On 06/10/24, R1’s medical and health condition changed. R1 was noted to have an unsteady gait due to weakness, which resulted in his/her inability to stand and walk. R1 was admitted to a Skilled Nursing Facility (SNF) for rehabilitation, where R1 was evaluated by a Physical Therapist (PT) on 07/02/2024. R1’s DPOA (Duly Power of Attorney) was aware of R1’s change of condition.

On 07/05/2024, R1 was admitted back to the facility from SNF but was later sent to the hospital, on 07/05/2025, due to being unresponsive or unarousable to stimuli. After 07/05/2024, R1’s change of health/medical condition, including level of care, became more apparent, such as but not limited to R1’s inability to reposition in bed, including transferring from/to bed/wheelchair, increased body mass, and shortness of breath (SOB).

On 07/22/2024, R1 was seen by his/her Occupational Therapist (OT), who documented that R1 was asleep in bed, could not stay awake, was wheezing, was unresponsive, was not following commands, and was completely bedbound.

On 07/24/2024, R1 was seen by a physical therapist (PT) who recommended the initiation of hospice services as an option to R1’s DPOA. It was unclear whether R1’s DPOA agreed to the recommendation of the hospice services.

Lastly, on 07/25/2024, R1 was sent to the hospital due to staff observing R1 to be less responsive and was cold touch with chest congestion.

On 04/02/2025, LPA obtained and reviewed R1's Care Plan for 07/05/24. The goal was to safely transfer R1 t/from bed/wheelchair. The plan was to obtain PT/OT home health for lower extremities strengthening. If R1 requires more than 2 people to transfer, then leave R1 in bed and provide care services to R1 there, including repositioning every 2 hours to avoid pressure injury and maintain skin integrity. Call 911 if R1 appeared in distress during transfers.

Based on LPA's overall review of R1’s care plan, R1 had been experiencing physical and cognitive decline, with suspected water weight gain, and had become unresponsive. Staff attempted to assist R1 out of bed daily with 2-person assistance to transfer R1 from bed to wheelchair and leave R1 in bed if 2 staff members were not able to hold R1’s upper extremities and move his/her lower extremities at the same time during the transfer.

Continued on LIC9099-C

On 06/02/2025, LPA obtained and reviewed the facility’s note that was faxed to R1’s physician, requesting PT/OT services for R1 to help strengthen his/her legs during transfers. R1’s physician referred to PT or OT for R1 wherein he/she was seen, and noted on 07/23/34 physician’s visit, R1 requires to be repositioned every two hours.

On 04/02/2025, the LPA obtained R1’s 2024 weight record. Based on the LPA’s review, R1 gained weight from 05/2024 to 07/2024, from 179 to 200 lbs. Based on an interview with S2, S2 stated R1 was getting puffy along with water retention. As a result, transferring R1 became challenging as R1 was dead weight due to weaker upper and lower extremities, and R1 was not supporting his/her weight.

On 04/02/2025, the LPA obtained and reviewed R1’s Appraisal needs and services plan dated 06/06/2023, signed by R1’s DPOA on 06/28/2023, which indicated that R1 required assistance with ADLs, dressing, grooming, showering, and incontinence care. Based on an interview with S2, the facility conducted annual Appraisal Needs and Services Plans and conferences but was unable to complete the 2024 plan on time, as R1 had been in and out of the hospital multiple times starting in June 2024.

On 04/02/2025, the LPA obtained and reviewed R1’s Functional Capability Assessment for 07/022024, which indicated that for transferring, R1 was unable to move in/out of bed or chair, unable to reposition, needed help moving the wheelchair, and did not walk.

On 04/02/2025, the LPA obtained and reviewed R1’s LIC 602 Physician’s Assessment reports for 10/20/2023 and 06/28/2024, which listed diagnoses including dementia, hypothyroidism, hypertension, edema, and a cardiac pacemaker. R1 was determined to be bedridden due to both physical and mental conditions and could transfer only with cooperation.

On 04/02/2025, the LPA obtained and reviewed LIC624 Incident Report for 07/25/2024, which stated that R1 was sent to the hospital for a change of status as R1 was observed less responsive, had chest congestion, and low body temperature of 94°F.

On 04/02/2025, the LPA obtained and reviewed R1’s shower log from May to July 2024, which showed R1 was scheduled for showers twice a week. In May 2024, R1 received showers as scheduled. In June 2024, R1 received showers as scheduled, except on days when R1 was hospitalized. In July 2024, R1 received sponge baths on days when R1 was not in the hospital.

Continued on LIC9099-C

ADM stated that R1’s responsible party/durable power of attorney (DPOA) was aware that R1 was dead weight, could take 4 care staff to transfer R1 t/from bed/wheelchair, and required bed repositioning by 2 care staff. ADM added that upon R1’s discharge from SNF on 07/05/2025, an assessment was done for R1.

The facility and DPOA had verbally agreed on the plan of care or appraisal, and safety protocols, dated 07/05/2025. The plan was to obtain PT/OT home health for lower extremities strengthening. If R1 requires more than 2 people to transfer, then care services will be provided to R1 on bed, including repositioning every 2 hours to avoid pressure injury. ADM stated that on 07/25/2025, R1 was sent to the hospital as R1’s condition worsened with congestion, wheezing, and decreased responsiveness.

On 07/09/2025, the LPA interviewed six staff members (S2, S3, S6, S7, S8 and S9). S2 stated they had scheduled showers for R1 twice a week and always attempted to provide showers in the shower room using a chair as part of the staff’s willingness to get R1 out of bed and provide care. Sometimes, when staff were able to transfer R1 on a chair, R1 would not support his/her body. R1’s flaccid physical state would put R1 in an unsafe position. Sometimes during transfers, R1’s repository condition diminished and R1 would exhibit labored breathing along with wheezing. During these unsafe times for R1 to use the chair, staff bathed R1 in bed.

S3 said along with two to three staff members, they tried to get R1 out of bed on most days. They repositioned R1 every two hours in bed when R1 appeared pale and began breathing heavily during transfers. S6 stated that two to three staff members lifted and transferred R1 to a shower chair and rolled the chair to the shower room. S6 described R1 as “dead weight” and reported that there were times when R1’s condition changed mid-transfer, requiring staff to leave R1 in bed.

S7 reported that R1 required two to three staff members for transfers, became agitated during transfers, and would breathe heavily. S8 stated that R1’s willingness to get out of bed often depended on R1’s mood and confirmed that R1 was given showers twice a week with the assistance of three to four staff members.

S9 reported that at times, R1 appeared sleepy throughout the day and had to remain in bed. When R1 was seated in the dining room but became sleepy, staff would ask the supervisor to transfer R1 to bed.

Continued on LIC9099-C

No deficiencies were cited under the California Code of Regulations, Title 22.

An exit interview was conducted with the Health and Wellness Director. A copy of this report was discussed and provided to the Health and Wellness Director, Teresa Ly, whose signature on this form confirms receipt of this report.