Regarding Allegation #1: this investigation revealed that Resident #1 was admitted to Cedar-Sinai Hospital on 12/18/21 for (1) shallow pressure ulcer (with adjacent cellulitis and underlying phlegmonous change of the subcutaneous tissues lateral to the greater trochanter), but no CT evidence of abscess or osteomyelitis. (2) Left acetabular protrusion deformity (with severe left hip osteoarthritis). Resident #1 was seen by ED Attending Physician (Dr. Grant Ross, Cedar-Sinai Hospital). The following were diagnosis throughout Resident #1’s hospitalization (from 12/18/21 to 12/23/21): 12-18-21: Dx: left hip decubitus 4 cm in diameter - Unstageable. 12-19-21: Dx: left hip wound. Registered Dietitian (RD) consult received for pressure injury. Skin: L Hip-Wound Ostomy and Continence Nurses (WOCN) to evaluate. 12-20-21: Dx: Left Hip - Patient has an unstageable pressure injury with black/brown non-viable tissue covering base of the wound bed, peri wound intact – 4 x 3 x 0.1 cm. 12-21-21: Dx: Left hip wound with dry eschar centrally, surrounding erythema minimal, no drainage, no fluctuance. 12-22-23: Dx: left hip wound. Skin: Unstageable L Hip. Anticipated discharge plan is SNF when medically stable. 12-23-21: Resident #1 was seen by the wound care Registered Nurse and Plastic Surgeon for the left-hip pressure sore and recommended local wound care for now. Resident #1 was discharged from the hospital on 12/23/21 and transferred to a skilled-nursing facility for a higher level of care. Resident #1 did not return to the facility as the resident passed away in December 2022 – unknown cause of death. Resident #1’s Power of Attorney (family member) resided out of the country and was unreachable for a copy of the death certificate. [RA Ceniceros reviewed Cedar-Sinai Hospital medical records (dated 12/18/21 to 12/23/21) and Unusual Incident Report (dated 12/21/21)].

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Civil penalties could not be assessed due to the facility closure, effective 10/10/23.

Regarding Allegation #3: this investigation revealed that Resident #1 was receiving home health wound care from Care More Home Health. On 12/13/21, Witness #5 assessed and treated Resident #1's left-hip area and the resident was noted to have an "unstageable" wound. On 12/17/21, Witness #6 determined that the wound was deeper, rounder, and unstageable. Based on interviews conducted of facility staff, 1 out of 3 corroborated that they would reposition Resident #1 every two (2) hours and tried making arrangements for a wound care specialist but were unsuccessful. [A review of the facility’s “Narrative Charting” documented timeframes (every 2-3 hours) that the resident was repositioned by facility staff. A review of the Facility Staff Training Record (sign-in sheet) was conducted on the topic of "Repositioning a Resident".] On 12/11/21, Witness #5 (W5: Krystal Adams, NP of Care More Home Health) was notified by facility staff that Resident #1 had a skin breakdown on the left-hip area. On 12/13/21, Witness #5 assessed and treated Resident #1's left-hip area and noted to have an "unstageable" wound. Witness #5 ordered Home Health to treat the wound in collaboration with the Care More team and the community (facility). On 12/17/21, Witness #6 (W6: Linda Goh, RN of Accredited Home Health Care) visited Resident #1 to admit the resident and treat the wound. Witness #7 (W7: Anne Caisip, LVN of Allen Flores Consultant Group) was also present with Witness #6. It was determined that the wound was deeper, rounder, and “unstageable”. [RA Ceniceros reviewed the Unusual Incident Report (dated 12/21/21).] (Former) Administrator (A1: Stephanie Radu) was notified that it was determined that the resident needs to be sent to the ER for further evaluation. On 12/18/21, Resident #1 was transported to Cedar- Sinai Hospital. Witness #4 (Nurse Practitioner, Byung Cheol Yoo, NP) documented, per ED note, a caregiver at the assisted living noticed Resident #1’s left hip decubitus wound on 12/3/21; and, they tried to make arrangements for a wound care specialist, but were unsuccessful. Resident #1 was diagnosed with decubitus wound 4cm in diameter – unstageable. [RA Ceniceros reviewed Cedar-Sinai Hospital medical records (from 12/18/21 to 12/23/21).] Resident #1 was discharged from the hospital and transferred to a skilled-nursing facility (SNF) on 12/23/21 for a higher level of care. Witness #2 wasn't sure there was neglect on the facility's part but felt that facility staff should have communicated better with Resident #1's home health nurse regarding the resident's wound. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff did not seek timely medical attention for resident is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D).

No exit interview was conducted as the facility closed its doors; however, a copy of the Complaint Report and Appeal Rights were rendered (via USPS certified mail) due to Licensee surrendering its license on 10/10/23.

Regarding Allegation #2: this investigation revealed that when Resident #1 was admitted to Cedar-Sinai Hospital on 12/18/21, Resident #1 stated to the ED Attending Physician (Witness #1: Dr. Grant Ross, Cedar-Sinai Hospital) that staff at the facility hit the resident. Resident #1 was confused upon admission and since been stabilized, Resident #1 denied any forms of abuse to Witness #1. (RA Ceniceros observed the hospital medical report documentation, dated 12/18/21). Per Witness #1’s documentation, there is no physical evidence or concerns of Resident #1 being abused at the assisted-living facility. Interviews conducted of facility staff, 3 out of 3 corroborated that they are aware of being a mandated reporter and have not observed residents in care being abused by a facility staff member. Interviews were not conducted of residents in care as the facility closed its doors on or about 10/11/23. Interviews conducted of witnesses, 2 out of 1 corroborated that there were no concerns of facility staff abusing Resident #1. Per Witness #1 (PCP) medical report (dated 12/18/21) and Witness #3 (ISP MD) discharge summary (dated 12/23/21) documented that there were no physical evidence or concerns of resident being abused or neglected at the assisted-living facility; and, Resident #1 later denied to the MDs any forms of abuse from staff. [RA Ceniceros observed facility staff in-service training records (via sign-in sheet) on the topics of "Personal Rights" and "Mandated Reporting".]

Based on the evidence gathered, interviews conducted, and records reviewed, 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 of NEGLECT/LACK OF SUPERVISION: Staff hit a resident while in care is found to be UNSUBSTANTIATED.

No exit interview was conducted as the facility closed its doors, effective 10/10/23. A copy of the Complaint Report was rendered to the Licensee (via USPS certified mail).