Regarding Allegation #1: this investigation revealed that Resident #1 moved into the facility in the assisted-living unit in 2012 and in 2017 transferred to the memory care unit. Resident #1 required total care and was to be monitored every two (2) hours. Facility operated understaffed with one (1) LVN, one (1) med tech, one (1) caregiver, one (1) activity director during the day and mid shifts for (approximately) 26 memory care residents. Inadequate staffing in the memory care unit meant “cutting corners” (i.e., basic care) and ensuring the residents were not in harm’s way and kept together in a communal setting and not in their assigned rooms. Resident #1 had been unchecked by facility staff for three (3) days (according to the facility’s “Narrative Charting” for the resident). On 06/14/22, Resident #1 was found in an altered state before facility staff called 9-1-1. Upon Resident #1 being transported to the hospital, the resident appeared dehydrated with poor skin turgor and dry mucus membranes based on medical records. Resident #1 was hospitalized at Southern California Hospital Culver City (SCHCC) on 06/14/22 at 9:50 p.m. Admitting diagnosis was acute prerenal failure, renal failure, hyperchloremia, severe dehydration, high serum creatine, hypercalcemia, leukocytosis, increased lactic acid level, hypernatremia. A medical decision was made that the resident had severe dehydration, hypernatremia, hyperchloremia, altered mental status (AMS), severe malnutrition with progression, not eating leading to renal failure. Resident #1 had severe electrolyte abnormalities that would necessitate admission to the hospital with beginning correction in the emergency department. On 06/15/22, Resident #1 was transferred to Kaiser Permanente with admitting diagnosis of end-stage dementia and not eating - which led to hypernatremia and acute kidney injury. A decision was made by Witness #1 (following a conversation with the resident’s attending physician) not to proceed with

Based on the evidence gathered and interviews conducted and medical records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Facility failed to obtain immediate medical care for a 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(s) issued (ref. LIC 9099D). Civil penalty assessed.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition; including, but not limited to the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Executive Director (Jasmine Hezar).

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 PHYSICAL PLAN: Facility failed to ensure a safe and healthful environment for a resident by removing intact window blind slats is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed based on interviews conducted of facility staf (A2, S5 - S8)f, the majority corroborated that they had not received a complaint from one of the resident's family member/responsible person/power of attorney regarding missing items from a resident's room. Attempted interviews were conducted of Residents #2 - #4; however, due to their cognitive impairment, it was discontinued at the time. Resident #1 could not be interviewed as the resident passed away on 06/24/22. RA Elizabeth Ceniceros observed the Client/Resident Personal Property and Valuables (LIC 621) form and there was no documentation of the following missing items: small dinette glass table with (3) chairs, an artificial tree, a coffee table top, (2) emerald gold rings, and clothing mixed with another resident’s clothing in the drawer, and (2) rug documented as inventory.

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 PERSONAL RIGHTS: Facility failed to safeguard a resident’s personal items is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to the Executive Director/Administrator, Jasmine Hezar.