Ararat Nursing Facility: Resident Dies in Lift Fall - CA
The June 1 incident at Ararat Nursing Facility resulted in immediate jeopardy violations after federal inspectors found the 15099 Mission Hills Road facility failed to follow basic safety protocols for a resident who required two-person assistance for all transfers.
Resident 1 had lived at the facility since July 2021 with diagnoses including Parkinson's disease, Alzheimer's disease, and dementia. Her cognitive skills for daily decision-making were severely impaired, and she was completely dependent on staff for eating, bathing, dressing, and personal hygiene.
The resident's care plan, initiated March 3, specifically required two or more staff members to provide physical assistance when using mechanical lifts. Her fall risk score was 16 — well above the 10-point threshold indicating high fall risk. The care plan called for placing a floor mat next to her bed to prevent injuries from falls.
On June 1 around 11 a.m., CNA 1 brought a mechanical lift into the resident's room to weigh her. The nursing assistant placed a sling under the resident while she was in bed, then left her unattended to find another staff member for assistance.
"I was almost at the door when I heard a loud sound," CNA 1 wrote in progress notes. "I turned my back, opened the curtain and I saw my resident on the floor on the legs of the lifting machine." The notes indicated blood around the resident's head.
The facility immediately transferred the resident to a hospital emergency department. Medical records show she sustained a V-shaped laceration across her forehead extending to the area between her eyebrows and nasal bridge, another laceration below her right eye, and bruising around both eyes from trauma.
A CT scan revealed a Type III odontoid fracture — a break in the neck area of the spine — and multiple facial bone fractures. The resident died in the emergency department that afternoon.
CNA 4, who had previously cared for the resident, told inspectors the patient "was not alert and was fully dependent on staff for care." She explained that mechanical lifts always required two staff members because "it's dangerous if done by self."
"If it is just one person, it's dangerous because the sling moves, or the resident can move," CNA 4 said. "Having only one staff cannot hold the lift machine and keep the resident steady on the sling all at the same time."
LVN 1 arrived at the scene and found the resident on the floor with blood coming from her forehead. The licensed vocational nurse said CNA 1 explained she had placed the mechanical lift sling underneath the resident, then left to call for assistance, and that's when the resident rolled off the bed, hitting her head against the metal legs of the lift machine.
RN 1 rushed to the room and saw the resident on the floor with nursing staff trying to stop the bleeding. When asked what CNA 1 should have done differently, the registered nurse said simply, "I would not have left the resident alone."
During a phone interview, CNA 1 acknowledged she knew the rules required two staff members for lift machine use. She described the procedure: "I put the sling under the resident, the sling is what carries the resident. I turned around towards the door, then I heard a loud noise and saw the resident face down on the leg of the lift machine."
The nursing assistant admitted her mistake: "From the start of this, I would have walked in with the second person already from the beginning so they can assist with the care needed for the resident."
When asked about safety measures, CNA 1 confirmed there was no floor mat where the patient had landed — despite the care plan requiring one.
RN 4 reviewed the resident's records with inspectors and confirmed the care plan interventions included placing a floor mat next to the bed to prevent injuries. "Having a fall is not desirable, but it is better to land on a soft surface than a hard surface," the nurse explained.
The care plan for functional abilities, initiated March 3, clearly stated staff needed to provide "two or more persons physical assist" when transferring the resident in and out of bed or wheelchair using a mechanical lift.
Inspectors discovered another violation: the resident had no physician's order for mechanical lift use. RN 4 confirmed this requirement was missing from the resident's June 2024 physician orders. The facility's own policy, revised in 2014, states: "The resident will have a physician's order for the use of a mechanical lift."
"I would not have left the resident alone," RN 4 told inspectors. "I would not leave the lift machine unattended because we always make sure the residents' environment needs to be free from hazards."
The registered nurse explained the mechanical lift posed a hazard because it was made of metal. "Because CNA 1 left Resident 1 alone, and because the mechanical lift was left unattended at the resident's bedside, Resident 1 ended up having a fall with a sustained injury."
LVN 5 criticized the nursing assistant's actions, saying CNA 1 "was supposed to keep Resident 1 safe." The licensed vocational nurse noted that proper protocol would have been to lower the bed, replace the floor mat, and remove the machine. "Because this was not done, the resident fell off the bed."
Federal inspectors called immediate jeopardy on June 13 in the presence of the administrator, director of nursing, and risk management nurse. The facility submitted a removal plan the following day.
The immediate response included suspending CNA 1 on June 1 and terminating the employee on June 7 after completing an investigation. Registered nurse supervisors conducted rounds to ensure no other residents were affected by similar unsafe practices.
The facility identified 17 residents with Parkinson's disease or parkinsonism diagnoses and audited their care plans. Staff received emergency training on mechanical lift safety, environmental hazards, and the requirement for two-person assistance.
New protocols now require all mechanical lift weighing to occur on Monday mornings under supervision of risk management nurses or supervisors. The facility updated skills checklists to include return demonstrations of transfer techniques using lift machines.
The administrator posted a memo requiring two persons for all mechanical lift use and established daily meetings to discuss residents who might need lifting assistance. Supervisors now conduct visual audits of staff transfer practices on all shifts.
Federal inspectors accepted the facility's corrective action plan and removed the immediate jeopardy finding on June 14 at 4:50 p.m.
The resident's death resulted from what inspectors called a failure to ensure she was "free from accidents" — a basic safety requirement that cost an Alzheimer's patient her life when a nursing assistant left her alone with a piece of metal equipment designed to help, not harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Nursing Facility from 2024-06-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Ararat Nursing Facility in MISSION HILLS, CA was cited for violations during a health inspection on June 14, 2024.
Resident 1 had lived at the facility since July 2021 with diagnoses including Parkinson's disease, Alzheimer's disease, and dementia.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.