Health inspection·November 6, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a care plan (a written plan that outlined how the facility and staff would meet the resident needs) for four out of five sampled residents (Residents 2, 3, 4, and 5) when there was no care plan present that described the use of a mechanical lift (medical device on wheels that was used to transfer residents who could not bear their own weight).This had the potential for residents not to obtain or maintain their highest practical physical, mental, and psychosocial well-being and lead to potential accidents from not being transferred properly.Findings:A review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning, dated 9/7/23, indicated a care plan would be developed for each resident that included standards for meeting safety and health care needs.A review of Resident 2's admission Record, dated 7/18/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of quadriplegia (unable to move arms and legs on their own). Resident 2 was their own responsible party (RP, decision maker). A review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/25/25, indicated that Resident 2 was dependent (required maximum assistant could not do on own) upon facility staff for showers, using the bathroom, and to transfer out of bed into a chair. A review of Resident 2's Lift/Transfer Evaluation, dated 11/4/25, indicated Resident 2 could not bear any weight (support weight while standing).A review of Resident 3's admission Record, dated 1/14/16, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of dementia (severe memory loss) and muscle weakness. Resident 3 was not their own RP. A review of Resident 3's MDS, dated [DATE], indicated Resident 3 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 3's Lift/Transfer Evaluation, dated 8/5/25, indicated Resident 3 could not bear any weight.A review of Resident 4's admission Record, dated 8/12/20, indicated, Resident 4 was admitted to the facility on [DATE] with the diagnoses of dementia and muscle weakness. Resident 4 was not their own RP.A review of Resident 4's MDS, dated [DATE], indicated Resident 4 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 4's Lift/Transfer Evaluation, dated 10/21/25, indicated Resident 4 could not bear any weight.A review of Resident 5's admission Record, dated 9/6/24, indicated, Resident 5 was admitted to the facility on [DATE] with the diagnosis of adult failure to thrive (a gradual decline in health that had no explanation). Resident 5 was not their own RP. A review of Resident 5's MDS, dated [DATE], indicated Resident 5 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 5's Lift/Transfer Evaluation, dated 10/11/25, indicated Resident 5 could not bear any weight.During a concurrent record review and interview on 11/5/25 at 4:15 pm, with Administrator (Admin), Residents 2, 3, 4, and 5's Care Plans were reviewed. Admin stated, There should be a care plan for [residents that use] a mechanical lift. Admin reviewed each resident's active care plan and the discontinued care plans and confirmed, there was no care plan present that indicated Residents 2, 3, 4, and 5 Page 1 of 9 055656 055656 11/06/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0656 required the use of a mechanical lift for transfer. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055656 Page 2 of 9 055656 11/06/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed prevent an avoidable fall with injuries when staff had not correctly used a Hoyer lift (a mechanical device with a sling that has straps which are to be securely attached to the device used to lift and carry a resident to a desired location. This lift requires two staff for a safe transfer, one to operate the lift and one to guide the resident), for one of five sampled residents (Resident 1) when:1a. Staff had not ensured the straps on the Hoyer lift were secure and the sling straps came off and dropped Resident 1 onto the floor.1b. While one staff operated the Hoyer lift, the second staff had not stood by and guided Resident 1 during the transfer.1c. Staff placed Resident 1 in a Hoyer sling that had damaged straps which were rigid and stiff and should not have been used.1d. Staff placed Resident 1 in a Hoyer sling that was not previously identified to be the correct size for her. The cumulative effects of these failures caused Resident 1 to fall out of the Hoyer lift on to the metal leg of the lift and onto the floor. Resident 1 sustained four broken bones in her lower back and pelvis (the large bony structure near the base of the spine), severe back pain with an increased need for narcotic pain medication, the need for supplemental oxygen use (extra air breathed in by a tube in the nose), and a hospital stay. Findings: 1a. A review of the facility's policy and procedure (P&P) titled, Fall Management Program, revised 3/13/21, indicated, the purpose of the P&P was to provide residents a safe environment that minimizes complications associated with falls.A review of the admission Record, dated 8/15/20, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of fusion of spine, cervical region (a surgical procedure where two bones in the neck are joined together to stop them from moving) and low back pain. A review of the Physician's Order, dated 8/25/23, indicated, Resident 1 could make their own decisions. A review of the Minimum Data Set (MDS, a resident assessment tool), dated 8/21/25, indicated a Brief Interview of Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed. Resident 1 scored 15 out of 15 which indicated good memory. The MDS indicated Resident 1 had limited movement of both legs, and Resident 1 was dependent on two facility staff for transfers from the bed to the wheelchair, bathroom, and shower. A review of the, Post Fall Evaluation, dated 10/29/25, written by Licensed Nurse (LN) A indicated, Certified Nurse Assistant (CNA) B and Nurse Assistant (NA, an uncertified nurse assistant who is still in training) D attempted to transfer Resident 1 from the bed to the wheelchair and witnessed both lower sling straps (closer to the legs) dislodge from the mechanical lift. Resident 1 fell to the floor next to the bed and landed on her back. A review of the hospital's, History and Physical, dated 10/29/25, indicated, Resident 1 was brought into the emergency room by ambulance due to a three-to-four feet fall from a mechanical lift, landing on her backside.A review of the medical imaging report done at the hospital titled, CT [rotating x-ray machine] Abdomen [belly area] Pelvis [hip area] dated 10/29/25, indicated, Resident 1 had acute (sudden) fractures of the right sacrum (bone that connects the spine to the pelvis), right L5 transverse process fracture (last bone in the spine, just above the sacrum), right inferior pubic ramus fracture (a bone that points down from the pelvis), and a fractured coccyx (tailbone).During a concurrent observation and interview on 10/31/25 at 9:43 am, Resident 1 was observed in bed, lying on her back, and wearing a nasal cannula (oxygen tube that fits into the nose). Resident 1 confirmed falling from the mechanical lift on 10/29/25 and stated, I was getting up into the wheelchair and the sling gave way. It looked like the sling detached from the Hoyer [the brand name of the mechanical lift that was used]. I don't feel like I slipped out, I fell straight down. During the interview, Resident 1 055656 Page 3 of 9 055656 11/06/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0689 Level of Harm - Actual harm Residents Affected - Few appeared to become short of breath while talking and paused in between sentences. Resident 1 confirmed, CNA B and NA D transferred her using the Hoyer lift when she fell and stated, [CNA B] and [NA D] got me into the Hoyer. Resident 1 became tearful and stated, I can't lift my body more than two inches off the bed. The pain is excruciating and sharp. Resident 1 described excruciating pain as a ten-out-of-ten, where ten was the worst pain ever. Resident 1 attempted to raise the upper half of her body off the bed, cried out in pain, and stated, see, I can't do anything. Resident 1 stated, I'm upset because I was able to leave weekly to visit my husband and now I can't go anywhere. It's the holidays, I can't go home to visit or celebrate the holidays. Resident 1 became teary eyed and stated, I have to cancel my mammogram [test to detect early warning signs of breast cancer], my DMV [Department of Motor Vehicles] appointment, all my appointments are cancelled. During an interview on 10/31/25 at 11:47 am, CNA B confirmed assisting with a transfer, utilizing the Hoyer lift. CNA B stated, I saw her fall, she just went straight down, she didn't slip out of the sling, she fell straight down. I thought the sling broke, but it didn't, the lower straps weren't on the Hoyer, and they came off at the same time.During an interview on 10/31/25 at 12:04 pm, Director of Staff Development (DSD), stated, I went to the room [after being alerted of the fall], and I observed the top loops hooked to the Hoyer, but not the bottom loops.During an interview on 10/31/25 at 1:06 pm, NA D confirmed assisting with Resident 1's Hoyer lift transfer, and witnessed Resident 1's fall. NA D stated, I was the one who used the Hoyer, when I pulled the Hoyer out [away from bed], I swung the Hoyer around, both lower straps fell off. She [Resident 1] landed on her back and onto the leg of the Hoyer. I'm not sure how the straps came off. Both straps came off at the exact same time.During an interview on 10/31/25 at 1:30 pm, with the facility's Director of Nursing (DON) and Administrator (Admin), DON stated, I thought the sling broke, but it didn't. I looked at it myself. Admin confirmed the sling did not break and stated, I did look at the sling, it was fine.During a concurrent interview and record review on 10/31/25 at 2:13 pm, with DSD, CNA B's Corrective Action Memo written by the DSD and dated 10/31/25, regarding Resident 1's fall with injuries, was reviewed. The section titled, Employer's Statement indicated, This disciplinary action is regarding safety and safe handling of residents. CNA [CNA B] did not have a second CNA present during mechanical lift transfer. DSD indicated that it was an unsafe practice to use an NA instead of a CNA when using the Hoyer lift to transfer residents. DSD indicated that an NA should never be the substitute for another CNA when using the Hoyer lift.During a concurrent interview and record review on 10/31/25 at 2:15 pm, with DSD, NA D's Corrective Action Memo dated 10/31/25, regarding Resident 1's fall, was reviewed. DSD confirmed, corrective action was taken against NA D for, This disciplinary action is regarding safety, scope of practice [list of care that can legally be provided] and safe handling of residents. The level of competence has not been exhibited during event of patient transfer with mechanical lift the level of competency was not exhibited for safe handling of resident during transfer, and the scope and practice of NA was not exhibited or adhered to. A review of the care plan titled, ADL (activities of daily living, examples include but not limited to dressing, transfers, eating) dated 3/18/24, indicated, Resident 1 required the assistance of two staff members for mechanical lift transfer and that care would be provided by CNAs, Licensed Nurses, Registered Nurses, and Restorative Nursing Aides. NA was not listed on the care plan. A review of the hospital's, Discharge Summary, dated 10/30/25, indicated, Resident 1 was being discharged from the hospital, was in a considerable amount of pain (a great degree of physical suffering), and required strong narcotic pain relief. The Discharge Summary indicated, [Resident 1] required supplemental oxygen, likely due to chronic debility [long term physical strength] and need or strong pain relief (a side effect of strong pain medication was breathing less, which could 055656 Page 4 of 9 055656 11/06/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0689 Level of Harm - Actual harm Residents Affected - Few cause the need for supplemental oxygen). During an interview on 11/5/25 at 2:55 pm, Licensed Nurse (LN) A stated, [Resident 1] didn't wear oxygen before the fall. She was low, 88 percent (%) [normal oxygen saturation levels (oxygen level in the blood) are around 90 to 100%] at the hospital and she has a low pain tolerance. [Resident 1's] MS Contin [generic name morphine sulfate, a strong narcotic pain medication] and Percocet [a strong narcotic pain medication] were increased after the fall.A review of Resident 1's Physician's Order, dated 10/30/25, after the fall, indicated a new order for, Oxygen at 1 liter [a unit of measure] per nasal cannula to keep oxygen saturation at or above 88%, every shift.A review of the, Order Summary Report, dated 10/28/25, indicated on 7/14/24 (before the fall), Resident 1 had an order for Morphine Sulfate ER (extended release), 15 milligrams (mg, a unit of measure) one tablet, by mouth two times a day for chronic pain. A review of the, Order Summary Report, dated 11/5/25, indicated on 10/31/25 (after the fall), Resident 1's Physician increased her Morphine Sulfate ER, 15 mg to two tablets, twice a day for pain management.A review of the, Order Summary Report, dated 10/28/25, indicated on 5/21/25 (before the fall), Resident 1 had an order for Percocet, 10-325 mg give one tablet by mouth three times a day for chronic pain. A review of the, Order Summary Report, dated 11/5/25, indicated on 10/31/25 (after the fall), Resident 1's Physician increased her Percocet 10-325 mg to one tablet every 6 hours as needed for severe pain (7-10 out of 10 on the pain scale). 1b. A review of the CNA Nursing Assistant Certification, (training book, utilized by the NA during the CNA training program) with the copywrite (year it was published) of 2020, indicated, that one nursing assistant would operate the mechanical lift and the second nursing assistant would care for the residents during the transfer (utilizing their hands or the straps on the sling to guide and stabilize the residents). The training book indicated that when the resident was lifted in the air, the resident would be facing the operator of the mechanical lift during the transfer. During an interview on 10/31/25 at 11:47 am, CNA B stated, I was furthest away from the door, [NA D] was on right side of the bed, closest to the door. I wasn't paying attention to the hooks during the transfer. During an interview on 10/31/25 at 12:04 pm, DSD stated, It is my expectation, that when there is a CNA and a NA performing a Hoyer lift transfer, the CNA controls the Hoyer and the other CNA is the spotter [guiding the resident], hands on, and guiding the resident. During an interview on 10/31/25 at 1:06 pm, NA D stated, I was the one who used the Hoyer, when I pulled the Hoyer out [away from the bed], I swung the Hoyer around, both lower straps fell off. NA D stated, [CNA B] was positioning the wheelchair at the foot of the bed and I was pulling the Hoyer away from the bed to put [Resident 1] in her wheelchair. [CNA B] was not next to the resident [Resident 1] and was not assisting (spotting) or guiding hands on while I operated the Hoyer. During an interview on 11/5/25 at 8:50 am, Nurse Assistant Training Program (NATP Instructor) stated, I don't say spotter when I teach, I say two-person transfer, one operated the Hoyer, and the other person is ensuring resident safety by holding and guiding the resident so there is no swinging or swaying and their legs don't hit anything. You're not just standing there, they are looking for feet placement and that the straps are securely in the hooks, all the way, during the transfer. NATP Instructor stated, when the resident was raised up in the Hoyer sling, the resident should be facing the Hoyer operator.During a concurrent interview and observation on 11/5/25 at 12:15 pm, was conducted with CNA B and NA D. NA D confirmed Resident 1 was facing the closet while suspended in the air on the Hoyer lift and stated, [Resident 1's] back was to me and her face and feet were facing [CNA B]. CNA B confirmed she had been standing at the foot of Resident 1's bed during the transfer. CNA B confirmed she had not provided hands on guidance to Resident 1 during the Hoyer transfer and stated, I was not near [Resident 1] during the transfer, I was at the wheelchair. NA D and CNA B were observed by the surveyor and demonstrated 055656 Page 5 of 9 055656 11/06/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0689 Level of Harm - Actual harm Residents Affected - Few their positions during the transfer of Resident 1 and they were approximately five to six feet from each other. CNA B was standing at the foot of Resident 1's bed and NA D was standing on the right side of the bed, near the middle of the mattress. 1c. A review of the undated User Instruction Manual, indicated, a damaged sling should never be used.A review of the facility's 5-day Investigation (the results of the facility's investigation regarding Resident 1's fall), dated 10/31/25, indicated, Upon review, it was noted that the color-coded straps and hooks are quite ridged [unable to bend]; any alterations in tension, whether downward or upward, could shift the entire strap as a unit. The 5-day Investigation indicated it was possible for the sling straps to become dislodged from the Hoyer lift if there was a loss of tension (tightness created in the sling loop when pressure was applied). During an interview on 10/31/25 at 1:30 pm, Admin confirmed, the straps on the sling used on Resident 1, were stiff.During a concurrent observation, interview, and record review, on 11/4/25 at 11:45 am, with Environmental Supervisor (EVS) and Central Supply/CNA (CS/CNA) F, the laundry room was observed. EVS and CS/CNA F showed the surveyor the sling used on Resident 1 when she fell. EVS stated, We held it [kept the sling in the laundry room] to keep it off the floor [from being used]. EVS and CS/CNA F confirmed all four looped straps on the sling were observed to be stiff and when held up, they did not fall, bend, or collapse into itself. The undated, Guideline for Identifying Deteriorated Slings (sling guidelines) was reviewed. CS/CNA F confirmed, the Hoyer sling guidelines indicated that a sling with stiff loops (straps) was considered damaged and should not be used. During an interview on 11/4/25 at 12:25 pm, CNA B confirmed, the loop straps on the sling used on Resident 1 the day she fell were stiff and stated, I didn't know it meant they needed to replaced, they are all [slings] like that.1d. A review of the undated, User Instruction Manual indicated, Hoyer slings and lifts are not designed to be interchangeable with other manufacture's products. Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury to patient and/or caregiver.During an interview on 11/4/25 at 3:18 pm, CNA B stated, I've never been provided training on what size Hoyer sling to use for a resident. I eyeball it. The facility provided training on sling size after it happened [after Resident 1 fell out of the Hoyer lift]. During a concurrent interview and record review on 11/4/25 at 10:48 am, with DSD the Total Mechanical/Lift Transfers in-services, dated 10/29/25 and 10/30/25 were reviewed. DSD confirmed staff had not received training on how to select the correct size sling prior to Resident 1's fall with injuries.During an interview on 11/4/25 at 12:15 pm, CNA B and NA D both confirmed eyeballing the sling was how they determined what size to use.During a concurrent observation and interview on 11/4/25 at 11:45 am, with EVS and CS/CNA F, the sling that was used during the Hoyer lift transfer, when Resident 1 fell, was observed. EVS and CS/CNA F confirmed that there was no information label on the sling that indicated the brand name, sling size, or weight limit. CS/CNA F confirmed that without the information that should be on the label attached to the sling, one could not determine what size or brand the sling was. 055656 Page 6 of 9 055656 11/06/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their Resident Safety and Maintenance Service policies and procedures (P&P) when:1. Facility staff knew the mechanical lift (device on wheels used to transfer residents that could not walk) was broken, did not report it, and used it to transfer four out of five sampled residents (Residents 2, 3, 4, and 5); and2. The Maintenance Department failed to ensure the broken mechanical lift was removed from use, reported as broken, and did not consistently perform monthly routine maintenance of all mechanical lifts that were utilized in the facility.This had the potential to cause an accident and injuries from using broken equipment to lift and transfer all residents who required the use of a mechanical lift and negatively impact their physical and emotional well-being.Findings: 1. A review of the facility's P&P titled, Resident Safety, revised 4/15/21, indicated, any facility staff that identified an unsafe situation, should immediately notify their supervisor or the charge nurse. A review of the admission Record, dated 7/18/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of quadriplegia (unable to move arms and legs on their own). Resident 2 was their own responsible party (RP, decision maker). A review of the Minimum Data Set (MDS, a resident assessment tool), dated 10/25/25, indicated a Brief Interview of Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was performed. Resident 2 scored 14 out of 15 which indicated good memory. The MDS indicated Resident 2 was dependent upon facility staff for showers, using the bathroom, and to transfer out of bed into a chair. A review of Resident 2's Lift/Transfer Evaluation, dated 11/4/25, indicated Resident 2 could not bear any weight (support weight while standing).A review of the admission Record, dated 1/14/16, indicated, Resident 3 was admitted to the facility on [DATE] with the diagnoses of dementia (severe memory loss) and muscle weakness. Resident 3 was not their own RP. A review of the MDS, dated [DATE], indicated Resident 3 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 3's Lift/Transfer Evaluation, dated 8/5/25, indicated Resident 3 could not bear any weight.A review of the admission Record, dated 8/12/20, indicated, Resident 4 was admitted to the facility on [DATE] with the diagnoses of dementia and muscle weakness. Resident 4 was not their own RP.A review of the MDS, dated [DATE], indicated Resident 4 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 4's Lift/Transfer Evaluation, dated 10/21/25, indicated Resident 4 could not bear any weight.A review of the admission Record, dated 9/6/24, indicated, Resident 5 was admitted to the facility on [DATE] with the diagnosis of adult failure to thrive (a gradual decline in health that had no explanation). Resident 5 was not their own RP. A review of the MDS, dated [DATE], indicated Resident 5 was dependent upon staff for showers and transfers out of bed into a chair.A review of Resident 5's Lift/Transfer Evaluation, dated 10/11/25, indicated Resident 5 could not bear any weight.During an interview on 11/4/25 at 11:28 am, Maintenance Supervisor (MS) confirmed, when a mechanical lift was broken, it was labeled as broken, and removed from use. During a concurrent observation and interview on 11/5/25, with Certified Nurse Assistant (CNA) B the only mechanical lift that was available for use, located on Station 2 was observed. There were two legs (the base of the mechanical lift that was on wheels) that opened and closed on its own while pushing the mechanical lift forward, and the handle (used to open and close the legs) lifted out and detached from the mechanical lift. CNA B stated, the handle for opening the legs, slides on its own, and comes off. CNA B confirmed that the broken mechanical lift was not reported to anyone today.During an interview on 11/5/25 at 12:35 pm, Central Supply/CNA F confirmed the handle to the mechanical lift came off and stated, They always have to tighten it up. It was just serviced Residents Affected - Few 055656 Page 7 of 9 055656 11/06/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to.During a concurrent observation and interview on 11/5/25 at 12:38 pm, CNA G stated, I have been here since 2021, sometimes when you push or turn the mechanical lift, the legs open. CNA G was in the process of taking the broken mechanical lift into Resident 2's room when MS arrived. MS confirmed having knowledge that the mechanical lift's handle came off and stated, I tighten the bottom, not the handle. CNA G stated, I've been here for four years, it has been reported multiple times. MS stated, If they don't add it to the maintenance log, then it's word of mouth (verbally telling MS something was broken and not writing it down). The handle was removed from the base of the mechanical lift, and the bottom of the handle was covered in black tape. MS walked away and did not remove the broken mechanical lift from service.During a concurrent observation and interview on 11/5/25 at 12:48 pm, CNA B and CNA G were observed taking the broken mechanical lift to Resident 2's room. CNA B asked the surveyor, Can we use the mechanical lift? CNA B was notified, that the surveyor was not allowed to advise. CNA B and CNA G were observed utilizing the broken mechanical lift to move Resident 2 from the wheelchair to the bed. Once Resident 2's body was lowered onto the bed, the entire mechanical lift tilted to the left and both right wheels came approximately two inches off the ground. There was no observed awareness by CNA B or CNA G that the mechanical lift had tilted. Resident 2, CNA B, and CNA G denied feeling or noticing that the mechanical lift had tilted. CNA B and CNA G both looked at the wheels of the mechanical lift and confirmed they were off the floor. During an interview on 11/5/25 at 1:04 pm, CNA H stated, This [broken] mechanical lift was used on Residents [2, 3, 4, and 5] today. I've been here for four years; this mechanical lift has been broken since I started. CNA H confirmed, both legs open and close uncontrollably on their own, with or without residents in the sling (strong fabric that attached to the mechanical lift and suspended residents up in the air). CNA G confirmed, the handle that is supposed to open and close the legs came off the mechanical lift. CNA G stated, I've asked maintenance so many times to fix it, I stopped asking. I don't normally use it, but that's what we had on our hall to use. During the interview, CNAs B, G, H and I were all present during the interview with CNA G. All four CNAs reviewed which residents were transferred utilizing the broken mechanical lift during their shift on 11/5/25. CNAs B, G, H, and I confirmed the following transfers using a broken mechanical lift: CNAs B and G transferred Resident 2 for lunch and back to bed. CNAs H and I transferred Resident 3 after breakfast and CNAs B and I transferred Resident 3 for lunch. CNAs H and I transferred Resident 4 after breakfast and CNAs B and I transferred Resident 4 for lunch. CNAs B and G transferred Resident 5 after breakfast and CNAs G and I transferred Resident 5 for lunch.In total, CNAs B, G, H, and I completed seven transfers for four residents.During an interview on 11/5/25 at 1:18pm, MS stated, I started [working here] in April 2024 and the handle to the mechanical lift had been coming off before I started working here. MS was asked if anyone had reported the earlier observation of the mechanical lift tilting and the wheels coming off the ground and MS stated, They didn't tell me that the wheels came off of the ground.A review of the Battery-Powered Patient Lift (user manual), with the copyright year of 2022, indicated, the mechanical legs must be in the open position, and the shifter handle (the handle) must be locked into place to ensure stability and safety of residents during transfers. The user manual indicated that if the mechanical lift was damaged or broken, the mechanical lift was not to be used. During a concurrent observation and interview on 11/6/25 at 7:43 am, Resident 2 was observed sitting up in bed and smiling. Resident 2 stated, I have concerns about the condition of the Hoyer (brand name of a different mechanical lift and was the term often used for all mechanical lifts), as you've seen, the one used yesterday is not in great shape. When you move that Hoyer forward, the legs open and close and the handle comes out. Resident 2 confirmed, the broken mechanical lift was not utilized often by facility staff 055656 Page 8 of 9 055656 11/06/2025 Oakwood Healthcare Center 375 Cohasset Rd Chico, CA 95926

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and stated, During transfers, while it's moving, and I'm in the air, the legs have closed, or the handle comes off. They have a hard time maneuvering it. Resident 2 stated, I don't feel safe in the Hoyer they used yesterday. It makes me think, oh this one again and it causes extra swinging [movement while suspended in the air].2. A review of the facility's P&P titled, Maintenance Service, revised 1/1/12, indicated, the Director of Maintenance was responsible for maintaining work order requests and maintenance records. The P&P indicated Maintenance Staff would follow safety regulation to ensure residents were safe.During a concurrent observation and interview on 11/5/25 at 12:38 pm, MS was observed holding the handle of the broken mechanical lift in his hand. After MS and CNA G discussed CNA G's concerns about the mechanical lift, MS placed the handle back into the base of the mechanical lift and walked away. MS did not remove the mechanical lift from service.During an interview on 11/5/25 at 1:18 pm, MS stated, I've never reported the handle to anyone, it usually stays on pretty good. A review of the Maintenance Log, dated 7/15/25, indicated, the handle to the mechanical lift needed to be tightened, and the repair was made on 7/16/25.During an interview on 11/5/25 at 1:50 pm, Maintenance Assistant (MA) stated, I didn't know about the mechanical lift legs until today. I inspected the mechanical lift last week, they were loose, and I tightened it. Staff purposely break it because they want new toys. The handle is news to me. MA confirmed, when the mechanical lift was inspected, MA never pulled on the handle to ensure it was securely attached to the mechanical lift and stated, it was fine as of Saturday [11/1/25].During an interview on 11/5/25 at 3:09 pm, Administrator (Admin) stated, No one notified me the mechanical lift was not working.During a concurrent interview and record review on 11/6/25 at 11:05 am, with MS, the instructions for mechanical lift inspections titled, Logbook Documentation, dated 11/3/25 was reviewed. MS confirmed, the instructions indicated, the handle would be inspected to ensure it operated smoothly and was locked into place. MS stated, during inspection the handle should have been pulled. The Work History Report (report) dated 11/30/24 through 11/30/25 was reviewed. MS confirmed, the report indicated, the mechanical lifts had not been provided the monthly inspection by MS or MA from 3/1/25 through 4/30/25. MS confirmed, the report indicated the mechanical lifts were inspected on 11/3/25 and when asked where they documented any issues discovered during inspections, MS stated, there was nowhere to document issues. 055656 Page 9 of 9