Complaint·July 2, 2025

The investigation revealed the following: Allegation: Staff did not seek timely medical attention for a resident. It is being alleged that a resident had rashes, edema, and was limping, and despite the reports, staff did not seek timely medical attention for the resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that staff did not fail to seek medical attention for a resident, and 1 out of 3 staff interviewed stated they did not know if staff did not seek timely medical attention for a resident in the past. 2 out of 3 staff interviewed stated that a resident never reported needing medical attention to staff. 3 out of 3 staff interviewed stated that staff ensures to seek medical attention for residents in a timely manner when they need it. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that they don’t know if staff have failed to seek medical attention for a resident in a timely manner. 5 out of 6 residents stated that staff do seek medical attention for residents when they need it. 5 out of 6 residents stated that they did not know if a resident ever reported needing medical attention to staff. 5 out of 6 residents stated that they are satisfied with the services being provided to them. A review of records revealed that R1s daughter (F1) emailed Dr. Whiteman on 11/01/23 letting the doctor know that her mother had swelling in her right leg, below the knee, for over two months. She also sated that her mother had a corn on her right pinky toe, and that her mother reported a 7 out of 10 on the pain scale. On 04/05/24, F1 emailed Dr. Whiteman advising that R1 had an urgent care visit for leg swelling and skin lesions. Medical records from Cedars-Sinai Medica Network dated 11/02/23, revealed that F1 took R1 to the hospital, and was seen for age-related osteoporosis without current hyperlipidemia, mixed hyperlipidemia, major neurocognitive disorder (HCC), leg swelling, corn, primary hypertension. Medical records from Cedars-Sinai Medica Network dated 11/03/23, revealed that F1 took R1 to the hospital, and was seen for toe pain, bilateral and tyloma. Medical records from Cedars-Sinai Medica Network dated 04/04/24, revealed that F1 took R1 to the hospital, and was seen for a follow up podiatry evaluation, bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Continued on LIC9099-C Medical records from Cedars-Sinai Medica Network dated 07/12/24, revealed that F1 took R1 to the hospital, and was seen for bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Medical records from Cedars-Sinai Medica Network dated 12/13/24, revealed that F1 took R1 to the hospital, and was seen for age-related osteoporosis without current pathological fracture, rash, mixed hyperlipidemia, and primary hypertension. Although staff interviewed stated that they did not fail to seek medical attention for R1, records reviewed revealed that R1 was seen on several occasions at Cedars-Sinai Medica Network for health-related issues. Based on record review, and interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited, please see the attached LIC 9099-D. Exit interview conducted. Appeal rights and a copy of this report was provided to Manager, Miran Bae. The investigation revealed the following: Allegation: Staff mismanaged residents’ medication. It is being alleged that a staff administered Alendronate 70mg to a resident, despite never having been prescribed. It is also alleged that no explanation was given as to how a prescription never prescribed could have been administered. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of staff interviewed stated that staff has not mismanaged a resident’s medication. 3 out of 3 staff interviewed stated that staff dispenses resident’s medication(s) on time and as prescribed by their physician. On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that staff dispenses their medications on time and as prescribed by their physician. 5 out of 6 residents stated that staff has not mismanaged their medication. 5 out of 6 residents stated that they did not know if staff mismanaged a resident’s medication in the past. 5 out of 6 residents stated that staff administer their medication on time and as prescribed by their physician. 5 out of 6 residents stated that they are satisfied with the services being provided to them. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. 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 dispensed medication not prescribed to resident. It is being alleged that staff administered Alendronate 70mg despite never having been prescribed to a resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that they did not know if staff administered Alendronate 70 mg to a resident in the past. An interview conducted with S2 revealed that they did not know of this allegation and denied ever confirming this allegation with a resident’s responsible party. Continued on LIC9099-C On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that they did not know if staff dispensed medication(s) not prescribed to a resident in the past. 5 out of 6 residents interviewed stated that staff administer their medication to them on time and as prescribed by their physician. 5 out of 6 residents stated that they are satisfied with the services being provided to them. Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. 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. Exit interview conducted. Appeal rights and a copy of this report was provided to Terry Han, Admission Assistant.