Westlake Convalescent Hospital: Patient Left in Hoyer Lift - CA
The inspection, conducted April 24, 2026, stemmed from a complaint. What the inspector found that morning required no interpretation.
At 9:06 a.m., the inspector walked into Resident 1's room alongside a registered nurse. The resident was up in the Hoyer lift, positioned over the bed. Nobody else was there. The registered nurse immediately called out for the certified nursing assistant assigned to the resident's care.
The nursing assistant, when she arrived, offered an explanation: she had stepped away to call another staff member for assistance. Then she said something that landed in the inspection report without qualification. She stated that she was not supposed to leave Resident 1 in the Hoyer lift unattended.
She knew. She left anyway.
Resident 1 had been admitted to the facility with chronic respiratory failure, a surgically created opening in the neck for airway access, and complete dependence on a ventilator to breathe. A resident assessment completed April 4, 2026, documented impaired cognition for daily decision-making and total dependence on staff for every basic activity, including transfers. A history and physical from April 9, 2026, went further: the resident did not have the capacity to understand or make decisions at all.
The care plan, also revised April 9, flagged Resident 1 as a fall risk due to poor safety awareness and directed staff to assist with all transfers.
The Hoyer lift is a sling-based mechanical device used to move patients who cannot bear their own weight. It suspends a person off a surface during transfer. A resident left alone in one, mid-transfer, has no ability to call for help, reposition, or prevent a fall if something shifts. For a resident on a ventilator with a tracheostomy, a fall or sudden movement carries consequences that extend well beyond a broken bone.
The Director of Nursing, interviewed the same morning at 11:20 a.m., said staff should not leave residents unattended in a Hoyer lift. She added that best practice calls for at least two staff members present during any Hoyer lift transfer, specifically because of safety concerns.
That standard, two people present, was not met. The nursing assistant was alone with the resident to begin with, which is why she left to find a second person. The resident was suspended in the lift while she went looking.
The facility's own written policies, last reviewed in January 2026, stated that resident safety and supervision to prevent accidents were facility-wide priorities. A separate policy on safe lifting committed the facility to using appropriate techniques and devices to protect residents' safety and well-being.
The inspection cited the facility for failing to provide an environment free from accident hazards, specifically for this one resident. The level of harm was classified as minimal harm or potential for actual harm. Six residents were sampled during the inspection. The lapse was found in one of those six cases.
What the classification does not capture is the particular vulnerability of the person in that sling. Resident 1 could not breathe independently. Could not ask for help. Could not understand what was happening or signal distress in any conventional way. The care plan said so in writing. The nursing assistant assigned to this resident's transfer knew, by her own account, that leaving was wrong.
She said she was calling for another staff member. The inspector found the resident alone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westlake Convalescent Hospital from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
WESTLAKE CONVALESCENT HOSPITAL in LOS ANGELES, CA was cited for violations during a health inspection on April 27, 2026.
The inspection, conducted April 24, 2026, stemmed from a complaint.
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.