Complaint·January 15, 2026

Continued from LIC9099 one of the leg slings came off causing R1’s body weight to shift and fall. The two staff members assisting R1 focused on helping their upper body because they didn’t want R1 to hit their head. R1’s toe and ankle hit the metal of the hoyer lift because R1’s legs are not functional and R1 cannot move them. Per interview, on 08/17/2025, R1 was observed to have no apparent injuries and an internal incident report was made. On 08/18/2025, R1 was observed to have redness so R1’s Responsible Party and Primary Care Physician were notified. Facility requested a home health nurse to come to the facility for further assessment. Review of R1’s incident reports showed that on 08/22/2025, they were sent to the ER where it was found that they had a fractured big toe and ankle. Report also stated that the injury was from a hoyer lift incident that occurred on 08/17/2025 and that facility staff received additional hoyer lift training on 08/19/2025. Review of R1’s progress notes showed the following: · On 08/18/2025, facility staff observed that resident’s left leg was swollen and complained of pain when touched. · On 08/19/2025, R1 was observed laying on top of their hoyer lift sling on the floor. Per progress note, one of the loops of the sling was not on it causing R1 to wing to the side. R1 sustained a bruise on their left arm and a swollen big toe that had redness. · On 08/20/2025, R1 was observed to still have swelling and redness to the area. · On 08/22/2025, R1’s home health agency conducted a visit and requested for an x-ray for R1 · On 08/23/2025, R1 returned to the facility with a fractured ankle and broken big toe. Review of R1’s incident reports and progress notes indicated that a separate incident occurred on 11/18/2025. Per report, R1 was found on the floor by facility staff and was sent to the hospital for further evaluation. Per incident report, preliminary tests indicated that R1 did not sustain any fractures or major injuries. Review of R1's medical records stated that x-rays revealed R1 sustained leg fractures and was admitted to a skilled nursing facility. Facility addressed the knee incident appropriately. Based on record review, interviews conducted, and observations made, the allegation of "Staff did not properly transfer a resident in care resulting in resident sustaining fractures" is Substantiated . A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Continued on LIC9099C Continued from LIC9099C Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. **An immediate Civil Penalty in the total amount of $500 has been issued for not seeking timely medical care (See LIC-421IM). An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).** Exit interview conducted. Copy of report, Plan of Corrections, and Appeal Rights, discussed and provided to Executive Director. Signature on form confirms receipt of documents.