complaint·May 7, 2025

Continued LIC9099-C page 2 Appraisal Need and Services Plan (Dated 10/12/2023), Safeguards for Cash Resources, (Dated 10/14/2023) Preplacement Appraisal Information (Dated 10/14/2023), Safeguards for Property Valuables (Dated 10/14/2023), Personal Rights (Dated 10/14/2023), Consent Forms (Dated 10/23/2023), Progress Notes (10/14/2023 - 01/25/2024), and Legend Home Health Medical Records (Dated 02-18-2023 - 01/25/2024) Investigation Reveals the following: It was reported that the resident #1 (R1) arrived at Torrance Memorial Medical Center's Emergency Room on January 25, 2024, with serious wound issues, including stage 3, stage 4, and unstageable pressure ulcers on the heel, leg, and lower back. Staff members #1 and #2 (S1-S2), interviewed, confirmed the allegation. S1 and S2 stated that R1 had been receiving wound care treatment prior to admission and was referred from a facility that was closing. Upon admission to Golden Care Living III, the resident presented with a pre-existing decubitus ulcer in the buttocks and groin area. R1 was referred to Legend Home Health, Inc., for ongoing wound care treatment. The nurse and primary care physician remained in constant communication throughout the resident's entire stay at the facility. Allegation: Resident #1 went to the hospital with serious wound issues: Stage 3, Stage 4, and unstageable wounds. On 05/07/2025, the Department interviewed two staff members #1 and #2 (S1-S2), regarding the alleged allegation that resident #1 (R1) was admitted to the hospital due to serious wound issues: Stage 3, Stage 4, and unstageable wounds. 2 out of 2 staff stated it is true resident #1 (R1) was admitted to the hospital with serious wound complications. S1-S2 stated that R1 was admitted to the facility on 10/14/2023 and was already receiving treatment for pressure wounds at the time of admission from Home Health, from 02/17/2023 - 01/25/2024, before the resident was admitted to Golden Care Living III. S1 and S2 states, R1 was hospitalized on 01/25/2024 while under the care of Legend Home Health Care, Inc., due to worsening wound conditions, including Stage 3, Stage 4, and unstageable wounds. See continued LIC9099-C page 3 Continued LIC9099-C page 3 On 05/05/2025, the Department interviewed five residents. Residents #2 through #6 (R2-R6), regarding the alleged allegation that resident #1 (R1) was admitted to the hospital due to serious wound issues: Stage 3, Stage 4, and unstageable wounds. The Department was unable to interview Resident #1 due to R1 no longer residing at the facility as of 01/25/2024. R2-R6 stated that they had no knowledge of the complaint allegation. 5 out of 6 residents interviewed denied the allegation and stated that they did not witness any residents with serious wounds. R2-R6 stated they had no concerns or problems and were happy with the care and supervision provided. R2-R6 stated that the staff are doing an excellent job of maintaining their living conditions at the facility. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated. There were no deficiencies cited. LPA Bunker provided Caregiver/Staff Jeremy Nebres with copies of the Complaint Investigation Reports LIC-9099 and LIC-9099Cs. An exit interview was conducted.