The incident at St Clare Commons involved a resident who required maximum assistance from one to two staff members for transfers, according to his care plan. The facility identified 28 residents who depend on mechanical lifts for transfers out of 54 total residents.
Certified Nursing Assistant #300 entered the resident's room at 9:18 A.M. on November 25 to help him get to the bathroom. She attempted to transfer him from bed to wheelchair by taking both of his hands and pulling him from sitting to standing position.
The resident sat back down on the bed each time.
After three failed attempts, the nursing assistant retrieved a mechanical lift and successfully moved the resident to his wheelchair, then to the bathroom. She operated the lift alone.
The facility's own policy requires at least two nursing assistants to safely move a resident with a mechanical lift. Staff must also receive training and demonstrate competency using the specific machines before operating them.
The administrator confirmed during an interview that two staff should be present for mechanical lift transfers. The administrator also acknowledged that the facility never provided mechanical lift training to the nursing assistant involved.
The nursing assistant told inspectors that the resident was "typically able to stand and pivot into the wheelchair" but sometimes needed more help. She confirmed she transferred him using the mechanical lift without a second staff member present and said the facility did not provide training on mechanical lifts when she was hired.
The resident's medical record showed an admission date of May 1, 2025, with diagnoses including dementia, muscle weakness, and depression. His quarterly assessment from November 5 indicated he was cognitively impaired and required partial assistance moving from sitting to standing.
His care plan, dating to his admission, identified an activities of daily living deficit related to activity intolerance, dementia, fatigue, and impaired balance. The plan called for maximum assistance of one to two staff for transfers.
The facility's lifting machine policy, dated May 22, 2025, explicitly states that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The policy also requires staff training and competency demonstration on the specific equipment used in the facility.
The violation occurred despite the facility having a written policy addressing exactly the safety concerns that arose. The nursing assistant operated equipment she had never been trained on, without the required second staff member, after unsuccessfully attempting manual transfers that could have injured both herself and the resident.
The resident's dementia diagnosis made the situation particularly concerning, as cognitively impaired residents may not be able to communicate discomfort or follow instructions during transfers. His documented muscle weakness and impaired balance created additional fall risks.
The inspection was conducted in response to a complaint filed as case number 2676960. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting some residents.
The facility census of 54 residents means that more than half depend on mechanical lifts for safe transfers. The widespread need for this equipment makes proper training and adherence to safety protocols essential for preventing injuries.
The nursing assistant's admission that she received no mechanical lift training when hired suggests a systematic failure in staff orientation and competency verification. The administrator's confirmation of this training gap indicates management awareness of the problem.
The incident highlights the gap between written policies and actual practice. While St Clare Commons had appropriate safety protocols on paper, staff were operating critical equipment without the required training or supervision.
The resident involved in this incident continues to require mechanical lift assistance for transfers, relying on staff who may or may not have received proper training on the equipment essential for his daily care and safety.
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.