complaint·December 2, 2025

Allegation: Staff neglect during transfer resulted in a resident being dropped. The allegation alleges that while being transferred with a Hoyer Lift it broke, and the resident fell to the ground. During the facility inspection LPA observed a Hoyer Lift in R1’s room that was operating properly. During record review, LPA received and reviewed the Daily Logs, that indicates on 06/04/2025, R1 was observed sliding out of their wheelchair, an additional staff was called to assist with helping R1 to be lowered to the ground. Then the Hoyer Lift was used to transfer R1 to their bed. LPA observed during record review that the Hoyer Lift(s) were provided through R1’s former hospice agency and their medical program. Additionally, during record review, LPA received and reviewed Staff In-Service Logs, dated 05/22/2025, and material regarding Assisting with Proper Positioning, Commonly Used Mobility Devices, and Hoyer Lift usage with a two (2) person assist. During interviews with Staff S1-S8, were asked if they have been trained on how to use the Hoyer Lift, eight (8) out of eight (8) stated yes, they have had training regarding the Hoyer Lift on Relias, in an In-Service, and directors show you how to use it. Additionally, during interviews with Staff S1-S8, were asked if there have been any issues with a residents’ Hoyer Lift, three (3) out of eight (8) stated there was a reported issue with Resident R1’s Hoyer lift and it was replaced by the hospice agency right away. During interviews with Staff S2 and S3 stated that when they were transferring R1, the lift was not holding R1 and it slowly lowered R1 to the floor. Staff S2 and S3 stated they requested additional assistance and R1 was transferred manually. Staff S2 and S3 stated they reported the incident to the Wellness Director at the time who came and checked the lift and ensured a replacement was sent by the hospice agency. During interviews with Residents R1-R10, were asked if they have experienced a fall while being assisted with transferring either manually or with a Hoyer Lift, nine (9) out of ten (10) stated no they have not experienced a fall while being assisted with transferring. During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated . An exit interview was conducted with Executive Director, Esperanza Naaktgeboren, and a copy of this report was provided.