Federal inspectors observed the violation on December 30 during a complaint investigation at Winchester Terrace. The nursing assistant entered Resident 21's room at 11:39 a.m. with a mechanical lift, with no other staff present. Twenty minutes later, she exited the room with the lift, still working alone.
When questioned immediately after the transfer, the nursing assistant confirmed she had moved the resident using the mechanical lift without a second staff member. She acknowledged knowing that facility policy required two people for mechanical lift transfers and that she had received training on proper lift procedures.
Resident 21 has been at Winchester Terrace since October 2019. Medical records show the resident has normal pressure hydrocephalus, hemiplegia affecting one side of the body, and dementia. A November assessment revealed the resident was cognitively impaired and required total staff assistance with all activities of daily living.
The resident's care plan, dating back to admission, specifically identified mobility deficits related to dementia and hemiplegia. It called for using a mechanical lift with two staff members for all transfers in and out of bed.
Doctor's orders from December 2022 required a Hoyer mechanical lift for all of the resident's transfers.
The facility's own policy, updated in August, states clearly: "Always use two staff members when transferring a resident using a mechanical lift."
Mechanical lifts are designed to safely move residents who cannot transfer independently, but they require proper staffing to operate safely. The lifts use fabric slings that must be positioned correctly under the resident, then attached to the lift's arms before the resident is raised and moved.
Operating a mechanical lift alone creates multiple safety risks. A single staff member cannot adequately position the sling, ensure proper attachment points, and monitor the resident's condition throughout the transfer. If the resident becomes distressed or the equipment malfunctions, one person cannot simultaneously operate the lift controls and provide hands-on assistance.
For residents with dementia, these risks increase significantly. Cognitive impairment can cause confusion or agitation during transfers, making it difficult for residents to follow instructions or remain calm. The resident may try to grab onto the lift or attempt to get out of the sling during the transfer.
Hemiplegia, which affects one side of the body, creates additional positioning challenges. The paralyzed or weakened side requires careful support during transfers to prevent injury. A single staff member cannot adequately monitor and support both the affected and unaffected sides of the body while operating lift controls.
The violation occurred during routine care, suggesting it may not have been an isolated incident. The nursing assistant's admission that she knew the two-person requirement indicates the safety breach was deliberate rather than accidental.
Winchester Terrace houses 53 residents. Federal inspectors classified this as a minimal harm violation affecting few residents, but the potential consequences could have been severe. Falls from mechanical lifts can cause fractures, head injuries, and other serious trauma, particularly dangerous for elderly residents with multiple medical conditions.
The discovery came during an unrelated complaint investigation, raising questions about how often similar safety violations occur without detection. Inspectors did not indicate whether facility administrators had implemented additional oversight or retraining following the incident.
The nursing assistant confirmed her training on mechanical lift procedures, indicating that knowledge of proper protocols existed but was not followed. This gap between policy and practice represents a fundamental breakdown in resident safety procedures at the facility.
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.