Video footage from September 16 captured the incident at Terra Bella Health and Wellness Suites, where an unidentified staff member used the lift to move Resident #2 from a shower chair to her bed. The resident remained suspended in the air for the entire 10-foot journey, visibly swinging as her weight shifted side to side.
The resident required maximum assistance for all transfers due to severely impaired cognition and limited range of motion in both arms and legs. Her diagnoses included dementia, contractures of both shoulders, and muscle wasting and atrophy.
Federal inspectors found the facility failed to provide adequate supervision to prevent accidents during the November inspection. The violation occurred despite the facility's director of nursing acknowledging that mechanical lift transfers require two staff members.
"If one person was used, the resident could fall during the transfer," the director of nursing told inspectors on October 15.
The in-room camera footage showed the staff member connecting the mechanical sling to the lift while Resident #2 sat in her shower chair. After raising her out of the chair, the worker moved the entire apparatus approximately 10 feet toward the bed, making a complete 180-degree turn in the process.
Throughout the transfer, the resident remained approximately three feet above the ground. The video clearly showed her swinging while suspended in the air as the single staff member maneuvered the lift across the room.
Resident #2's care plan, dated March 29, 2025, specified that she required mechanical lift assistance for transfers. Her quarterly assessment revealed she was dependent on staff for all transfers, including moving from chair to bed and bed to chair.
The resident's medical records showed she had severely impaired cognition and contractures that limited her functional range of motion. She required maximum assistance to move from sitting to lying positions and from lying to sitting positions.
Federal inspectors reviewed the facility's mechanical lift policy, which was last revised on May 5, 2023. The policy failed to address how many staff members should be present during mechanical lift transfers.
The inspection was conducted in response to a complaint. Inspectors determined the violation placed residents at increased risk for inadequate supervision, though they classified the level of harm as minimal or potential for actual harm.
Terra Bella Health and Wellness Suites admitted the resident in question earlier this year. The facility's failure to ensure proper supervision during mechanical lift transfers violated federal requirements that nursing homes maintain accident-free environments for residents.
The mechanical lift incident represents a fundamental breakdown in resident safety protocols. Despite having equipment designed to safely transfer residents with mobility limitations, the facility allowed staff to operate the device in a manner that could result in serious injury.
Mechanical lifts are standard equipment in nursing homes for residents who cannot support their own weight during transfers. When operated correctly by two staff members, they provide a safe method for moving residents between beds, chairs, and other locations.
The September video footage captured the exact type of safety violation that federal regulations are designed to prevent. The resident's visible swinging motion while suspended in the air demonstrated the instability that occurs when mechanical lifts are operated by a single person.
Inspectors found that the facility's own director of nursing understood the safety requirements but failed to ensure staff followed proper procedures. The gap between stated policy and actual practice left vulnerable residents exposed to unnecessary risk.
The violation affected one of four residents reviewed during the inspection. Federal inspectors classified the finding as affecting few residents, but the incident highlighted systemic problems with staff supervision and training.
Resident #2's advanced age and multiple medical conditions made her particularly vulnerable to injury from improper transfer techniques. Her dementia, muscle atrophy, and joint contractures required careful handling during any movement between locations.
The facility's mechanical lift policy, despite being recently updated in 2023, omitted the fundamental safety requirement for two-person operation. This gap in written procedures may have contributed to the unsafe practice captured on video.
The inspection revealed how inadequate supervision can turn routine care activities into dangerous situations for nursing home residents. A simple transfer from shower chair to bed became a safety violation that could have resulted in serious injury.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terra Bella Health and Wellness Suites from 2025-11-26 including all violations, facility responses, and corrective action plans.
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