Winchester Terrace: Solo Lift Transfer Safety Failure - OH
That finding emerged from a complaint inspection conducted December 30, 2025, at the 53-bed nursing facility.
The resident at the center of the violation, identified in inspection records as Resident #21, has lived at Winchester Terrace since October 2019. The resident has normal pressure hydrocephalus, hemiplegia, and dementia, and is cognitively impaired. Every activity of daily living requires total staff assistance. A physician order in place since December 2022 specifies a Hoyer lift for all transfers. The care plan, active since the resident's admission, lists two staff members as required for every mechanical lift transfer in or out of bed.
On the morning of December 30, a state inspector watched CNA #200 enter the resident's room at 11:39 a.m. with the mechanical lift. Nobody else went in. At 11:59 a.m., the aide came back out with the lift. Still nobody else.
The inspector stopped the aide in the hallway.
CNA #200 confirmed she had completed the transfer alone. She confirmed the resident required two-person assistance. She confirmed she had been trained on mechanical lift procedures and knew the two-staff requirement going in.
The facility's own Hoyer lift policy, updated as recently as August 2025, states plainly that two staff members must always be used when transferring a resident with a mechanical lift.
A mechanical lift transfer done by one person instead of two carries real risk. The equipment suspends a resident in a sling off the ground. If something goes wrong — the sling shifts, the resident moves unexpectedly, the lift itself becomes unstable — a single aide has no backup. For a resident with hemiplegia, who cannot compensate with one side of the body, and with dementia, who cannot reliably communicate distress or assist in any way, the margin for error is narrow.
Nothing went wrong on December 30. The inspection report classifies the violation at the lowest level of harm: minimal harm or potential for actual harm. Resident #21 was transferred and the aide moved on.
But the inspection finding turns on something that makes the classification almost beside the point. This was not a case of an undertrained aide improvising in an emergency or misreading a policy. CNA #200 knew the rule. She had been trained on it. She confirmed it applied to this specific resident. She did the transfer alone anyway.
The violation was flagged as an incidental finding, meaning inspectors were at Winchester Terrace investigating a separate complaint when they observed the transfer. The report does not describe what the original complaint concerned.
Winchester Terrace had 53 residents at the time of the inspection. The report reviewed one resident for mechanical lift transfers. That one review produced a confirmed violation.
The facility's policy requiring two staff for mechanical lift transfers has been on the books, in its current form, since August of this year. The physician order requiring the Hoyer lift for Resident #21 has been in place for three years. The care plan calling for two-person assistance dates to the resident's first day at the facility in 2019.
Resident #21 spent those 20 minutes on December 30 suspended in a lift, moved by one person, in a room where the door eventually closed and no second set of hands was anywhere nearby.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Winchester Terrace from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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: September 19, 2026 · Our methodology
WINCHESTER TERRACE in MANSFIELD, OH was cited for violations during a health inspection on December 31, 2025.
That finding emerged from a complaint inspection conducted December 30, 2025, at the 53-bed nursing facility.
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.