complaint·March 24, 2025

thereafter could not maintain this standing position and had started to fall down. It was learned that one of the facility staff reacted and pushed R1 onto R1's bed in order to avoid the resident falling onto the floor possibly sustaining additional injuries. It was learned that facility staff then proceeded to reposition R1 in order to turn and pivot R1 to lay correctly in R1's bed. It was learned that the facility resident was solely dependent on the (2) caregivers to assist her in this process so that R1 could be repositioned correctly in R1's bed. It was learned that the facility caregivers attempted to maneuver R1 in R1's bed without grabbing or pushing the resident excessively to prevent further injuries and bruising. It was learned that, at no point in this whole incident, did the facility caregivers climb onto R1 while trying to turn her. In addition, it was learned that the facility caregivers did not ever use their knees to push or pivot R1 while R1 was laying in the bed. As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred. There were no deficiencies observed or cited at this time. Exit Interview power and started to fall down. It was learned that the caregivers who were present did not properly assist in this transfer which led to the eventual fall of R1. As R1 was falling down, it was learned that one of the facility caregivers pushed R1 to one side onto the bed in order to avoid R1 from falling onto the floor and possibly sustaining additional injuries. Based on interviews, it was learned that this was not the correct steps that facility caregivers should have taken in order to properly assist in the transfer of a resident. It was learned that the policies and procedures for an appropriate transfer of the residents were not correctly followed in order to avoid any further injuries and falls related to individuals unable to independently transfer. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was left with the facility designated Administrator at this time. Exit Interview