complaint·November 2, 2024

Investigation Revealed the Following: Allegation #2: Staff did not supervise residents resulting in multiple falls and injuries. Regarding the allegation “Staff did not supervise residents resulting in multiple falls and injuries.” It is being alleged that resident was admitted to Torrance Memorial Hospital, on 12/4/21, for a fall that result in a left hip fracture and a left femur fracture. This investigation revealed resident #1 (R1) was admitted to Senior Living Lifestyle – Palos Verdes on 07/24/21. An interview was conducted with Licensee/Robert Smith who stated R#1’s first fall occurred approximately (1) week after R#1’s admission. The department found this fall resulted in serious injuries to the head, hip, and ribs. The Licensee stated that during R#1’s admission to the facility, R#1 was assessed and deemed a “fall risk”. The Licensee stated that after the fall in August of 2021, the facility failed to employ a fall risk plan. The department found on 12/01/21, R#1 fell again at the facility and the fall resulted in a hip and femur fracture. The Licensee stated after the second fall occurred preventative measures were put in place for R#1 when R#1 returned to the facility from skilled nursing in January of 2022. The department conducted and interview with R#1 and R#1 did not recall the falls that occurred while residing in the facility. Based on the departments review of medical records, supporting documentation, and interviews conducted; the department found the facility failed to provide R#1 the appropriate level of care and supervision and this resulted in R#1 sustaining injures due to falls. Allegation #3: Facility did not seek timely medical attention for resident. This complaint alleges that the facility did not seek timely medical attention for Resident R1 after R1 fell and sustained serious injuries on 12/1/21. On 12/01/21, Resident (R#1) fell at the facility, and this resulted in a left hip and femur fracture. The department conducted an interview with Licensee/Robert Smith, who stated he contacted 911 following R#1’s fall; however, the department was unable to find records of this call. Evaluation Report continues LIC 9099-C The department found the Licensee did contact R#1’s Home Healthcare agency on 12/1/21 to conduct an evaluation of R#1 after the fall. On 12/1/21, the Home Health agency conducted the evaluation and found no signs of injury. The Licensee states he also contacted R#1’s family member on 12/2/21 to report the fall. The family member requested Home Health perform an x-ray. The family member visited the facility on 12/4/21 to transport R#1 to the hospital due to Home Health not having the equipment to perform an x-ray on R#1. The department found R#1 fell on 12/1/21 and did not receive medical attention until 12/4/21; therefore, R#1 did not receive timely medical attention for injuries sustained. Additionally, The Licensee did not arrange for R#1’s medical needs to be met or provide transportation. Allegation #4: Staff are not meeting residents care needs. It is alleged that staff are not meeting residents care needs, resulting in resident #1 (R1) sustaining injuries. The department found that Resident #1 (R1) was admitted to the hospital 8/5/21 after a un-witnessed fall. On 01/27/21, the Licensee Richard Smith stated to department that R1 could independently transfer to and from bed and did not need assistance. The Department reviewed R1’s Physician’s report LIC 602A (dated 07/11/21) and Functional Capability Assessment form (dated 07/11/21) which indicated that R1 could not engage in self-care. R1 needs assistance with walking i.e. walker/wheelchair and needs help repositioning in bed from side to side as well as help with personal hygiene tasks. On 12/01/21, when the resident tried to transfer from one bed to another bed, it resulted in a fall. As a result of the fall, R1 sustained a broken left hip and a fractured femur. Licensee Richard Smith did not contact emergency personnel, nor did he transport R1 to the hospital instead he called the resident’s home health agency. According to the home health agency, they did not find any visible injuries; however, on 12/04/21, a family member transported R1 to Torrance Memorial Hospital where R1 was diagnosed with left hip fracture as well as a left femur fracture. Subsequently, the facility did not have a preventative measures plan in place to keep R1 safe, considering this was the second fall that occurred at the facility. Evaluation Report continues LIC 9099-C During this investigation, LPA found sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D). - An immediate civil penalty of $500 is warranted accordance with California Health and Safety Code. See LIC421IM. An exit interview was conducted, and a copy of the Complaint Report was given to Robert Smith/Licensee. Investigation Revealed the Following: Allegation#1: Resident (R1) sustained pressure injury while in care. This complaint alleges that R1 developed a stage 2 pressure injury after an injury that occurred on 12/4/21. The department interviewed the licensee Richard Smith (S1). The Licensee indicated that the resident #1 (R1) was admitted to Senior Living Lifestyle- Palos Verdes on 07/24/21. R1’s Physician Report (LIC602A) dated 07/11/21 revealed that (R1) is ambulatory and requires assistance with daily living activities and had no pressure injuries and no history of pressure injuries. The department found (R1) resided in the facility from 7/24/21-1/29/22. During this time R1 was hospitalized for a fall that occurred at the facility on 12/4/21. The department reviewed hospital records and found no evidence of a pressure injury when R1 was hospitalized. The department was unable to find facility records to support R1 sustained a pressure injury or R1 developing a pressure injury while residing at this facility. Additionally, on 01/14/21, R1 was discharged from the hospital without a care plan for pressure injuries as R1 was not diagnosed with a pressure injury while hospitalized. Allegation #5: Facility are not providing residents with food of good quality. The investigation revealed the following: Regarding the allegation: Facility staff are not providing residents with food of good quality, it is being alleged that resident #1 (R1) did not get receive food of good quality, resulting in malnutrition. On 01/27/21, The department interviewed the Licensee Richard Smith (S1) and two residents (R1-R2). The department found 2 out of 2 residents were interviewed and stated that they eat three meals daily, never deprived of food and stated the food is terrific. The Department staff witnessed the residents enjoying their meals, while the licensee assisted in R1 & R2 with their meals. Evaluation Report continues LIC 9099-C Allegation #6: Staff are mismanaging resident’s medication. Regarding the allegation, “Staff are mismanaging resident’s medication,” it is being alleged that Resident #1 (R1) did not receive the correct medication. The resident R1’s Physician’s Report (LIC 602A) dated 07/11/21 revealed that R1 cannot self-care and requires assistance with activities of daily living and medication administration. The Department records review indicated that the facility consistently assists with administering medication to R1 since R1 was admitted at Senior Living Lifestyle—Palos Verdes on 07/24/21. According to the Identification and Emergency Information (dated 07/11/21). The Department records reviews dated 07/12/21 to 01/20/22, indicated no mismanagement on the Medication Administration Record (MAR). The Department did not observe any discrepancy. There is insufficient evidence to support the allegation of staff mismanaging resident’s medication. During this investigation, the Department did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of the Complaint Report was given to Robert Smith /Licensee.