Complaint·July 2, 2025

The investigation revealed the following: Allegation: Resident sustained an unexplained injury while in care. It is being alleged that a resident in care had swelling and bruising around their right eye that was not there 2 days prior. On 06/18/25 at 10:00 am-11:45am LPA conducted Interviews with R2-R10, 9 of 9 residents interviewed denied the allegation above, and reported feeling safe living at the facility. On 06/18/25 and 6/27/25 LPA conducted interviews with S1-S8 regarding the allegation above, 8 of 8 staff interviewed denied the allegation above. Per 8 of 8 staff interviewed, families and Primary Care Physicians are notified of any falls or injuries a resident may experience while in care. On 06/26/25 LPA conducted a review of R1's file, LPA observed incident reports dated: 05/19/25, 06/04/25, and 06/16/25, per incident reports R1 experienced un-witnessed falls and declined medical attention. LPA confirmed incident reports dated: 05/19/25, 06/04/25, and 06/16/25 were sent and received by CCLD. During file review LPA observed documented fall risk assessments conducted on 06/04/25, 06/09/25, and 06/16/25, per fall risk assessments R1 was at high risk of falls. In addition, during file review LPA observed an order from provider dated 6/16/25 for residents to be sent to ER due to recent falls and refusal of medical attention. On 06/27/25 LPA conducted telephone interview with R1 regarding the allegation above, R1 denied the allegation above. Per R1, R1 is clumsy and has fallen quite a bit. R1 states that the facility has offered medical service after each fall, however R1 did not see it necessary as R1 is able to take care of self. R1 stated the staff at Vista Del Mar have been very kind since R1’s has been admitted. 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. Exit interview conducted, and a copy of this report was provided.