The December 29 incident at Four Seasons Health Care illustrates how the facility failed to assess residents for proper lift equipment, putting them at risk for falls and injuries during what should be routine transfers from beds to wheelchairs.
Federal inspectors found the nursing home had no system to ensure staff used correctly sized slings when operating full-body mechanical lifts for residents who cannot transfer independently.
During the 3:45 p.m. observation, two CNAs prepared to move Resident #2 from bed to wheelchair using a Hoyer lift. But CNA #2 discovered no sling in the room and left to find one.
"I could not find the one she normally uses," the aide said when he returned with a large Invacare sling.
The facility's own sizing chart posted in the supply room shows large slings accommodate residents weighing 198 to 350 pounds. But inspectors found no evidence the facility had assessed Resident #2's weight or determined the appropriate sling size for safe transfers.
Thirty minutes later, inspectors observed another problematic transfer. Two CNAs moved Resident #1 from a recliner to bed using a mechanical lift with a "Proactive" brand sling that had no size marking.
Resident #1's care plan specified the need for a "two person hoyer (full body mechanical) lift and two assist with transfer." But like Resident #2, no assessment determined what sling size would safely support this resident during transfers.
When inspectors asked CNA #1 how staff determine proper sling sizes, she referenced the chart in the supply room. The chart lists three categories: medium slings for residents 99 to 210 pounds, large for 198 to 350 pounds, and extra-large for 270 to 600 pounds.
The weight ranges overlap significantly. A 200-pound resident could theoretically use either a medium or large sling according to the chart, but the facility provided no guidance on which to choose.
CNA #2 later confirmed to inspectors that they had used an incorrect sling during Resident #2's transfer.
Administrative nurse #3 acknowledged the facility's systemic failure during a 5:15 p.m. interview. The nurse confirmed Four Seasons had not assessed residents requiring mechanical lifts for appropriate sling sizes.
The facility's own policy, dated December 2023, requires staff to "identify correct lift and sling for the resident" before any transfer. The policy emphasizes ensuring "each resident is safely transferred using the Hoyer Lift."
But without individual assessments, staff had no way to know which slings matched which residents. The posted chart provided weight ranges but no resident-specific information.
Mechanical lift transfers involve suspending residents in fabric slings while a hydraulic device moves them between surfaces. Using an incorrectly sized sling can cause residents to slip through the fabric or create unstable positioning that leads to falls.
The inspection found both residents required two-person assistance with mechanical lifts, indicating they likely had limited mobility and would be particularly vulnerable to injury from transfer accidents.
Four Seasons also failed to educate staff about proper sling selection, leaving CNAs to make safety decisions without adequate information or training.
The facility's policy emphasized safety but provided no mechanism to achieve it. Staff knew a chart existed but had no resident-specific guidance about which equipment to use for whom.
When the designated sling couldn't be found, staff improvised rather than ensuring safety first. The "could not find" moment became a grab-whatever-fits approach that violated the facility's own safety protocols.
Federal inspectors classified the violations as having potential for minimal harm affecting few residents. But the systemic nature of the failures suggests the problem extended beyond the two residents observed during the December 29 inspection.
The facility must now develop individual assessments for all residents requiring mechanical lifts and train staff on proper equipment selection before transfers can resume safely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Seasons Health Care Inc from 2025-12-29 including all violations, facility responses, and corrective action plans.