complaint·April 28, 2026

(Continued from LIC 9099) It was reported that Staff restrain resident in chair. LPA reviewed the Physician's Report and Hospice Paperwork and orders. R1 came to the facility from the hospital and was transported via ambulance on a gurney. R1 is a two-person assist. R1 has a history of six falls from the prior facility and a wheelchair with a seat belt, as well as a walker, were provided. A geri-chair recliner was ordered and provided by the hospice agency. The geri chair is able to fully recline to a bed; which assisted staff in changing diapers. Since R1 was a two-person assist, instead of moving R1 from a chair to R1's bed; the geri-chair was used. A request for an exception for the geri-chair was not received by the Department. Upon interview, three of three staff denied that Staff restrain resident in chair but did report the resident often tried to get out of the chair and was a fall risk. Three of three staff confirmed the chair was reclined so resident was unable to get up from chair. Therefore, the geri-chair was intentionally being reclined in an effort to restrain resident from getting up from the chair. One of two witnesses confirmed the allegation. One of two witnesses did not confirm, nor deny the allegation. Based on LPA record review and interviews, the preponderance of evidence standard has been met. Therefore the allegation that Staff restrain resident in chair is Substantiated. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Lorna Smith, Administrator and a copy of this report was given to the facility along with a copy of the LIC 811, LIC 9099-D and Appeal Rights.