complaint·September 24, 2024

Regarding the allegation: Resident sustained multiple pressure injuries while in care. It is being alleged that resident #1 (R1) sustained multiple pressure injuries while in care. R1 is no longer residing at the above facility. While in care of the above facility, R1 received one (1) wound care on their sacro coccyx right buttocks sacral area, pressure ulcer stage 3 and received hospice care from “Mensa” with the son’s authorization. Mensa Hospice Care had case notes describing the wound and the care of the wound. One (1) out of ten (10) residents confirmed that they have been in the hospital for pressure injuries, but they were returned to the above facility after they got the care they needed and confirmed that they have a history of heel injuries. Three (3) out of three (3) staff confirmed that if any type of injury occurs especially injuries that have to do with wounds they are sent to the hospital and upon their return to the above facility the resident is cared for on the doctor’s orders. Hospice or Home Health is recommended for the resident depending on the type of injury and/or medical condition they have. The other residents confirmed they have not received any pressure injuries while in care. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Facility did not have sufficient staff to care for the residents. It is being alleged that resident #1 (R1) was not being provided staffing to meet their needs. R1 is no longer residing at the above facility. R1 was in the memory care section of the above facility where there are two (2) caregivers and one (1) housekeeper per shift. R1 was also put under Mensa Hospice Care on June 18, 2024, so their needs could be met and have an additional staff providing care to them. Four (4) out of ten (10) residents confirmed that there is a need for more staff, but their care might be slow, but it still gets done. Three (3) out of three (3) staff confirmed that there are several staff to help the residents. In addition, Hospice and Home Health are recommended for the resident’s that need extra care. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff failed to observe the resident resulting to multiple falls. It is being alleged that resident #1 (R1) fell multiple times and it resulted in stitches. R1 is no longer residing at the above facility. R1 fell twice since their stay at the above address. On 10/2023 and on 01/2023. Both falls were reported to CCLD-California Community Licensing Department and both times R1 was sent to the hospital. Northridge and Tarzana hospitals did not state that R1 needed any stitches for their fall and R1 was released back to the above facility. Ten (10) out of ten (10) residents confirmed that the staff have never failed to help them or left them unattended if they fell. Three (3) out of three (3) staff confirmed if a resident falls or an injury occurs with them the resident is transported to the hospital, an incident report is written, and sent to CCLD- California Community Licensing Department. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) is UNSUBSTANTIATED at this time. Regarding the allegation: Staff over medicated the resident in care. It is being alleged that Resident #1 (R1) was sedated all day and would not get out of their bed. R1 is no longer residing at the above facility. R1’s paperwork confirms that R1 was bedridden and was taking multiple medications for their health. Ten (10) out of ten (10) residents confirmed that they have not been over medicated. Three (3) out of three (3) staff confirmed almost all their residents take medication and that the medication has different side effects and that to their knowledge a resident has not been sent to the hospital for being over medicated. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) is UNSUBSTANTIATED at this time. LIC 9099C-continued Regarding the allegation: Staff did not reappraise the resident regularly while in care. It is being alleged that resident #1 (R1) was not appraised and reappraised to determine his or her individual needs and services. R1 is no longer residing at the above facility. R1 was admitted to the above facility in 2022. There was a pre-placement appraisal which indicated an ambulatory status on 05/2022. The Assisted Living Waiver indicates they had a history of falls which is dated 11/2022. R1’s Resident Information/Care Plan dated 08/2023 indicates they were now non-ambulatory, and their Physician Report 04/2023 also stated non-Ambulatory with history of falls. The updated paperwork from the hospitals showed R1 had become bedridden and there is an updated Resident Information/Care Plan that shows R1 was bedridden. The resident care director and administrator both stated that R1’s health had decreased while they lived at the above facility. On 09/14/23, R1 went to the hospital for a psychological evaluation and on 01/09/24, R1 went to the hospital again for a seizure. On 04/27/24, R1 was sent to the Northridge hospital, and they transferred R1 to a Woodland Hills Skilled Nursing Facility for further rehabilitation due to R1’s health. Woodland Hills Skilled Nursing discharged R1 back to the above facility in June 2024 with home health recommendation and R1 was placed under Hospice with son’s authorization on June 18, 2024. Ten (10) out of ten (10) residents confirmed that they are aware of their health changes, needs and services. Three (3) out of three (3) staff confirmed that the reappraisal happens when a resident’s health changes. The staff confirmed that the residents must go to the doctor for this to happen and the resident’s needs and services are then updated. One (1) of the staff also stated that R1’s health was deteriorating while in the care of the above facility. Therefore, based on the LPA's records review, staff and resident interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. An exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Resident Care Director, Mary Jane Reyes.