Complaint·May 16, 2025

Allegation #1: Resident (R1) sustained a fracture due to a lack of care from staff. It is alleged that Resident (R1) fell and sustained a vertebral fracture injury due to falling from R1’s wheelchair. This investigation revealed that R1 was admitted to Vista Del Mar Senior Living on 03/03/24. A record review of R1’s Physician Report (dated: 03/15/24) revealed that R1 is non-ambulatory and requires staff assistance to transfer to and from bed. On 4/22/25, staff found R1 sitting on the floor in R1’s room. Staff observed R1’s forehead was bleeding, and an abrasion under the left eye. Staff reported R1 experienced an unwitnessed fall and called 911. R1 was transported to Memorial Care Long Beach Medical Center, where an imaging test was performed. The department conducted a review of Memorial Care of Long Beach's medical records and found that the imaging test results detected R1 sustained a cervical spine fracture and soft tissue swelling. The department conducted a record review of the facility’s notes and found that R1 experienced unwitnessed falls from R1’s wheelchair in R1’s room on 03/25/24, 3/26/24, and 3/28/24. The department conducted a review of the facility notes and found that R1 did not prefer to sleep in a bed and would sleep in R1’s wheelchair. The department conducted interviews with S1-S4 and found that staff were aware that R1 would fall asleep in R1’s wheelchair, fall forward, and fall from the wheelchair. Report continued on LIC9099-C The department found no record of the facility implementing a fall risk management plan for R1. The department conducted interviews with three residents (R1-R3). 3 out of 3 expressed no issues with staff supporting their needs. During this investigation, the department found sufficient evidence to support the above-mentioned allegation(s). Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and a citation was issued (ref. LIC 9099D). An immediate civil penalty of $500 is warranted in accordance with the California Health and Safety Code. See LIC421IM. An exit interview was conducted. A copy of this report, along with the appeal rights were provided to the Executive Director Suzette Johnson. Allegation #2 : Staff refused to accept the resident back at the facility following a hospital visit. It has been alleged that staff refused to accept a resident back at the facility following a hospital visit, despite the resident being cleared for return. On April 22, 2024, the resident was admitted to Memorial Care Long Beach Medical Center (MCLBMC) after experiencing an unwitnessed fall from a wheelchair. On April 30, 2024, between 10:00 AM and 12:00 PM, the department interviewed Staff Member 1 (S1), who denied the allegation. S1 stated that on April 23, 2024, R1 arrived in the office on a gurney without a cervical collar (C-collar), prompting S1 to send the resident back to the hospital. S1 indicated that she had spoken with the emergency room physician at MCLBMC regarding the resident's condition. The physician explained that the resident had two cervical spine fractures and required a C-collar and further treatment; however, the R1 refused care. S1 informed the physician that the resident needed to be placed in a skilled nursing facility before returning to the assisted living facility, as the facility could not provide the necessary level of care. The physician agreed with this plan and consented to find an alternative placement. S1 also noted that R1 was not cooperating with the hospital staff, resulting in the hospital discharging R1. Report continued on LIC9099-C On 04/30/2024, the department interviewed four staff members (S1-S4), 4 out of 4 denied the allegation and stated that R1 was not refused readmission to the facility, the facility wanted R1 to go to skilled nursing for more treatment, in then come back to the facility after treatment. On 05/16/2025, the department interviewed 5 Residents (R1-R5) 5 out of 5 denied the allegation. The department reviewed medical records from Memorial Care Long Beach Medical Center dated 04/22/24 to 04/24/24, indicated that R1 refused multiple attempts for an MRI and refused to wear a C-collar for R1's neck fractures, and demanded to be discharged from the hospital. On 04/23/24 at 11:07 am, the hospital called the facility and spoke to S1 and stated that R1 does not want any further care and does not want to wear a C-collar; therefore, R1 will be discharged back to the facility. Based on the records reviewed and interviews conducted, there is insufficient evidence to support the allegation that the staff refused to accept the resident back at the facility following a hospital visit. 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 is Unsubstantiated. No citations were issued. An exit interview was conducted, and a copy of this report was provided to the Executive Director Suzette Johnson.