Health inspection·July 29, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a two-person assist was used when using the Hoyer Lift (a mechanical device used to lift and/or transfer a person) for one of three sampled residents (Resident 1).This deficient practice had the potential to result in Resident 1 falling from the Hoyer Lift.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a condition where your brain's ability to function properly is impaired by a chemical imbalance in your body), vascular dementia (a progressive state of decline in mental abilities caused by an impaired blood supply to the brain), and cerebral infarction (also known as a stroke, where a loss of blood flow to a part of the brain occurs). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/29/2025, the MDS indicated Resident 1's cognitive skills (process of thinking) for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort or the assistance of two or more helpers is required) on staff's assistance with oral hygiene, bathing, personal hygiene, and chair/bed-to-chair transfer.During a review of Resident 1's History and Physical (H&P), the H&P indicated Resident 1 did not have the capacity to understand and make any decisions.During a review of Resident 1's Care Plan titled, Activities of Daily Living (ADL) Self-Care Performance Deficit, dated 3/18/2025, the Care Plan's interventions indicated to assist in transfers as needed.During a review of Resident 1's Physical Therapy (PT) Discharge summary, dated [DATE], the Discharge Summary indicated Resident 1 was total dependent with transfers.During an interview on 7/29/2025 at 10:32 a.m., with Responsible Party (RP) 1, RP 1 stated, on 7/25/2025, Certified Nursing Assistant (CNA) 1 transferred Resident 1 from the wheelchair to the bed. RP 1 stated CNA 1 did not have another staff member present when CNA 1 transferred Resident 1 back to bed. RP 1 stated she was told Resident 1 required a two-person assist when the Hoyer Lift was used. During an interview on 7/29/2025 at 11:21 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, on 7/25/2025, RP 1 requested for Resident 1 to be assisted back to bed. LVN 1 stated she informed CNA 1 of RP 1's request and CNA 1 went to Resident 1's room to transfer Resident 1 back to bed. LVN 1 stated CNA 1 used the Hoyer Lift to transfer Resident 1 from the wheelchair to the bed and did not have another staff member to assist him. LVN 1 stated, He should have asked me because a two-person assist was required when operating the Hoyer Lift. LVN 1 stated a two-person assist was required to ensure Resident 1's safety where one person operated the Hoyer Lift while the second person supported and guided Resident 1 to the bed. During an interview on 7/29/2025 at 11:58 a.m., with CNA 1, CNA 1 stated, on 7/25/2025 at 6:45 p.m., he was told to transfer Resident 1 from his wheelchair to the bed. CNA 1 stated he used the Hoyer Lift to transfer Resident 1 back to bed and did not have another staff member to assist him. CNA 1 stated when operating the Hoyer Lift, he was supposed to have another person there to ensure Page 1 of 2 555128 555128 07/29/2025 Downey Community Health Center 8425 Iowa Street Downey, CA 90241

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 had a safe transfer from the wheelchair to the bed. During an interview on 7/29/2025 at 12:02 p.m., with Registered Nurse (RN) 1, RN 1 stated Resident 1 was very confused and did not always have the awareness of what was happening. RN 1 stated Resident 1 was unable to support himself with his legs therefore the Hoyer Lift was used to transfer Resident 1 from the bed to the wheelchair and vice versa. RN 1 stated due to Resident 1's impaired cognition, a two-person assist was necessary to ensure Resident 1's safety during a Hoyer Lift transfer. RN 1 stated if Resident 1 were to fall from the Hoyer Lift, CNA 1 would not have been able to safely guide Resident 1 to the floor or to his bed. During an interview on 7/29/2025 at 12:15 p.m., with the Director of Nursing (DON), the DON stated the manufacturer's guideline for the Hoyer Lift recommended a two-person assist when operating the Hoyer Lift for the safety of the residents. The DON stated a two-person assist was recommended if the Hoyer Lift was to shift, the second person would be there to help guide the residents to bed or to the chair. The DON stated all residents were at risk for falls and injuries. During an interview on 7/29/2025 at 1:09 p.m., with the Director of Rehab (DOR), the DOR stated a two-person assist was the safest way to operate the Hoyer Lift. The DOR stated Resident 1 was dependent on the staff's assistance with transfers. The DOR stated Resident 1 had poor cognition, often very confused, and had days where Resident 1 may or may not follow commands. The DOR stated due to Resident 1's overall condition, a two-person assist was necessary during Hoyer Lift transfers to ensure Resident 1's safety and to prevent falls and major injuries.During a review of the facility's document titled, Invacare Reliant (brand of Hoyer Lift) Battery-Powered Patient Lift User Manual), dated the year 2023, the document indicated Invacare recommended two assistants be used for lifting preparation and transfers and was based on the evaluation of the healthcare professional for each individual use. 555128 Page 2 of 2