Staff consistently stated that facility protocol strictly required two staff members to operate a Hoyer Lift safely. Facility management confirmed that caregivers received annual Hoyer Lift training, including S1. All interviewed personnel with knowledge of the incident corroborated that S1 neglected to seek the required assistance from a second caregiver for the transfer in question. Management informed that S1 was immediately suspended after the incident and subsequently terminated. S1 was interviewed regarding the allegation and admitted to the violation, stating they mistakenly attempted to transfer R1 alone. S1 additionally admitted to previously transferring residents without second-caregiver assistance because S1 perceived that their coworkers were too busy or unwilling to help. During the incident in question, S1 informed that one of the sling straps or loops failed to attach or secure properly to the Hoyer lift, resulting in the accidental fall.

An outside source (OS1) responsible for R1’s care decisions informed that R1 had previously lost mobility in both legs and one arm, having minimal movement in the remaining arm. OS1 informed that upon speaking with facility staff after the incident, they were informed that the fall occurred due to a staff member conducting a Hoyer Lift transfer by themselves, which was contrary to facility policy. OS1 noted that the facility staff immediately initiated emergency medical services for R1 and were forthcoming regarding the incident.

Facility records relevant to the allegation were reviewed. R1's Medical Assessment, dated 09/25/2025, stated that R1 suffered from a major neurocognitive impairment, motor impairment/paralysis, was not able to communicate needs or follow instruction, suffered from disorientation and lack of hazard awareness, and required full assistance with care needs. R1's Care Plan indicated that they required two-person assistance for transfers. The facility's Safe Transfer Policy indicated that residents requiring two-person assists must have two staff members present for transfers. Personnel records confirmed that S1 was terminated for transferring a resident without the assistance of a second staff member, which did not comply with safety procedures per company policy. Medical records revealed that R1 sustained facial and knee fractures as a result of the fall.

(Continued on LIC9099 p.3)

Based on the comprehensive evidence obtained from staff interviews, camera footage, and the caregiver's own admission, it is proven that S1’s failure to practice mandatory safety precautions directly resulted in R1 sustaining facial and knee fractures. The preponderance of evidence has been met, therefore, the allegation of neglect resulting in serious bodily injury is substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Mark Ranno, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.