Health inspection·December 3, 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 observation, interview, and record review, the facility failed to keep one of three sampled residents (Resident 1) free from falls when Resident 1 fell after Certified Nursing Assistant (CNA) 3 completed a two-person required mechanical lift (device used to safely raise, lower and transfer individuals with limited mobility) transfer without assistance using a stand-up lift (device to assist individuals transfer from a seated position to a standing position), failing to follow the resident's care plan and physician's order requiring a Hoyer lift (overhead full body sling lift) transfer. This failure resulted in Resident 1's fall causing her discomfort and need to be transported to the emergency department (ED) on 11/20/25 for evaluation and had the potential to cause significant injury and harm.During a review of the facility's report dated 11/19/25, the report indicated, . November 18, 2025 approximately 8:15 p.m. [Resident 1's name] was coming back from being taken to the bathroom, CNA transferred her from the shower chair via a stand-up lift.During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including intervertebral disc (cushion between vertebrae that acts as a shock absorber) stenosis of neural canal (narrowing of the spinal canal squeezing the spinal cord causing leg weakness, numbness and balance problems) of thoracic (central part of the spine) and lumbar (lower back) region, neuropathy (injury of peripheral nerves causing numbness, tingling, burning pain and increased sensitivity), morbid obesity (extreme amount of excess body fat) and osteoarthritis (degenerative joint disease) of knee. During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 12/3/25 at 10:39 a.m., Resident 1 was lying in bed with her legs dangling off the side of the bed. Resident 1 had significant edema (swelling) in her lower legs and feet. There was fresh gauze bandages wrapped around each of her lower legs. Resident 1 stated she fell two weeks ago because CNA 3 decided to use a stand-up lift instead of the lift which supports her body in a sitting position (Hoyer lift) that the staff normally used for her. Resident 1 stated, I have only used the stand-up lift one other time, I do not like it. Resident 1 stated CNA 3 had used the stand-up lift on the previous occasion also. Resident 1 stated she had both shoulders replaced and the stand-up lift causes pressure on her shoulders making it very uncomfortable to use. Resident 1 stated CNA 3 placed her in the stand-up lift by herself, and there should always be two staff members using the mechanical lift. Resident 1 stated she warned CNA 3 she was falling, and she slid out of the lift. Resident 1 stated there was a man waiting to perform an ultrasound (an imaging technique using sound waves to create pictures of the Page 1 of 3 555758 555758 12/03/2025 New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few inside of the body) on her and CNA 3 was pushing the lift and the man stood there and watched her fall. Resident 1 stated she landed hard on her tailbone, and it jerked her head, but she did not have any injuries. Resident 1 stated she was later sent to the emergency room (ER) a couple days later because she was having shoulder pain. Resident 1 stated the ER did X-rays and scans on her and determined there was nothing broken. During an interview on 12/3/25 at 10:20 a.m. with CNA 1, CNA 1 stated Resident 1 required a Hoyer lift transfer to get in and out of bed. CNA 1 stated there needed to be at least two staff members present when transferring residents with a mechanical lift for safety. CNA 1 stated Resident 1 needed to use the Hoyer lift because she has issues with her feet and swelling making it difficult to use the stand-up lift. During an interview on 12/3/25 at 11:00 a.m. with CNA 2, CNA 2 stated there was a list at the nurse's station indicating which residents needed mechanical lift and the type of lift ordered for each resident. CNA 1 stated Resident 1 required a Hoyer lift transfer because she has issues with her feet, swelling and pain, making it uncomfortable for her to stand. During a concurrent interview and record review on 12/3/25 at 11:27 a.m. with the Director of Staff Development (DSD), Resident 1's Order Summary Report (OSR) dated 12/3/25, was reviewed. The OSR indicated, . use Hoyer lift for transfers. The DSD stated Resident 1 required the Hoyer lift for transfers because she had swelling and pain in her lower legs from edema. The DSD stated Resident 1 could not bear weight and she would not be safe in a stand-up lift. The DSD stated the physician order for the Hoyer lift was a result of Resident 1's fall on 10/7/25. Resident 1's IDT [interdisciplinary team-team from different healthcare disciplines who work together to provide comprehensive resident care] Note, dated 10/8/25, the note indicated, . For residents safety the hoyer lift is the safest way to transfer the resident. Resident 1's IDT Note, dated 11/20/25, the note indicated, . Fall . Resident will be a hoyer lift for all transfers for the safety of the resident . The DSD stated the stand-up lift should not have been used. Resident 1's Morse Fall Scale, dated 10/2/25, indicated, . Score: 60 . The DSD stated any score above 45 indicated a high risk for falls. Resident 1's Post Fall Assessment, dated 11/18/25, the assessment indicated, . Date and Time of Fall Incident . 11/18/25 20:15 [8:15 p.m.] . CNA stated that she was assisting resident to her bed from shower chair after using the toilet and resident slid down to her bottom. Resident 1's fall risk care plan was reviewed, the care plan indicated, . resident is at high risk for falls. 11/18/25 witnessed fall. Hoyer lift for transfers as needed. Resident 1's Radiology Report, dated 11/19/25 was reviewed, the report indicated, . Shoulder. Left . No acute fracture [broken bone] or dislocation. Status post shoulder replacement. During a review of Resident 1's shoulder X-ray, dated 11/19/25, the X-ray indicated there was no fracture or dislocation of the left shoulder.During a review of Resident 1's Nurse's Note, dated 11/20/25 at 9:59 p.m., the note indicated, . CN [charge nurse] called into res [resident] room d/t [due to] res is crying. stated that she moved her left arm and then it gave her excruciating [intense] pain . she wants to go to the ER. [name of physician], notified. called [name of] ambulance . res transferred from bed to gurney.During a review of Resident 1's Nurse's Note, dated 11/21/25 at 3:51 a.m., the note indicated, . Resident returned from [name of hospital] via ambulance . During an interview on 12/3/25 at 11:50 a.m. with the Administrator (ADM), the ADM stated Resident 1 was transferred with a stand-up lift by CNA 3 and CNA 3 was aware she should not have used it to transfer Resident 1.During an interview on 12/3/25 at 11:52 a.m. with the Director of Nursing (DON), the DON stated there was an investigation of Resident 1's fall and the fall was caused by CNA 3 using the wrong lift on Resident 1. During a telephone interview on 12/3/25 at 3:55 p.m. with CNA 3, CNA 3 stated Resident 1 required a mechanical lift transfer because she had issues with her feet. CNA 3 stated she was aware Resident 1 was supposed to be transferred with a Hoyer lift, but the resident 555758 Page 2 of 3 555758 12/03/2025 New Bethany Skilled Nursing 1441 Berkeley Dr Los Banos, CA 93635

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few insisted on the stand-up lift. CNA 3 stated she used the stand-up lift to transfer to take Resident 1 to the bathroom and back to bed. CNA 3 stated when she brought Resident 1 from the bathroom to her bed the resident slid out of the lift to the floor. CNA 3 stated she used the lift alone but was supposed to wait for another staff member to help her. CNA 3 stated there should be two staff members when using the mechanical lift. During a telephone interview on 12/3/25 at 4:12 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the charge nurse at the time of Resident 1's fall. LVN 1 stated she was passing medication when a CNA told her Resident 1 was on the floor next to her bed. LVN 1 stated there was an ultrasound technician in the room holding Resident 1 in a sitting position. LVN 1 stated she was told Resident 1 slid out of the stand-up lift. LVN 1 stated Resident 1 should not be transferred with a stand-up lift because she has swelling and blisters to her legs. LVN 1 stated it was important to have two people using the mechanical lift for safety. During a review of the facility's policy and procedures (P&P) titled Lifting Machine, Using a Mechanical, dated 2001, the P&P indicated, . purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device . At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Types of lifts that may be available in the facility are . Floor-based full body sling lifts. Overhead full body sling lift. Sit-to-stand lifts.During a review of the facility's P&P titled Falls-Clinical Protocol, dated 2001, the P&P indicated, . staff will evaluate and document falls that occur . when and where did the happen. Falls should be categorized as . Other circumstances such as sliding out of a chair. 555758 Page 3 of 3