Print Inspection: CHOW012369

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents, including an unsafe transfer for 1 of 1 sampled resident (#2) who required a Hoyer lift for transfers. Reasonable precautions were not exercised during a Hoyer lift transfer for Resident 2, which placed the resident at risk of harm. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2026 with diagnoses including dementia and spinal stenosis. The resident's service plan, dated 06/04/26, indicated the resident required the assistance of two staff and a Hoyer lift for transfers. The resident required full assistance from staff for all her/his care and did not bear weight, related to wounds on his/her feet and weakness. The resident additionally had a wound to his/her bottom. The resident often stayed in bed but was agreeable to get up into the wheelchair for some meals and activities. The resident had short- and long-term memory impairments with some confusion but could make some of his/her needs known. Observations of the resident during a transfer from the bed to the wheelchair on 06/08/26 showed the following: * The surveyor entered the room at 1:40 pm. The resident was in the Hoyer sling; sling loops were hooked two at the top of the sling and two loops hooked at the bottom of the sling at the hooks located on the swivel arm on the Hoyer. The resident was in the air a few inches above the mattress. Staff 6 (CG/MT) and Staff 7 (CG) were located next the bed, one staff on each side. The staff moved to the same side of the bed and began to pull the Hoyer lift away from the bed and towards the wheelchair near the center of the room. The resident was in the air in the sling approximately three feet above the floor. The resident was in a reclined position with his/her legs extended out straight. * The staff were unsure of the best approach to the wheelchair and discussed options out loud, amongst themselves. The legs to the Hoyer lift remained in the closed (narrow) position, rather than open (wide) position. The resident was turned left and then right approximately 180 degrees, and lastly in a full circle, by spinning the entire sling/resident at the swivel on the arm of the Hoyer. The staff lifted the wheelchair up over one leg of the Hoyer base and the resident was lowered towards the wheelchair. The resident remained in a leaned back position with both legs extended straight out in front of him/her, and staff were unable to place the resident in the wheelchair seat. * The resident’s legs and feet were caught on the edge of the motor box of the lift and then again at the edge of the wheelchair while staff adjusted his/her position in the sling while in the air. The surveyor asked staff to adjust the resident’s feet/legs before continuing movement. * The resident was lifted higher into the air, and the lift was again adjusted. The resident remained in the air while staff determined how to approach the next attempt to be placed in the wheelchair. The wheelchair was turned around so the back was facing in between the two legs at the base of the Hoyer. The resident was lifted further into the air in an attempt to push the resident over the back of the wheelchair and then lowered. The resident was pushed forward but his/her bottom was not quite high enough to clear the back of the wheelchair. The resident was again moved backwards and the wheelchair moved out of the base of the Hoyer. * Staff 6 (CG/MT) and Staff 7 (CG) were both asked if they had received previous training on the use of the Hoyer lift, and both acknowledged they had received training. The staff were both asked if they had experience transferring the resident prior to the current observation, Staff 6 indicated she had not transferred the resident to the wheelchair before, and Staff 7 indicated he had not transferred the resident before. The resident continued hanging in the sling several feet above the ground in a reclined position with his/her legs extended straight out. The surveyor asked the staff to call for additional assistance to complete the transfer. Neither staff attempted a call for help on the facility walkie talkies visible in their pockets. * The wheelchair was repositioned back near the center of the room with the seat facing the door. The resident was turned using the swivel of the lift arm, less than 180-degree turn, so s/he faced forward and towards the door as well. The Hoyer was pushed closer to the wheelchair, and the resident was lowered over the wheelchair. The resident was not lined up with the seat of the wheelchair and when lowered his/her bottom was not on the seat. The residents low back was at the edge of the wheelchair seat and the resident’s right buttock was sitting on top of the open footrest pad. The resident’s legs were extended out straight and unbent. The staff further lowered the Hoyer, which put the resident’s feet firmly on the ground. The resident expressed pain with the foot placement. * The staff attempted additional adjustments of the lift and the resident. The staff then lowered the lift further to the ground to release the tension on the loops and straps attached to the swivel arm. Staff 6 (CG/MT) unhooked the top loop of the sling from the swivel bar on her side (right side of the resident) and told Staff 7 (CG) to do the same. Staff 7 unhooked the loop of the sling from the swivel bar on his side (left side of the resident). The resident’s lower body was supported by the sling under his/her lower body which remained attached to the Hoyer lift by a loop on each side of the sling. The staff each held onto the top portion of the sling on their respective sides. The staff attempted to lift the resident up and back into the wheelchair. The resident’s bottom did not make it up onto the seat of the wheelchair; no visible change in position was noted. The staff continued to discuss next steps while holding the top of the sling. * The surveyor again asked staff to call for assistance, advised that the resident was slipping and if the loops were not reattached the resident was going to fall to the floor. First, Staff 6 (CG/MT) got the very last loop on the sling into place on the hook of the swivel arm. Staff 7 (CG) did the same with more difficulty as the swivel arm was slanted significantly towards the other side of the resident. The resident was more significantly reclined in the sling due to the placement of the loops on the swivel arm. The staff lifted the resident back into the air, legs extended straight and upper body laying back in a significant reclined position. Staff 6 made two attempts to call for assistance as well as adjusting channel numbers to make sure the right one was in use. No response was received on the walkie talkie. * The surveyor advised the staff she would go get assistance and asked them to stop the attempts to put the resident in the wheelchair. The surveyor left the resident’s room at 2:05 pm and directed the first staff member to the room quickly for assistance with the transfer within 1-2 minutes. Staff 3 (Regional Director of Operations) headed towards the room and additionally grabbed Staff 10 (MT) to come and assist as well. The surveyor followed directly behind Staff 10 into the resident’s room. The resident was in the sling, in the air and Staff 3 assisted the care staff to reposition the resident and his/her legs to move the Hoyer towards the wheelchair. Staff 10 joined and assisted with the resident’s legs and bending into a position to help with a seated position. The resident was becoming more irritated and wanting to be finished. At approximately 2:10 pm, Staff 3 and the surveyor left the room as the resident’s bottom was being lowered into the wheelchair and feet placed on the footrests. Staff 3 sent the facility RN into the room to check in with the staff. The surveyor asked to meet with the facility RN and administrator to review the observation and concerns. Staff 2 (RN) was unable to locate the administrator, so details of the observation were discussed with him. Staff 2 shared the information with the administrator later in the afternoon, and the surveyor also met with the administrator. In an interview at approximately 2:12 pm, Staff 2 stated all staff were trained on the Hoyer lift on Thursday and Friday of the previous week, 06/04/26 and 06/05/26. The wheelchair was recently brought in by hospice after the resident’s admission. Staff 2 acknowledged the resident should not have been left in the Hoyer sling, in the air, for an extended period. The resident should have been put back into the bed while staff determined a plan and then started again. Staff 2 further acknowledged the Hoyer sling should not be disconnected from the lift until the resident was properly in the wheelchair. Additional observations on 06/08/26 between 2:50 pm and 5:00 pm showed the following: Staff 2 (RN), Staff 11 (RCC), and Staff 12 (LPN) began completing Hoyer training with the staff currently in the building, including themselves. Staff 2 laid in the bed while other staff placed the sling, attached the sling, lifted him into the air, and transferred him into a wheelchair. Resident 2 was seated in the wheelchair in the activity room for ice cream. The resident was wheeled to the living room for a music performance when the snack was completed. The resident remained in his/her wheelchair in the living room until approximately 4:35 pm. The resident was intermittently nodding off, leaning far forward over legs and putting legs/feet behind or in front of the closed footrests. Staff 8 (CG) asked the resident if s/he wanted to lay down and the resident said yes. The resident was taken from the living room to his/her bedroom at 4:36 pm. Staff 8 called for assistance with a transfer, and Staff 9 (CG) came to assist. The resident’s wheelchair was placed near the doorway in the bedroom, Hoyer lift was placed in front of the resident with the legs open at the base, the lift was pushed forward around the wheelchair and sling loops attached at the top and the bottom. The resident was told what staff were doing, was raised into the air, with his/her feet/legs protected and repositioned as moved, and then the lift was rolled backwards from the wheelchair and the legs slid under the bed when the resident was placed over the mattress. The resident was lowered to the bed, with his/her head protected while the swivel arm was lowered, sling loops were removed from the hooks on the arm, and the lift was moved out of the way. The staff continued to roll the resident, remove the sling, adjust him/her for comfort, and provide fluids before departing. The staff both indicated they had received training on the use of the Hoyer the previous week and again today. The staff further indicated they had not had opportunity to transfer the resident himself/herself prior to today. Staff 8 and Staff 9 stated the resident was new to the facility but overall very easygoing and friendly. The resident had some stiffness, and his/her legs needed help to get into a bent position. An attempt was made to rewatch Staff 6 and Staff 7 transfer the resident between 06/09/26 and 06/10/26, after additional training was received. The resident did not choose to get up out of bed during that time. A copy of the Hoyer training completed on 06/04/26 and 06/08/26 was provided to the surveyor. Reasonable precautions were not exercised during a Hoyer lift transfer for Resident 2, which placed the resident at risk of significant harm. The need to ensure residents were assessed for and provided with safe transfer techniques was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (Regional Director of Operations, Staff 4 (Regional Nurse/RN), and Staff 5 (Regional Nurse/LPN) on 06/08/26, 06/09/26 and 06/10/26). The staff acknowledged the findings.

1. Re-training of staff by RN, RCC, and hospice on proper hoyer techniques. 2. Annual re-test for retained knowledge. RCC to train new care staff. 3. Quarterly and as needed. 4. RN, ED, and RCC.