The incident at Interlochen Health and Rehabilitation Center involved a newly admitted resident who required total assistance for all transfers. When the man fell, CNAs A and B lifted him by placing their hands under his arms rather than using a mechanical lift or proper body positioning.
CNA A told inspectors on January 29 that if someone couldn't stand or bear weight, they were considered "total," meaning they couldn't do any part of the lift themselves. She acknowledged that when using a gait belt for transfers, staff should steady residents by their pants waistband, not their arms.
The facility's Assistant Director of Nursing confirmed the resident was unable to bear weight and hadn't changed since his admission. He said therapy typically screened new residents the day after admission, but icy weather had impacted therapy staffing. After proper assessment, staff should have used a mechanical lift and "should never lift someone under the armpits."
A Regional RN interviewed that evening said there were two or three acceptable ways to transfer someone in the resident's situation. None involved using the resident's arm.
"They could have pulled the resident's arms out of the sockets," she said.
The facility's other Assistant Director of Nursing said lifting a resident the way the CNAs had done "could cause physical trauma or skin tears."
Both CNAs had passed proficiency audits in November 2025 covering one-person assisted, two-person assisted, mechanical lift, and ambulatory resident transfers. They performed satisfactorily in all categories just two months before the incident.
The Regional RN said staff were trained on proper resident movement but were currently being retrained. She said it was nursing management's responsibility to ensure staff knew how to lift correctly, and they had conducted training and skills check-offs on all types of transfers.
The facility's transfer policy outlined proper procedures for moving residents from bed to chair but contained a critical gap. The undated policy made no mention of what to do when a resident was unable to assist in a transfer or bear weight.
The policy did specify using a gait belt around the resident's waist, making sure it was "tight enough that only a slight hand movement will guide the patient." For residents requiring two-person assistance, it instructed staff to "grasp the gait belt and gently stand and turn the resident."
For residents who could assist, the policy said to stand on the resident's weak side and "encourage the resident to use his or her strong side and to assist in the procedure as much as possible." It directed staff to support residents by placing a gait belt around their waist "for you to hold and steady the resident."
The policy instructed residents to place their hands on chair arms for support and told staff to "move with the resident" and ensure they were "all the way back in the chair."
The facility's fall policy required staff training in safe transfer techniques and proper body mechanics, but the document didn't specify protocols for residents who had already fallen and couldn't bear weight.
The inspection occurred during a complaint investigation on January 29, 2026. Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
Despite the CNAs' recent satisfactory performance on transfer assessments, the dangerous lifting technique violated basic safety principles designed to prevent shoulder dislocations, skin tears, and other injuries to vulnerable residents who depend entirely on staff for safe movement.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Interlochen Health and Rehabilitation Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
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