complaint·October 27, 2023

This complaint investigation was conducted by Christine Ferris, Investigator from Community Care Licensing Division’s Investigations Branch (IB). The investigation consisted of interviews with R1, facility Assistant Administrator (AA), Licensed Vocational Nurse (LVN), Glendale Police Department Detective, Facility Resident, R1's records review - included but not limited to Admission Agreement (dated: 09/30/18), Physician’s Report (dated: 11/15/22), Appraisal Needs and Services Plan (dated: 10/15/18, 10/04/19, 05/03/21 and 04/27/23), Progress Notes (dated: 05/24/23 and 06/16/23), Preplacement Appraisal Information and Resident Appraisal (dated: 04/19/19) and other relevant documentation. On 06/27/23, Investigator Ferris subpoenaed Glendale Police Department Report. On 08/04/23, Investigator Ferris followed up on a status of the inquiry. On 08/14/23, Investigator obtained and reviewed a copy of the report. In addition, Investigator subpoenaed R1’s Medical Records on 06/21/23 and reviewed on 07/17/23. Allegation: "Resident sustained an unexplained injury in care." The investigation findings revealed that R1 had been living at this facility since 2009, while it was licensed under “Emerald City”. At that time, R1 was independent and able to ambulate without an assistance. In 2017 change of ownership took place and the facility became “Los Feliz Gardens". During that year R1’s physical and mental health condition started to deteriorate. R1 became wheelchair bound, dependent and diagnosed with Alzheimer’s. On 06/16/23, R1 sustained multiple unexplained injuries. When Fire Department/ Paramedics first arrived, no one could explain what had happened. Due to lack of information and injuries observed, Fire Department Captain contacted the police for a possible assault. Investigator’s interview with LVN revealed that he/she had been employed by a Home Health Agency and treated patients at Los Feliz Gardens for three (3) years. On 06/16/23, LVN was assigned to see another resident for treatment, at Los Feliz Gardens. Around 7:00am, LVN passed by R1’s room and observed R1 sitting on a wheelchair awaiting breakfast to be delivered. LVN went to see a wound patient near R1’s room and upon completion, about 7:30-7:45am, LVN passed by R1’s room and saw R1 "face down" on the floor near his/her dresser and R1’s wheelchair was on the side. LVN entered to assist R1. After R1 was placed on a wheelchair, LVN phoned 9-1-1, waited in the room until paramedics arrived and once paramedics arrived, LVN left the facility. On 06/19/23, during the initial visit, LPA Panushkina obtained a copy of “Care Coordination Notes” (dated on 06/16/23) confirming LVN’s statement. Moreover, Interview with Glendale Police Department, Detective, revealed that there has been no evidence to suggest that R1 was assaulted as initially assumed. Continue on LIC9099-C Detective informed the Investigator that R1’s injuries were more than likely a result of a fall. Additionally, Investigator’s interviews with three (3) residents revealed that the facility staff take very good care of R1 and attend his/her needs. All three (3) residents also informed the Investigator that the facility staff are attentive to their needs. Lastly, Hospital Discharge Diagnoses indicated R1 had an open fracture of metacarpal bone. During the initial visit conducted on 06/19/23, LPA Panushkina reviewed Progress Notes from 05/24/23 and 06/16/23 from R1’s Physician indicating that R1 is at high risk for pathological fracture due to severe osteoporosis. Based on interviews and document reviews, the investigation did not provide sufficient evidence to substantiate staff failed to provide proper supervision to R1 resulting in sustaining multiple injuries and fractures. Therefore, this allegation is deemed Unsubstantiated, at this time. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered.