complaint·May 22, 2025

"at least 2 people to hold R1 up and steady, otherwise R1 sways back and forth. R1 has slid down onto the floor before because we can't keep R1 steady - their legs are weak." The third person is the one who actually cleans and changes R1. LPA asked why they didn't change R1 when R1 was horizontal in bed. S3 responded that they have tried that but, “R1 is very heavy and difficult to move, especially when R1 is sound asleep. R1 is dead weight then, and some of the care partners are more petite than others. With an average person, that might not be an issue but R1 is big and heavy.” LPA observed care notes in logs which state, at 12:35 AM, during the NOC shift, , “We were not able to stand the resident up with 3 care partners. The resident was deadweight and was not assisting. Resident was very weak and was not understanding instructions. We contacted the med tech for advice. Alpha One assisted with continent care. Resident is becoming too heavy to turn and stand. The last observation made regarding weight/condition was in July. We have not received any updates regarding this issue. This issue continued as documented by another care partner on 08/13/24 when they logged, “The resident was hard to do continent care and we call help from assisted living. We checked R1 4 care partners at the bed.” LPA observed that an updated service plan was added to ALIS for R1 on 08/15/24. LPA noted the following upon reviewing the care plan dated 08/07/24. LPA observed from a review of records that from December of 2023, to October of 2024, R1 gained 18 pounds. LPA reviewed documents including discharge paperwork from Kaiser. R1 had a rash and swelling in their groin area and they were diagnosed with a urinary tract infection. On page 2 the new plan stated that the, “resident’s risk for falling will be noted by staff.”  It went on to state, "the resident is encouraged to be out in the common areas during waking hours. Resident is encouraged to sit or lay down when feeling or staff sees resident fatigued.  Resident wears proper footwear when awake and walking (tennis shoes) resident is on toileting services. Staff are to check on resident approximately every 2 hours for toileting assistance. Staff are to redirect resident back to the common areas, if and when, available.”  LPA requested incident reports for R1. From 07/06/24 to 09/01/24, R1 had 1 witnessed and 4 unwitnessed falls. R1 was not getting their incontinent care needs met. R1's care plan should have been updated after the first fall to include a strategic fall prevention plan in order to prevent the following falls from occurring. The standard for the preponderance of evidence has been met and the Department finds the allegation, "Staff are not meeting residents care needs." to be SUBSTANTIATED. According to the California Code of Regulations, Title 22, this deficiency was cited on the LIC9099 D page. A copy of this report was provided along with appeal rights and an exit interview was conducted.