Complaint Investigation Report, 01/13/2022 — Village at Sherman Oaks, the, Sherman Oaks CA

Between 10:00 a.m. and 12:00 p.m., LPA Balisi conducted a physical plant tour and obtained copies of pertinent documents relevant to the investigation. On 09/03/2021, from 12:45 p.m. to 1:30 p.m., LPA Balisi conducted a subsequent complaint visit to review and obtain copies of additional documents relevant to the investigation.

Investigator Real conducted interviews with the Assisted Living Director on 06/15/2021; with R1’s private caregiver on 07/16/2021; with Hospice employees on 08/04/2021 and 08/13/2021; with facility employees on 08/17/2021 and 08/19/2021; with former facility employees on 09/07/2021, 09/10/2021, and 09/28/2021; and with residents on 09/07/2021. On 12/13/2021, Investigator Real conducted additional interviews with two (2) family members of R1.

Investigator Real reviewed the facility progress notes for R1. The progress note dated 04/05/2021 at 7:28 a.m. indicated R1 had a skin tear on left hand. R1’s hospice agency was notified along with R1’s family member. The progress note dated 04/16/2021 at 10:45 a.m. indicated R1’s private caregiver reported to a facility staff #1 (S1) that R1 had a bloody lip. S1 checked R1’s lip and there was no trauma to the area. R1’s lips were dry and chapped with a bead sized amount of blood. S1 cleaned the area and applied lotion. Neither S1 nor the private caregiver noted any other areas of concern on R1’s face or head at that time. A short time later, R1’s private caregiver and a hospice employee showered R1 and observed a bump on R1’s forehead. The skin at the center of the bump was open and it appeared to be an abrasion. S1 reported changing R1 earlier and did not see any bumps on R1’s head

Investigator Real reviewed Oakhurst Hospice agency records for R1. The hospice notes for 05/05/2021 indicated that the hospice nurse observed R1 had a skin tear on the back of left hand that had been bandaged. The notes for 04/16/2021 indicated R1 had a small abrasion on forehead as well on one on upper lip and the cause was unknown. There were no abuse or neglect concerns noted in the hospice records.