Incident investigation·May 4, 2026

Licensing Program Analyst (LPA) Tao conducted an unannounced case management visit regarding the incident report submitted to the department on 04/04/2026. LPA met with Administrator Maria and explained the reason for the visit. Administrator submitted a copy of SOC 341 along with an incident report on 04/04/2026. The incident occurred on 04/03/2026 at around 11:30am. Resident #1(R1)’s son reported to the administrator Maria that R1’s leg and knee were hit by the metal part of the Hoyer lift when staff #2 (S2) transferring R1 using the Hoyer lift. R1’s son stated R1’s leg and knee were observed to have bruises, but no injuries were reported. Only one staff, S2, assisted R1 during the transfer of using the Hoyer lift. The Administrator stated only one resident at the facility needs to use Hoyer lift to transfer. LPA interviewed the administrator and two staff. Per the staff interview, Administrator denied that only one caregiver operating the Hoyer lift when assisting that resident. The staff interviews of staff#3 (S3) and staff#4 (S4) revealed the only one staff assisted resident when using Hoyer lift. The suspected abuser, staff#2 (S2), was no longer working at the facility and unable to contact that staff for interview. Per resident interview, only one caregiver assisted the resident during the transfer of resident using the Hoyer lift or mechanical lift. Per the physical plant tour, LPA did not observe a sign indicating two (2) caregivers are required to operate the Hoyer lift. Per record review, the facility’s policy and procedures, dated 06/01/2024, indicated two (2) caregivers are required to assist residents when operating Hoyer lift/mechanical lift. (-continues on LIC 809C-) An in-service training conducted by a professional vendor regarding the proper use of Hoyer lift was provided to staff on 04/07/2026. As mentioned above, the facility’s Human Service investigated and let go the suspected abuser/staff. The reason was violations of company policy using Hoyer lift. The facility is working on training new hires and will hire additional caregivers in May 2026. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Administrator Maria and a copy of this report, LIC 809D and appeal rights were provided.