complaint·April 15, 2025

Review of R1’s medical assessment records dated October 23, 2024, revealed that R1 was not confused or disorientated, had motor impairment/paralysis, was able to follow directions and could feed themselves but required staff assistance for all other activities of daily living (ADLs). R1 was not able to independently transfer to and from bed. Review of R1’s needs and service plan dated October 26, 2024, revealed that R1 requires one-person total assistance with transfers. Interviews with staff members corroborated R1’s need for assistance with transfers and explained that R1 has sensitive skin, thus there is a technique needed to be used when transferring R1. Interviews with staff revealed that, due to R1’s sensitive skin, R1 needs to be grabbed from under the palms when being transferred. In December of 2024, there was a new staff member in training. This staff member was assisting R1 with their transfer from their bed to their electric scooter. Per staff interviews, this trainee grabbed the tops of R1’s hands to transfer them from their bed to their electric wheelchair. Resident and staff interviews corroborated the incident of the trainee grabbing R1 from the top of their hands which resulted in bruising. Interviews with staff and residents revealed the observation of the bruising R1 sustained from the transfer and recalled the bruising lasting about a week. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of evidence exists to support the allegation. One deficiency is being cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). An exit interview was conducted with Resident Services Director , to whom a copy of this report, LIC 9099-C, LIC 9099-D, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided to.