complaint·August 5, 2025

(continued from LIC 9099) At around 5:00 PM and proceeded to assist R1 transfer to the toilet from the bed through the wheelchair, upon returning to the wheelchair from the toilet, R1's leg locked and unable to bend, a medical condition of R1 which happens from time to time. This made R1 panic so S1 sat R1 on the floor. On 04/15/25 incident, LPA's interview with Staff #3 (S3) revealed that S3 did not remember S1 falling but LPA's interview with R1's private caregiver revealed that S1 fell on 04/13/25 with S3 protecting R1. Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued. (continued from LIC 9099-A-C) Based on the information gathered during this and prior visit, the allegation is deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.