The incident at St Clare Commons involved Resident #25, a man with dementia, muscle weakness and depression who required maximum assistance from one to two staff for transfers. On November 25, Certified Nursing Assistant #300 attempted to transfer him from bed to wheelchair so he could use the bathroom.
The CNA grabbed both of the resident's hands and pulled him from sitting to standing. When he sat back down on the bed, she tried again. After the third failed attempt, she retrieved a mechanical lift.
She operated the lift alone.
Facility policy requires at least two nursing assistants for mechanical lift transfers. The policy, dated May 22, also mandates that staff receive training and demonstrate competency using the specific machines or devices utilized in the facility.
CNA #300 had received neither.
When interviewed later that day, the nursing assistant confirmed she had transferred Resident #25 using the mechanical lift without a second staff member present. She told inspectors the facility did not provide training on mechanical lifts when she was hired.
The Administrator confirmed during a separate interview that two staff should be present for mechanical lift transfers. The Administrator also acknowledged that the facility had not provided mechanical lift training to CNA #300.
St Clare Commons identified 28 residents who were dependent on mechanical lifts for transfers. The facility's census was 54 residents.
Resident #25 had been admitted to the facility on May 1. His care plan, developed the same day, documented an Activities of Daily Living self-care performance deficit related to activity intolerance, dementia, fatigue, and impaired balance. The plan called for maximum assistance of one to two staff for transfers.
A quarterly assessment completed November 5 showed the resident was cognitively impaired and required partial assistance from sitting to standing.
CNA #300 told inspectors that Resident #25 was typically able to stand and pivot into his wheelchair, but sometimes required more assistance. On November 25, he apparently needed more help than usual.
The nursing assistant's decision to use the mechanical lift represented an attempt to provide safer care than repeatedly pulling on the resident's hands. But operating the equipment without training or a second staff member violated facility policy designed to prevent injuries during transfers.
Mechanical lifts can malfunction or be operated incorrectly, potentially dropping residents or causing them to strike furniture or walls. The devices require coordination between two staff members to position the sling properly, operate the lift controls, and guide the resident safely during transfer.
The violation occurred despite the facility's written policy acknowledging these risks. The policy explicitly states that staff must demonstrate competency using mechanical lifts before operating them independently.
The inspection was conducted in response to a complaint filed with state regulators. Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents.
St Clare Commons has not indicated when it will provide mechanical lift training to CNA #300 or other staff members who may be operating the equipment without proper instruction.
The facility's failure to train staff on mechanical lifts represents a fundamental breakdown in resident safety protocols. With more than half of the facility's residents requiring mechanical assistance for transfers, the training gap affects a substantial portion of the resident population.
Resident #25 completed his transfer to the bathroom without apparent injury on November 25. But his experience illustrates the daily risks faced by nursing home residents when facilities fail to ensure their staff have appropriate competencies for the care they provide.
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.