Complaint·August 19, 2021

The investigation revealed the following: Allegation: Resident sustained multiple pressure injuries while in care. IB investigator reviewed R1 medical records and conducted interviews with witnesses and facility staff. Review of Hospital records and photographs document a sacral area and a perirectal area wound. However, there is no information that these wounds were formally staged. The first charting of the sacral area wound was not until R1 had been hospitalized for approximately 34 hours. Information obtained from Witness #1 (W1) supports the possibility that the wound could have developed in the hospital, not necessarily while in the care of Vista Del Mar. Review of R1 facility record does not document pressure injuries or wounds. The Administrator and facility staff were interviewed and denied R1 having multiple pressure injuries. Allegation: Resident sustained multiple falls while in care. IB Investigator interviewed W1 to obtain professional opinion is that R1 did sustain multiple witnessed falls is June and July which were not reported by the facility but did not see any evidence there were multiple unreported falls suffered by R1 . LPA Calderon interviewed S1-S4 and all confirm that R1 did have falls due to age, not waiting for staff while moving from wheelchair to bed. According to records reviewed R1 required prompts to not move out of wheelchair or bed with out assistance due to R1 dementia. The facility conducted a fall risk assessment in conjunction with R1 family and the falls were being addressed. Allegation: Staff did not give resident medication as prescribed. It is alleged staff did not give resident medication as prescribed. LPA Calderon interviewed S1-S4 all confirm that R1 medication was given correctly and there was no mistake with R1 MAR. LPA Calderon interviewed R2-R11 and all confirm no issues with medication and staff does a great job. LPA Calderon reviewed resident medications and Medication Administration Record and did not observe any discrepancies. Allegation: Resident was severely dehydrated. IB review of records revealed the facility documented their attempts to provide R1 fluids, although her oral intake abilities were diminishing as her dementia progressed. She was also on a diuretic medication. W1 stated that R1 was most likely dehydrated when she got to the hospital, but it was not a result of staff neglect at Vista Del Mar. The facility staff and Administrator denied neglect and stated R1 was provided fluids but was difficult for R1 to intake due to decline in health. Allegation: Staff did not ensure resident was fed. LPA Calderon interviewed S1-S4 and all confirm resident was given food, but R1 sometimes refused to eat. LPA Calderon interviewed R2-R11 and all residents confirm3 meals a day and no issues with food. Review of records revealed R1 was declining and often refused food. Allegation: Staff did not notify authorized representative of resident's change of health. LPA Calderon interviewed S1-S4 and all confirm communication with POA for R1 and any change of health was advised in writing. LPA Calderon interviewed R2-R11 all residents confirm that their families are given updated regarding their change in health. Allegation: Staff did not safeguard resident's personal belongings. LPA Calderon interviewed S1-S4 all confirm that R1 personal items were safe and no one stole the belongings. LPA Calderon interviewed R2-R11 and all confirm that no one has ever stole any of their personal items. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. A telephonic exit interview was conducted with Administrator James Bender, and a hard copy was provided face to face for records.