facility policy required two staff members to operate the lift safely.
The violation underscores the importance of both clear documentation and consistent policy enforcement in nursing home care, particularly for residents with significant mobility limitations who depend entirely on staff and equipment for basic daily activities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Advanced Health & Rehab Center of Garland from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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