Complaint·November 2, 2025

It is alleged that Resident (R1) sustained multiple rib fractures, including a clavicle fracture, along with a bruise on the lower back and buttocks. The department obtained and reviewed Cedars-Sinai Medical Center Hospital records for R1 dated 09/21/2024 . The department found on 09/21/2024, the facility's Med Tech (MT1) checked R1's vital signs in the a.m. (actual time not found on record) and found R1 was in an altered mental state. The facility then contacted R1's primary physician and called 911. At approximately 8:06 a.m., the Emergency Medical Services (EMS) arrived, and R1 was transported to Cedars-Sinai Medical Center. The department found R1 was in an altered mental state due to R1 not eating and refusing medication for two days. The Cedars-Sinai Medical Records review indicated that the facility informed the hospital that R1 had no history of falls; however, a review of the Home Health records indicated R1 had a secondary diagnosis of repeated falls. Additionally, R1 complained of low back pain and left arm pain prior to the 09/21/2024 hospitalization. On 04/15/2025, at approximately 2:26 pm, the department interviewed Med Tech (MT1), who stated that when R1 experienced an unwitnessed fall, staff did not document unwitnessed falls with Unusual Incident Reports, nor did the staff seek medical attention to rule out invisible injuries after unwitnessed falls. Based on reviews and interviews, the preponderance of evidence standard has been met; therefore, the above allegation is substantiated. Per the California Code of Regulations (Title 22, Division 6, Chapter 8), the deficiency noted above was observed, and a citation was issued (ref. LIC 9099D). At the time of the complaint visit, an immediate civil penalty of $500 was issued, and the licensee was informed that an enhanced civil penalty determination is pending reference to Health & Safety Code § 1569.49. An exit interview was conducted and plans of correction were developed and reviewed. A copy of this report and appeal rights were discussed with Administrator Steve Cho and a hard copy left with Kay Hwang. The department attempted to interview the staff members (S2), but they were unable to answer the interview questions. On 07/23/2025, LPA interviewed three staff members (S1-S3), five residents (#2-6, R2-R6). LPA was unable to interview R1 because R1 passed away on 09/21/2024. Allegation: Questionable Death. On 01/27/2025, at approximately 2:58 PM, the department reviewed records from Cedars-Sinai Medical Center regarding the care timeline dated 09/21/2024. According to the Cedars-Sinai Medical Records, R1 was transported from Sunny Hill Assisted Living Facility to Cedars-Sinai Medical Center Emergency Department on 09/21/2024, for altered mental status, with conditions including sepsis, shock, and a urinary tract infection (UTI). The department examined the Cedars-Sinai Medical Records and the death certificate provided by the Special Investigator Assistant (SIA). R1 was diagnosed with severe sepsis and acute UTI. The death certificate listed cardiopulmonary arrest, acute hypoxic respiratory failure, acute kidney failure, and pneumonia as causes of death. On 04/15/25, at approximately 2:26 pm, the department interviewed Med Tech (MT1), who stated that on September 18, 2024, R1 refused food and medications and complained of pain. The department reviewed the Cedars-Sinai Medical Record, which showed that the hospital Social Worker (SW) called Sunny Hills Assisted Living and spoke with a staff member (S2), who stated that R1 had refused all medication and food for the past two days. The SW noted that there were no concerns of suspected abuse or neglect based on R1’s mental state and physical mobility. On 04/15/2025, at 2:26 PM, the department interviewed Med Tech (MT1), who reported that on 09/18 and 19/2024, R1 refused to eat, refused medications, and did not allow MT1 to check R1’s vital signs. The department reviewed the emergency room case for R1, date 09/ 21/2024. R1 passed away on 09/21/2024, at 3:43 PM. A family member was contacted twice to inform them of the critical situation and prognosis. R1 was appropriately assigned a Do Not Attempt Resuscitation (DNAR) status. Subsequently, R1 experienced respiratory and cardiac arrest and died. The department's review of R1’s death certificate indicated that the causes of death were cardiopulmonary arrest, acute hypoxic respiratory failure, acute kidney failure, and pneumonia. Regarding the allegation, “Questionable Death,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have occurred or be valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur; as a result, the allegation is Unsubstantiated. Allegation: Staff did not notify the resident's representatives about the resident's change in conditions. The complaint alleges that the facility failed to contact the responsible party regarding the resident's change in condition. On 07/23/2025, LPA Richard interviewed Staff #1 (S1), who denied the allegation and reported that when R1 was admitted to the facility on 01/26, 2024, the staff attempted to call the phone number listed in the admission record for R1, but there was no answer. R1 personally signed the admission agreement. The S1 mentioned that they also called the phone number from a previous admission agreement, but again, no one answered. It was noted that R1 has not received any visitors except on one occasion. A couple of times, someone came with another person to speak with R1; that was the last time anyone saw them. For the past eight months, R1 has had that many visitors. On the same date, LPA interviewed three staff members (S1-S3), all of whom denied the allegation. Staff member S3 mentioned that during one attempt to contact the responsible party, the person who answered was very upset and told S3, "Do not call this number anymore; it is up to you now." Additionally, LPA interviewed five residents (R2-R6), with the help of an interpreter, all of whom stated that the facility does contact their families. LPA also reviewed the admission agreement dated 01/26/2024, which indicated that R1 was the only person who signed the agreement. There was no responsible party signature on file. LPA was unable to interview Resident #1 due to R1 passing on 09/21/2024 at Cedar Sinai Hospital. Based on interviews and observations, there is insufficient evidence to support the allegation: Staff did not notify the resident's authorized representatives of the resident's change in condition. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Allegation : Staff did not seek medical attention for the residents in a timely manner. The complaint claims that staff failed to seek medical attention for residents in a timely manner. On 07/23/2025, LPA Richard interviewed Staff member #1 (S1), who reported that on 09/21/2024, the caregiver contacted Med Tech (MT) to check the vitals of resident R1. After assessing R1's vitals, Med Tech discovered that R1 was exhibiting an altered mental status. The (MT) immediately notified R1's primary care physician and family. When there was no response, the facility called for Emergency Medical Services (EMS). As a result, R1 was transported to Cedars-Sinai Medical Center. On 07/23/2025, the Licensing Program Analyst (LPA) interviewed three staff members, Staff #1-3 (S1-S3). All three denied the allegations, affirming that staff members never neglected residents and always provided necessary medical attention. They stated that in the event of a Medical Emergency, they would call 911. The (MT) and (S1) reported that on 09/21/2024, staff promptly assisted Resident #1 (R1), who was then transported to Cedars-Sinai Hospital's ICU at approximately 8:06 AM, where R1 was admitted. There were no instances in which the facility failed to seek timely medical attention for a resident. On 07/ 23/2025, the LPA interviewed five residents, Residents #2-6: (R2-R6). All five residents stated that the facility usually calls 911 for them, or the Nurse comes to assist them when needed. Based on interviews and observations, there is insufficient evidence to support the allegation: Staff did not seek attention for the residents in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. Allegation : Staff locked the residents in their rooms. The complaint alleges that every time they visit R1, there is no way to exit the third floor because all the stairway doors are locked, and the elevator requires a key to operate. LPA interviewed S1, who stated that the elevator door is locked. However, if a visitor signs in, we will provide them with a code to open it. Additionally, a staff member is always present on the third floor to open the door for residents who wish to enter. LPA interviewed staff #1-3 (S1-S3), who stated that the residents do not need a key because the rooms are locked from the inside. The residents could open their doors from the inside, but when they are outside, they need assistance when returning to their rooms. S3 also stated that since R1 was admitted to the facility, R1 has only had one visitor following R1's admission to the facility. On 07/23/25, the LPA interviewed five residents (R2-R6), who all showed the LPA the key they had to open their rooms from the outside. On 07/23/25, the LPA inspected and observed that the third-floor rooms are locked from the inside, allowing residents to leave their rooms at any time. Based on interviews and observations, there is insufficient evidence to support the allegation: Staff did not seek attention for the residents in a timely manner. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated. No deficiencies were cited. Exit interview conducted. A copy of the report was given to Kay Hwang.