The incident at The Village of East Harbor occurred on November 30, when the family member of resident R901 requested toileting assistance. Instead of following the doctor's orders for mechanical lift assistance with two staff members, the nursing assistant performed a manual transfer alone.
R901, who has dementia, anxiety disorder, and osteoarthritis, requires direct assistance with all activities of daily living according to their care plan. The resident had been admitted to the facility earlier this year and was classified as transfer-dependent.
On November 20, a physician had specifically ordered transfers using a sit-to-stand lift with two-person assistance. The mechanical device provides support as residents move from seated to standing positions and requires staff presence for safe operation.
The nursing assistant, identified as CNA A, initially transferred the resident to the toilet manually without any assistance. After completing the transfer, they called for help from another nursing assistant to move the resident back from the toilet, but again performed the transfer manually rather than using the required equipment.
CNA A told inspectors they realized the error only after R901's daughter commented about the missing lift. "They realized they were supposed to have used the mechanical lift after R901's daughter commented about the lack of the lift," according to the inspection report.
The unit manager, Licensed Practical Nurse B, confirmed the nursing assistant knew about the physician-ordered transfer requirements but "chose to complete the transfer manually because they felt the resident was safe to do so that day." The manager added that such decisions were inappropriate regardless of staff judgment.
"That would still not be appropriate," LPN B told inspectors. The manager confirmed that residents should always be transferred according to current physician orders, without exception.
When federal inspectors visited the facility on December 22, they observed R901 sitting in a wheelchair in the common area. The resident was unable to respond coherently to questions about the reported incident.
The facility's Director of Nursing confirmed that staff expectations require completing resident transfers according to physician orders. The facility's own transfer policy states the goal is "to transfer the resident from the bed to chair, toilet or tub safely."
A disciplinary report filed after the incident stated that CNA A "failed to follow the ordered transfer status of a resident that requires a lift and two persons assist." The report emphasized that following ordered transfer status is imperative for safety reasons.
The violation represents a breakdown in basic safety protocols designed to protect vulnerable residents. Transfer-dependent residents face increased risks of falls and injuries when staff deviate from medically prescribed assistance methods.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The citation affects few residents, but highlights concerns about staff adherence to medical orders designed to prevent injuries.
The facility policy for transfer activities, most recently reviewed on November 15, emphasizes safe transfers but failed to prevent the deviation from physician orders in R901's case.
R901's family member had specifically requested appropriate toileting assistance, yet received substandard care that ignored medical requirements. The resident's dementia and multiple health conditions made proper transfer assistance particularly crucial for preventing falls and injuries.
The nursing assistant's decision to override physician orders based on personal assessment of the resident's condition that day violated both medical directives and facility policy. Such deviations can result in serious injuries for residents who depend on mechanical assistance for safe mobility.
The incident occurred despite clear documentation of transfer requirements and facility policies emphasizing safety protocols. Staff training and supervision systems failed to prevent the violation of basic care standards for a vulnerable resident with multiple medical conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Village of East Harbor from 2025-12-22 including all violations, facility responses, and corrective action plans.