complaint·February 10, 2022

Allegation #1, that “resident developed a UTI while in care,” has been substantiated based on the records reviewed and interviews conducted. On 9/21/21 LPA reviewed the Valley Presbyterian Hospital intake records for R1 and observed that R1 was admitted for a Urinary Tract Infection (UTI) on 4/3/21. At the time of LPA’s visit on 6/1/21, the most recent assessment done of R1 was from 1/11/19, and it indicates that R1 was incontinent and required full assistance with toileting, dressing and grooming. Allegation #2, that “resident wandered from the facility due to lack of supervision” has been substantiated based on the records reviewed and interviews conducted. On 5/11/17 the facility submitted an incident report for R1, indicating that R1 was "on monitoring throughout the day and was caught waiting at the bus stop...wanted to visit friends..does not know where they live.” A review of facility records shows that the most recent assessments conducted prior to this incident were on 1/3/17, when his level of care was assessed to have increased from “lvl 2” to “lvl 3” and he was recommended for memory care, and 12/8/16 when a Mental Status Questionnaire indicated that R1 was experiencing “severe brain dysfunction.” Allegation #3, that “Facility failed to report incidences,” has been substantiated based on the interviews conducted and records reviewed. On 6/1/21 LPA asked the Wellness Director and Resident Care Director if there were any other recent reportable incidents for R1 that came to mind, aside from the 5/21/21 choking incident, and both failed to mention or provide any documentation for the fact that R1 was taken to the hospital on 4/3/21 for a fall and UTI. On 9/21/21 LPA reviewed the 4/3/21 hospital records for R1 as well as the Woodland Hills South Regional Office’s log of incident reports from the facility, and did not observe any record of this incident being reported to Community Care Licensing. Report reviewed, signed and delivered. Exit interview conducted, deficiencies cited on 9099D page.