complaint·December 4, 2025

Continued from LIC9099... R1 then “bounced onto the floor.” R1 refused medical treatment and felt minimal pain. R1’s primary care doctor was notified and scheduled an X-ray appointment for R1 a week after the incident, which revealed a femur fracture. R1 reported that they had never had any other concerning incidents or falls during transfers. Facility staff claim that R1’s fall was due to their legs “buckling,” a condition they acknowledge has happened before. However, R1 maintains that on 09/14/2025, they fell solely because they believed someone had assured them it was safe to sit down. During a transfer on 10/22/2025, staff (S3, S4) did not correctly set up the Hoyer lift, causing it to tip over. As a result, R1 was dropped onto their bed and struck in the head by the Hoyer lift. S3 received a written reprimand due to the incident. Staff are not properly trained to use hoyer lift – Reporting Party (RP) alleges that facility staff are not properly trained to use the hoyer lift. Review of facility records indicated that the incident that occurred on 09/14/2025 did not include a hoyer lift, S1 and S2 were providing a 2-person assist to R1. Review of training documents dated 10/22/2025 show two separate training's, one at 0930 and the other at 1330, in order to include staff on different shifts, both training documents included the attendance signatures for S3 and S4. Interview with S3 indicated that the day of the hoyer lift training it was busy on the floor and S3 was not sure they were able to sit through the whole thing. On 10/28/2025 S3 and S4 received 1 on 1 retraining on hoyer lift operation and on 10/29/2025 the facility held a live demonstration on hoyer lift operation led by a hospice agency. Although the allegations may have happened or are valid, the Department has found there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated . No deficiencies cited. Exit interview conducted with Regional Director of Operations, whose signature on form confirms receipt.