Complaint·April 29, 2026

(Continued from LIC9099 p.1) Staff 1 (S1), who was involved in the transfer, confirmed that a conversation was not had with R1 regarding the assistive devices during the incident. S1 informed that while R1 has refused using the items in the past, they did not refuse them during this incident. Staff informed that R1 fell forward during the transfer in question, hitting their head on a dresser. S1 informed that they did not have a walkie to request help upon the fall so they informed R1 that they were going to find help and return, which was done within approximately 1 minute while R1 was lying on the ground. S1 acknowledged that R1 should have been wearing the gait belt and leg brace during the transfer and did not know why they were not on. Staff informed that updated instructions have been communicated to all caregivers and nurses regarding ensuring R1's assistive devices are on during each transfer, and calling for a second caregiver if R1 shows signs of weakness upon transferring. Staff additionally informed that signs are now up in R1's room, reminding staff to ensure R1's assistive devices are on during all transfers. An interview was conducted with R1 during and unannounced facility visit. R1 informed that they were supposed to wear their gait belt and leg brace during each transfer and that the items were not on during the transfer in question. R1 informed that they did not have a conversation with S1 regarding the brace/gait belt being on or off prior to the transfer. R1 stated that their foot "buckled" during the transfer, causing them to fall forward and hit the left side of their forehead on the front flat part of a dresser. R1 informed that signs are now placed in their room regarding the use of the gait belt and leg brace for transfers, and that staff now request an additional caregiver to assist them when needed. Outside source interviews were attempted, however LPA's phone calls were not returned. Records Review included the Unusual Incident/Injury Report for the incident, R1's progress notes, Service Plan, and photos. R1's service plan showed that the expectation at the time of the incident was for R1 to utilize a gait belt, leg brace, and cane during all transfers. The Unusual Incident/Injury Report and progress notes pertaining to the incident were consistent with staff and resident statements regarding the details of the fall during transfer. LPA directly observed the assistive equipment and furniture involved during the incident in question. R1 described and affirmed LPA's understanding of R1's contact with the dresser upon falling. LPA took photos of the dresser and signs posted on the wall that were placed after the fall. (Continued on LIC9099 p,3) (Continued from LIC9099 p.2) LPA personally walked and timed the path of travel that S1 took when requesting help for R1 after the fall. LPA walked at a conservative pace (not running) from R1's room to the open balcony on the second floor where S1 yelled for help to the reception desk below. The total amount of time round trip was 00:58:42. LPA's direct observation corroborated S1's statements regarding being away from R1 approximately 1 minute to get help after the fall. Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Executive Director Daniel Slaughter and Health and Wellness Director Raquel Mathews, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.