Prince of Peace Care Center: Lift Transfer Harm - ND
The complaint inspection, assigned the highest level of harm short of immediate jeopardy, found that the transfer caused real injury to a resident. The report does not describe the nature of the injury, but the facility's own response made clear that something had gone wrong badly enough to pull the lift and sling from service on the spot.
Both pieces of equipment were taken out of use immediately after the incident. Inspectors examined them and found them to be in working order. The problem, then, was not a broken machine. It was how the machine was being used.
That distinction matters. A malfunctioning lift is a maintenance failure. A functioning lift that still injures a resident is a training failure, a supervision failure, or both. The facility appeared to recognize this. Within the corrective plan, management required all staff involved in mechanical lift transfers to complete retraining before returning to their next shift. Six weeks of ongoing transfer audits were initiated. A physical therapist assessed the resident to determine whether the sling being used was the right size and type for that person.
The physical therapist found no changes were needed. No additional recommendations were made. That conclusion, offered without further detail in the inspection record, is difficult to square with the fact that a resident was harmed.
Every resident in the facility who uses a mechanical lift became part of the review that followed. The interdisciplinary team went through each of those residents to assess whether current interventions remained appropriate. Care plans were updated where the team identified gaps. All sling sizes across the facility were pulled and reassessed to confirm they fit the residents assigned to them.
A sling that does not fit correctly can shift during a transfer, leaving a resident suspended at an angle, unable to brace, with no way to signal distress before something gives way. Whether that is what happened here, the inspection report does not say. What it documents is that after one resident was hurt, the facility found it necessary to check every other resident's sling fit from scratch.
The facility also implemented what it called the "Safe Lift Stop for Safety Process," folding it into ongoing audits for any staff member completing a transfer using any type of lift equipment. The name suggests a pause-and-check protocol, a moment built into the procedure where staff are expected to stop and confirm that positioning, sling fit, and equipment function are correct before completing the lift. Whether that process existed before the incident and was not followed, or whether it was created in response to the harm, the report does not clarify.
Mechanical lift injuries are among the more preventable harms in nursing home care. The equipment exists precisely to reduce the risk of falls and soft tissue injuries during transfers, which are among the most dangerous moments in a resident's day. When a lift causes the injury it was designed to prevent, it usually means someone skipped a step, used equipment that did not match the resident, or was never shown the correct technique in the first place.
Prince of Peace Care Center is a small facility in a rural county in south-central North Dakota. The inspection was triggered by a complaint, meaning someone, a resident, a family member, or a staff member, reported what happened before inspectors arrived. The facility did not catch this through its own internal monitoring and self-report. It was reported.
The resident assessed by physical therapy after the incident was found to have no new clinical needs identified. Whether that assessment captured the full extent of what they experienced during the transfer, or in the hours and days after, is not reflected in the inspection record.
The corrective measures are now in place. The audits are running. The slings have been checked. Staff have been retrained. The lift is back in service.
The resident who was hurt is still there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prince of Peace Care Center from 2025-12-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 19, 2026 · Our methodology
PRINCE OF PEACE CARE CENTER in ELLENDALE, ND was cited for violations during a health inspection on December 22, 2025.
The complaint inspection, assigned the highest level of harm short of immediate jeopardy, found that the transfer caused real injury to a resident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.