complaint·October 3, 2024

On 04/22/2024, from 11:47am to 4:30pm, Licensing Program Analyst (LPA), Esther Cortez conducted the unannounced initial complaint visit. Upon arrival LPA Cortez met with the administrator Lori McKay and owner Lito Vitug and explained the reason for the visit. Between 12:00pm and 4:30pm the LPA toured the physical plant with the administrator, interviewed three (3) staff, conducted a file review and obtained copies of pertinent documents relevant to the investigation. The LPA determine further investigation was required. The administrator and staff were advised that a referral was submitted to Community Care Licensing Division (CCLD) Investigations Branch (IB). During today's visit LPA Cortes conducted staff and resident interviews, and obtained copies of pertinent documents relevant to the investigation. On 06/04/2024, from approximately 10:30am to 12:20pm, Investigator Real conducted interviews with the administrator and staff; on 06/11/24, from approximately 11:00am to 12:20pm, with residents; on 07/15/2024, at approximately 12:00pm, with R1’s resident representative; and on 07/22/2024, from approximately 10:30am to 2:25pm, with Corinthian Health Care Services, Inc. home health office manager and nurse. In addition, the investigator reviewed Sherman Oaks Hospital medical records, Corinthian Health Care Services, Inc. home health records, and facility file documents pertinent to the investigation. A review of R1’s physician’s report, dated 11/09/2023, indicated R1’s primary diagnoses was listed as history of sepsis, urinary tract infection, and pneumonia. The report indicated R1 had mild cognitive impairment, was able to follow instructions as well as communicate needs, R1 could leave the facility unassisted, dress and eat on their own, was able to transfer to and from bed independently and was identified as ambulatory. A summary of R1’s home health records obtained from Corinthian Home Health revealed R1 was placed on Corinthian Home Health Services on 02/02/2024 and was discharged on 04/01/2024 due to R1’s hospitalization. According to the records, R1 presented as alert & oriented, who received minimal to moderate assistance to perform activities of daily living (ADLs) safely, medication and meal preparation. R1 was recently discharged from Sherman Way Village Center (skilled nursing facility) related to a urinary tract infection (UTI) and weakness. R1 was admitted to Corinthian Health Care Services for RN assessment, medication, recon, pain management, fall precautions, and home safety. Skilled nurse performed evaluation and assessment of vital signs and overall body systems. The records indicate R1 used a walker for ambulation. Report will continue on LIC9099-C 3rd page. R1 has right lower extremities pain, poor balance, and unsteady gait. The home health notes did not identify any signs of illness and on 03/26/2024 home health was notified R1 had a fall incident. Multiple x-rays were done and showed negative results. On 03/28/2024, R1 was taken to the Sherman Oaks Hospital emergency room due to increased confusion. R1 was admitted to the hospital on 03/29/2024 and was discharged from home health. No abuse or neglect concerns were noted in R1’s home health records. According to the Sherman Oaks Hospital medical records, R1 was seen in the Emergency Department on 03/28/2024 at 8:20pm due to being more confused than R1’s baseline (history of confusion). R1 was awake, alert and denied being in any pain. R1 did not have any chest pain or shortness of breath and R1 denied fever or chills. R1 did not have abdominal pain, nausea, vomiting or diarrhea. R1 informed hospital staff that they felt cold. A physical exam revealed R1 was well developed and in no apparent distress. A urinalysis was done and showed no signs of infection, but some blood was seen. A chest x-ray revealed patchy air space opacites in both lungs which was noted as compatible with multifocal pneumonia. R1’s EKG was noted as abnormal. Lab work indicated R1 had slight leukocytosis, was anemic with low sodium, and was noted as having some acute renal failure. R1 was also noted as having encephalopathy and was admitted 03/29/2024 to the hospital for the pneumonia with a temperature of 98.4. R1 was not noted as having malnutrition at the time of hospital admission. During the hospital stay, R1 tested positive for MRSA and R1’s health declined. R1 was noted with worsening acute kidney injury leading to multiple organ failure and R1 passed away on 04/13/2024. A review of the Unusual Injury/Incident report, dated 03/26/2024, documented that on 03/25/2024, at approximately 4:45pm, while returning from an outing with R1’s resident representative, both R1 and R1’s resident representative stumbled and fell as they were walking up the stairs to the facility. The administrator immediately assessed R1 and R1’s resident representative. There were no injuries noted for R1. On 03/27/2024, an x-ray was ordered for R1’s right leg, right foot, right elbow, left hand, and right pelvic region. The results revealed no fractures and listed the diagnosis as pain and swelling. Report will continue on LIC9099-C 4th page. This page of the report is being amended to remove private information. Report will be emailed to the facility owner for signature, and hardcopy with signature will be on file. On the allegation “Neglect/Lack of Care: Facility employees failed to obtain timely medical treatment for Resident #1 (R1)”. Information obtained from the interviews conducted revealed R1 was sent to the Emergency Room on 03/28/2024 when R1 was more confused than usual. A review of R1’s hospital records revealed R1 was not in any serious distress and only reported feeling cold. The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time. On the allegation “Neglect/Lack of Care: Facility employees failed to provide an appropriate level of care resulting in Resident #1 (R1’s) death”. The Department’s investigation revealed R1 had a history of numerous health conditions including pneumonia. Upon R1’s admission to the hospital on 03/29/2024, R1’s chest x-rays found R1 had pneumonia. Despite R1 being diagnosed with pneumonia R1 was not in any distress upon admission to the hospital. R1 was admitted to the hospital for treatment and later tested positive for MRSA and R1’s health declined. R1 passed away in the hospital approximately two weeks later, on 04/13/2024. The information and evidence obtained during the investigation did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time. On the allegation " Staff did not meet resident’s needs"; it is the concern of the reporting party that Resident #2 (R2) had a rash on their body 4-5 times, had a UTI several times and they were not getting any treatment and the facility doctor was supposed to see R2 but did not. Residential Care Facilities for the Elderly (RCFE) are non-medical facilities that are not required to have nurses or doctors on staff, however staff revealed that the facility has an LVN on call that primarily sees ALW clients. A review of R2’s file revealed that R2 was admitted to the facility on 11/25/2023. A review of R2’s physician’s report, dated 11/09/2023, indicated R2’s primary diagnoses was listed as base of left femur fracture s/p surgery. The report indicated R2 had dementia, had a history of skin condition or breakdown with history of surgical wound, was able to follow instructions as well as communicate needs, R2 could leave the facility unassisted, dress and eat on their own, was able to transfer to and from bed independently and was identified as ambulatory. Report will continue on LIC9099-C 5th page. A review of R2’s Corinthian home health records obtained from the facility revealed R2 was receiving services from Corinthian Home Health starting on 12/29/2023. Corinthian Healthcare Services communication note revealed that on 02/12/2024, R2 started Keflex 500 mg four times a day for 7 days related to UTI, and they completed the antibiotics. Skilled nursing clinical visit not from Corinthian Healthcare services revealed that on 02/28/2024, a SN assessed R2’s condition, R2’s diagnosis was alteration in GU status related to UTI and that R2 was placed on ATB therapy: Bactrim DS 1 tablet twice a day oral starting that day (02/28/2024), and lastly, R2/caregiver were provided health teachings regarding measures to prevent or manage UTI. Skilled nursing clinical visit not from Corinthian Healthcare services revealed that on 04/05/2024, a SN assessed R2’s condition, and R2’s diagnosis were impaired skin integrity due to rashes on both arms and legs. SN cleansed the areas with normal saline, pat dry and applied Calmoseptine, and left open to air and reported R2’s condition to MD/HHA. Staff interviews revealed that shortly after R2 was taken to the hospital for a separate reason and never returned to the facility. A review of the Unusual Injury/Incident report, dated 03/29/2024, documented that on 03/28/2024, 9-1-1 Paramedics were contacted due to R2 exhibiting some confusion. R2 was transported to Sherman Oaks Hospital and the nature of the treatment was unknown at the time. There were no injuries noted for R1. A review of the Unusual Injury/Incident report, dated 04/09/2024, documented that on 04/07/2024, non-emergency transportation was arranged for R2 to get them to Sherman Oaks Hospital due to complaints of bodily pain. On the allegation “Staff did not meet resident’s needs” Information obtained from file reviewed conducted revealed R2 did present UTI infections and rashes, however R2 was being seen and treated by home health, and their physician. Staff interviews also revealed that R2 was not seen by the facilities LVN because R2’s daughter, doctor and home health were heavily overseeing R2’s health. In addition all resident's interviewed revealed that their needs are met by staff. The information and evidence obtained during the Department’s investigation did not sufficiently support the allegation, therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, copy of this report issued