Complaint·May 1, 2023

Regarding the allegation #1: Resident sustained pressure ulcers while in care It was alleged that the Resident (R1) was diagnosed with stage IV pressure injuries on the left and right buttocks while living at the facility. On 6/25/2020 and 9/3/2020, investigator conducted interviews with administrator and staff members S1-S5 regarding R1’s pressure injuries. On 6/25/2020, S1-S5 stated resident was placed on incontinent care and was found with 2 small red sores on the lower left and right buttocks. Investigator reviewed the records and notes instructed staff to change R1 every 2 hours. On 9/3/2020, interview conducted with witness (W1) confirmed R1 to wear adult diapers on 6/25/2020. On 10/13/2020, Investigator conducted an interview with R1, and resident was unable to recall any details. Interviews conducted with S1-S5, confirmed with the Investigator R1 diapers was changed every 2 hours. Kaiser Medical records revealed on 6/27/2020, R1 had a stage 2 pressure injuries ulcer on the bilateral gluteus. On 7/9/2020 Kaiser noted a stage 3 pressure injuries on the left and right buttocks. Based on interviews and records review, R1 did not sustain a stage 3 or 4 pressure injuries while living at the facility. The above allegation is found to be unsubstantiated. Regarding Allegation: Staff did not change residents soiled diaper in a timely manner It was alleged that resident was sitting in diapers for an extended period. On 10/5/2020, LPA conducted interviews with Residents (R1-R6). During interviews conducted, 6 residents stated they have no concerns with their diapers being change. Residents stated staff will change them every 2-3 hours and will call staff if needed to be change earlier and staff will assist. LPA conducted interviews with the Brad Dehann- Administrator, Sidonia Cordis- Resident Care Director and staff members S1-S7 regarding the above allegation. Administrator, Resident Care Director and S1-S7, stated residents that are incontinent are change every 2-3 hours. LPA reviewed R1’s Changing Log and dates that stated R1 was changed every 2 hours and Regarding Allegation: Unlawful eviction It was alleged that resident was evicted unlawful. Interviews conducted with the Administrator, Resident Care Director and residents S1-S7. On 10/5/2020 Administrator stated Resident Care Director stated R1 had went to the hospital on 6/27/2020. Administrator and Resident Care Director stated resident was able to come back to the facility once R was released from the hospital. R1 was unable to return to facility due to needing higher level of care. Residents Interviews conducted with S1-S7, did not hear of any unlawful eviction with any residents. LPA reviewed records and R1 was in the hospital and transferred to a skill nursing facility on 7/15/23. Resident still had belongings in the facility with the anticipation of returning but resident was unable to return to the facility. Resident was not evicted from the facility. Continuation LIC 9099 is on the next page. Regarding the allegation #2: Staff mismanaging residents’ medication. It was alleged that staff wanted to increase the resident’s medication. On 6/22/2020, medical records revealed that doctor had order an increase in R1’s medication Seroquel (Quetiapine) from 25mg to 1.5 tablets 3 times a day and then reevaluate. Medication order was schedule to start 6/22/20-7/15/20. On 6/25/2020 and 9/23/2020, Investigator conducted interviews with Administrator and Staff members, S1-S5. Staff members stated R1’s behavior was aggressive and was hard to monitor resident in the facility. Staff stated R1 would leave isolation room instead of quarantine and would wander the facility and jeopardize other residents. Staff stated R1 would be redirected but will be combative. Staff stated was aware of medication increase and was directed to check resident every 2 hours. Interviews and documents revealed the following: On 6/16/2020, records showed that, R1 tested positive for Covid-19. On 6/16/2020, a meeting was held by telephone with administrator and witnesses (W1 and W2) to discuss R1’s care plan, due to behavior changes. During meeting conversation administrator, W1 and W2 have all agreed to increase R1’s medication. On 6/16/2020, medical record notes from physician were documented that W2 stated R1 is being combative and having a hard time in isolation. Administrator, W1 and W2, have agreed to increase medication. On 6/21/2020, it was noted that R1 would leave the isolation room and wander. On 6/21/20, incident took place that R1 left the isolation room through a sliding glass door on the balcony. R1 entered a neighboring resident's room and had wandered into the hallway. On 6/22/2020, staff was notified of changes to increase medication. LPA reviewed R1 medication records for the month of June 2020. Investigation revealed that on 6/25/20-6/26/20 the medication Quetiapine was on hold for 2 days and not given to R1. LPA did not see any directives to hold medication from R1. Based on records review and interviews, it was determined that R1’s medication was mismanaged, and the above allegation is substantiated. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Administrator, and a hard copy was provided. Facility did not provide resident a refund It was alleged facility did not provide resident a refund. LPA conducted interview with (W1) stated the facility was to provide a refund due to R1 not living at the facility. Interview conducted with Administrator stated spoke to (W2) requested to have resident discharge from Vista Del Mar and not returning. LPA reviewed records and R1 belonging was moved out on 8/2/2020 and on 8/07/2020, refund was process. Exit interview conducted a copy of the report was provided.