Other·December 18, 2025

The following citation reflects the results of the California Department of Public Health investigation of facility reported incident number 2656642. The inspection was limited to the specific incident and does not represent the findings of a full inspection of the facility. The facility was found to be not in compliance with 42 CFR 483.1-483.75 - Subpart B - Requirements for Long Term Care Facilities and 22 CCR 72523 and 72311. State Class A citation 230022790 was issued for incident number 2656642 at Title 42 CFR §483.25(d)(1), (2) and at Title 22 CCR 72523 and 72311. 22 CCR §72523: Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 22 CCR § 72311. Nursing Service-General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient’s needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of the admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating and updating the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 10/31/25 at 9:30 am, the Department conducted an unannounced visit to the facility to investigate a fall that resulted in four broken bones. The facility failed to prevent an avoidable fall with injuries when staff did not correctly use 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 residents). Staff did not ensure the straps on the Hoyer lift were secure, and the sling straps came off and dropped Resident 1 onto the floor. While one staff member operated the Hoyer lift, the second staff member did not stand by and provide hands-on guidance for Resident 1 during the transfer. Staff placed Resident 1 in a Hoyer sling that had damaged straps which were rigid and stiff and should not have been used. 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 onto the metal leg of the lift and then 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), experienced severe back pain with an increased need for narcotic pain medication, required supplemental oxygen use (extra air breathed in by a tube in the nose), and underwent a hospital stay. Findings 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 Resident 1’s “Admission Record,” dated 8/15/20, indicated, Resident 1 was admitted to the facility on 8/15/20 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 that Resident 1 was capable of making her own healthcare decisions. A review of Resident 1’s Admission Minimum Data Set (MDS, a data driven clinical assessment) with an Assessment Reference Date (ARD) (the last day of the observation period for a MDS assessment) of 8/21/25, Section C (review of mental status) indicated a Brief Interview for Mental Status (BIMS, a review of mental status with scoring from 0 to 15, where 0 represents severe mental impairment and 15 represents intact cognition) was conducted and Resident 1 scored 15 out of 15 which indicated good memory. Section GG (functional abilities) 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 care plan titled, “ADL” (activities of daily living, examples include but not limited to dressing, transfers, eating) dated 3/18/24, indicated that Resident 1 required the assistance of two staff members for mechanical lift transfers and that care was provided by CNAs (Certified Nursing Assistant), Licensed Nurses, Registered Nurses, and Restorative Nursing Aides. The care plan did not list NA (Nursing Assistant) as an authorized caregiver. A review of the “CNA Nursing Assistant Certification,” (training book, utilized by the NA during the CNA training program) with the copyright (year it was published) of 2020, the training book instructed that one nursing assistant operated the mechanical lift while the second nursing assistant cared for the residents during the transfer by “utilizing their hands or the straps on the sling to guide and stabilize the residents.” It also indicated that “when the resident was lifted in the air, the resident would be facing the operator of the mechanical lift during the transfer.” 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 lying on her back in bed 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 appeared short of breath while speaking and paused between sentences. She confirmed that 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.” She described the pain as “a ten-out-of-ten, where ten was the worst pain ever.” When she attempted to raise the upper half of her body off the bed, she cried out in pain and stated, “see, I can’t do anything.” Resident 1 expressed her frustration, stating, “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.” She became teary-eyed and added, “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 that she assisted with the transfer using the Hoyer lift. She 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 1:06 pm, NA D confirmed that she assisted with Resident 1’s Hoyer lift transfer and witnessed the fall. She 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 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 1:30 pm, with the facility’s Director of Nursing (DON) and Administrator (Admin), the DON stated, “I thought the sling broke, but it didn’t. I looked at it myself.” The Administrator confirmed the sling did not break and stated, “I did look at the sling, it was fine.” The Administrator also confirmed that the straps on the sling used on Resident 1 were stiff. 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." The DSD stated that using an NA instead of a CNA during a Hoyer lift transfer was an unsafe practice. The DSD emphasized 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. The DSD confirmed that the facility took corrective action against NA D, “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 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 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 in the laundry room. 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 that all four looped straps on the sling were stiff and, when held up, did not fall, bend, or collapse into themselves. Staff reviewed the undated “Guideline for Identifying Deteriorated Slings.” CS/CNA F confirmed that “the Hoyer sling guidelines indicated that a sling with stiff loops (straps) was considered damaged and should not be used.” EVS and CS/CNA F also confirmed that the sling had no information label indicating the brand name, sling size, or weight limit. CS/CNA F confirmed that without the label, one could not determine what size or brand the sling was. 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 be replaced, they are all [slings] like that.” 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 11/5/25 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, with CNA B and NA D in Resident 1’s room, NA D confirmed that 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 that she had been standing at the foot of Resident 1’s bed during the transfer. She also confirmed that 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.” The surveyor observed CNA B and NA D demonstrate their positions during the transfer and noted they stood approximately five to six feet apart—CNA B at the foot of the bed and NA D on the right side, near the middle of the mattress. CNA B and NA D both confirmed that eyeballing (visually guessing) the sling was how they determined what size to use. 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 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