The investigation revealed the following: Allegation: Facility is in disrepair

The allegation alleges the elevator at the facility is not operational. During record review, LPA received and reviewed a service contract for a new company, Liftech Elevator Services, INC., (Dated 01/27/2025, 03/10/2026). During the visit, LPA observed the lift to the second floor was not operating. LPA observed activities being provided on the first and second floor. Additionally, LPA observed staff taking trays of food up to the second floor for lunch.

During interviews with Staff S1, S3-S4, were asked if the wheelchair lift is working properly, three (3) out of three (3) stated the lift has not been working since they returned from the evacuation. Additionally, S1, S3-S4, were asked how residents on the second floor are accommodated while the life was not operational, three (3) out of three (3) stated additional activities are provided on the second floor, and meals are taken to the residents on the second floor. During the course of the investigation, LPA was able to find evidence to support the allegation.

Based on observations, records reviewed and interviews, the preponderance of evidence standard has been met, therefore the above allegation Facility is in disrepair is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

Deficiencies were issued and plans of corrections were discussed on LIC9099D.

Note: *Citations that are not cleared by the POC due date of 04/03/2026 will have a $100 fine assessed for each day the citation is not cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared.

An exit interview was conducted with Muriel Cabacungan, Assistant Administrator, and a hard copy of this Complaint Investigation Report was provided.

The investigation revealed the following: Allegation: Resident sustained unexplained fracture resulting in hospitalization.

The allegation alleges a resident was experiencing pain and when transferred to the hospital was diagnosed with a hip fracture. On 01/08/2025 the facility received orders from Los Angeles County officials to immediately evacuate due to Pacific Palisades fires. On 01/09/2025 R1 was picked up by family to stay with until the evacuation order was lifted. During interviews with Staff S1 and S2, stated R1 was not experiencing unusual pain prior to leaving the facility. During an interview with W1 stated when R1 was residing with them, R1 would scream and complain when attempting to use the restroom. Additionally, W1 stated R1 did not experience a fall while staying with them. On 01/15/2025, R1 returned to the facility and was assisted to their room. On 01/16/2025, staff S1 and S2 stated R1 would complain of pain when asked to move. Staff notified R1’s family and Witness W4, who came to the facility. R1 was transferred to Kaiser Permanente Medical Center to get medically evaluated.

The medical records from Kaiser Permanente Medical center (01/17/2025) confirmed R1 was diagnosed with a right intertrochanteric femur fracture and right hip osteoporotic fracture. It was also noted R1 has a history of the following conditions: Osteoarthritis, spinal stenosis, moderately advanced degenerative changes of the lower lumbar spine and facets, with central canal stenosis at multiple levels, most prominent at L2-3 and L4-5, Neural foraminal narrowing predominately at L4 prominent at L5 and a previous left femur trochanteric hip fracture that was sustained back in 2023.

Based on interviews conducted and records review, there is not enough evidence to place where and when R1 sustained a fall that would have caused the fracture. There is no evidence to support that the fall occurred at the facility.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Resident sustained unexplained fracture resulting in hospitalization. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated

Report Continued On LIC9099-C

The allegation alleges that a resident has experienced multiple falls due to lack of supervision.

During the facility inspection, LPA observed sensors on R1’s floor in their room that notify staff when R1 attempts to or gets up. LPA observed a sensor pad on R1’s bed that notifies staff if R1 gets up.

During record review, LPA received and reviewed Unusual Incident /Injury Reports for R1 dated 02/28/2024, 11/30/2024 and 01/02/2025, that report R1 was found on the floor in their room. In the Unusual Incident Report dated 01/02/2025, stated R1 was found on the floor, staff immediately assisted and checked for any visible injuries. Vitals were checked and were stable and there were no complaints of pain. Medical care was rendered immediately, and proper notifications were made. LPA received and reviewed R1’s Kaiser Permanente discharge paperwork dated 01/27/2025, that lists current medications for R1 is taking. Upon conducting research of the medication, LPA observed four (4) out of four (4) of the Continue taking medications have a side effect that may cause dizziness, lightheadedness, or fainting when getting up from lying or sitting position. One (1) out of four (4) medications may cause an increased risk of bone fracture of the hip, wrist, and spine, more likely to occur if over the age of 50. One (1) out of the four (4) may cause trouble with controlling body movements, which may lead to fall and fractures.

During interviews with Staff S1-S4, stated R1 is considered a high risk for falls and precautions are taken such as rounds are conducted every 30 minutes and sensors have been placed in R1’s room to alert staff if R1 gets up unassisted. During interviews with Witness W4, who is a Registered Nurse and has been working with R1, denied witnessing any type of neglect/ lack of care on behalf of the facility staff.

During interviews with Resident’s R2 and R3, two (2) out of two (2) stated staff are constantly checking on residents to see if they need anything and assistance is provided immediately. Additionally, Resident’s R2 and R3 stated they have not witnessed any type of neglect or lack of care and do not have any issues or concerns regarding the level of care provided by the facility.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Resident sustained multiple falls due to lack of supervision. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

No citations were issued.

An exit interview was conducted with Muriel Cabacungan, Assistant Administrator, and a hard copy of this Complaint Investigation Report was provided.