The incident occurred November 25 at St Clare Commons, where 28 of the facility's 54 residents depend on mechanical lifts for transfers.
Certified Nursing Assistant #300 entered Resident #25's room at 9:18 a.m. to help the man get to the bathroom. The resident, admitted in May with dementia, muscle weakness and depression, required maximum assistance from one or two staff for transfers according to his care plan.
The nursing assistant grabbed both of the resident's hands and pulled him from sitting to standing. When the resident sat back down, she tried again. After the third failed attempt to manually lift him, CNA #300 finally retrieved a mechanical lift.
She then operated the lift alone to transfer the resident from bed to wheelchair, then to the bathroom. Facility policy required at least two nursing assistants for safe mechanical lift transfers.
The administrator confirmed during an interview that two staff should be present during mechanical lift transfers. The administrator also acknowledged the facility never provided mechanical lift training to CNA #300.
When questioned the same day, CNA #300 said Resident #25 typically could stand and pivot into his wheelchair, but sometimes needed more help. She admitted transferring him using the mechanical lift without a second staff member present.
CNA #300 told inspectors the facility provided no training on mechanical lift use when she was hired.
The facility's own policy, dated May 22, explicitly states that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy also requires staff to be trained and demonstrate competency using the specific machines or devices in the facility.
Resident #25's November assessment showed he was cognitively impaired and needed partial assistance moving from sitting to standing. His care plan, dating to his May admission, identified self-care performance deficits related to his dementia, activity intolerance, fatigue and impaired balance.
The resident's diagnoses painted a picture of vulnerability. His dementia affected his cognitive function. Muscle weakness limited his physical abilities. Depression compounded his challenges.
Yet the nursing assistant assigned to help him had received no instruction on the very equipment designed to keep both of them safe during transfers.
The mechanical lift violation emerged during a complaint investigation. Federal inspectors classified the deficiency as causing minimal harm or potential for actual harm to some residents.
St Clare Commons operates at 12469 Five Point Road in Perrysburg. The facility serves 54 residents, more than half of whom require mechanical assistance for basic transfers from bed to chair or wheelchair.
The inspection found that while the facility had clear policies about mechanical lift safety, it failed to train the staff responsible for implementing those policies. CNA #300's lack of training created risks for both herself and the residents in her care.
Mechanical lifts, when used properly with adequate staffing, prevent injuries to both residents and caregivers. The equipment requires specific knowledge about positioning, operation and safety checks.
Without proper training, nursing assistants may struggle with the equipment, potentially dropping residents or injuring themselves. The requirement for two staff members provides backup if something goes wrong during a transfer.
The November 25 observation revealed a dangerous gap between written policy and daily practice. While St Clare Commons required two-person mechanical lift transfers and mandatory training, CNA #300 worked alone with equipment she had never been taught to operate.
Resident #25, with his combination of dementia, muscle weakness and balance problems, represented exactly the type of vulnerable person mechanical lift policies are designed to protect. His repeated attempts to sit back down during manual lifting attempts showed his body's inability to support the transfer method CNA #300 initially tried.
The facility's failure to train staff on mechanical lifts affected the safety of 28 residents who depend on the equipment for daily transfers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Clare Commons from 2025-12-01 including all violations, facility responses, and corrective action plans.