The incident involved Resident 7, who was left alone while suspended in the lift as both nursing assistants exited the room. CNA14 and CNA15 initially denied the allegation when questioned by inspectors on September 17.
CNA15 told investigators at 6:21 PM that when she walked out to ask CNA16 for assistance, she left CNA14 in the room with the resident. She denied walking out and leaving Resident 7 alone in the Hoyer lift.
But the facility's own investigation reached a different conclusion. Director of Nursing 2 told inspectors during a 2:56 PM interview that the internal probe "determined CNA14 and CNA15 did leave R7 in the Hoyer lift and walked out of her room."
Both assistants were terminated as a result. CNA15 was fired on July 31, and CNA14 on August 13.
The nursing director explained that two staff members should be present whenever a Hoyer lift is used "for the resident's and staff's safety." During a follow-up interview on September 19, she said her expectation was for staff to follow manufacturer guidelines for equipment, demonstrate competency skills, and perform tasks while maintaining resident safety.
The facility administrator acknowledged systemic problems when questioned by inspectors. During a September 19 interview, she stated she was aware of "gaps and deficits with the facility staff." She said she would expect the facility to identify concerns and improve onboarding processes to ensure staff achieved "100 percent competencies."
The administrator called such training "important for resident safety."
Federal inspectors cited the facility for failing to ensure residents were free from abuse and neglect, finding minimal harm or potential for actual harm to a few residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carmel Manor from 2025-12-01 including all violations, facility responses, and corrective action plans.