The violation occurred at Greenview Nursing and Rehabilitation during routine care of Resident #1, who required mechanical assistance for all transfers according to their assessment records.
CNA A performed solo transfers despite completing facility training on safe lifting and mechanical lift operation on May 7, 2025. The nursing assistant had signed documentation confirming completion of the "Safe lifting and movement to Residents and Lifting Machine/Mechanical lift" training just eight months before the violation.
Facility policy explicitly states that "at least two nursing assistants are needed to safely move a resident with a mechanical lift" and that "two staff members must be utilized when transferring residents with a mechanical lift." The policy, revised in May 2025, emphasizes that mechanical lifts provide "a safer alternative" to manual lifting techniques.
The MDS Nurse discovered the violation and immediately updated Resident #1's care plan. She told inspectors that "every care area of a Resident was supposed to be care planned" and confirmed that the resident's assessment clearly documented their dependence on mechanical assistance for transfers.
However, the resident's transfer method was not properly documented in the Kardex system, creating a gap in care communication among staff members.
Greenview's transfer policy, updated just months before the inspection, specifically addresses mechanical lift safety. The facility requires staff to "demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file."
The policy warns that "staff members are expected to maintain compliance with safe handling/transfer practices" and states that "failure to maintain compliance may lead to disciplinary action up to and including termination of employment."
Staff must perform mechanical lifts "according to the manufacturer's instructions for use of the device" and follow each "resident's individual plan of care" during transfers.
The facility's accident prevention policy requires a "systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents." It defines adequate supervision as intervention "based on the individual resident's assessed needs and identified hazards in the resident environment."
Mechanical lifts include full body lifts, sit-to-stand lifts, and ceiling track mounted lifts. The equipment is designed to prevent manual lifting "except in medical emergencies," according to facility guidelines.
The violation represents a breakdown in the facility's safety protocols despite recent policy updates and mandatory annual training requirements. The DON brought the unsafe transfer practices to the MDS Nurse's attention, indicating management awareness of the compliance failure.
Greenview's lifting policy acknowledges that while "manual lifting techniques may be utilized dependent upon the resident's condition and mobility," mechanical lifts should be used as the safer option for residents like Resident #1 who cannot transfer independently.
The facility policy states its purpose is "to establish the general principles of safe lifting using a mechanical lifting device" but notes it "is not a substitute for manufacturer's training or instructions."
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The inspection occurred following a complaint about care practices at the facility.
The violation occurred despite the facility's stated commitment "to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the residents while keeping the employees safe."
Resident #1 remained dependent on mechanical lift assistance throughout their stay, requiring consistent adherence to the two-person transfer protocol that CNA A violated during their care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenview Nursing and Rehabilitation from 2026-01-29 including all violations, facility responses, and corrective action plans.
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