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Inspection visit

complaint

VISTAS AT OXNARD SENIOR LIVING,THELicense 5658024251 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

LPA Dulek spoke with relevant parties, including R1's family members, complainant, R1, R2, as well as facility staff and Administrator. Additionally, LPA reviewed a staff roster provided by the facility. LPA then determined the individual named by the complainant was not currently nor had the individual ever been employed by the facility. The individual in question was employed by R1's family as a private duty aide for R1. This individual never worked for the facility, and therefore does not qualify as facility staff. Therefore, based on interview and record review, the allegations that " Staff isolating residents from authorized representatives while in care," "Staff emotionally abuses residents while in care," "Staff creates fictitious medical reasons for residents without authorization," "Staff mishandles resident while in care," and "Staff retaliates against residents while in care" are deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened and/or is without a reasonable basis. Exit interview conducted. A copy of the report was provided via email. During the subsequent complaint visit conducted on 05/27/2020, LPA Dulek conducted FaceTime video call to conduct a medication audit for Resident #1 (R1) and review of Resident #2 (R2)’s medication at 3:43PM. LPA observed that although Staff #1 (S1) stated that R1’s routine medication Atropine was discontinued as of Friday 5/22/2020, documentation on the MAR reflects the medication was administered at 5:00PM on 5/26/2020. S1 indicated this is an error on the electronic MAR, but there is handwritten documentation of the error. Handwritten documentation was unable to be provided to the LPA upon request. Additionally, R1’s Senna-Docusate was not initialed as administered on 5/13/2020 and 5/16/2020. Further review of the MAR pass notes indicates that on 5/14, 5/15, 5/18, 5/19, 5/20, and 5/21/2020 “waiting for med delivery.” Staff #1 (S1) indicated that the new pack of R1’s Senna Docusate was started on 5/20/2020 and LPA observed 21 pills remaining in the bubble pack. LPA Dulek requested a copy of the physician’s orders to discontinue R1’s daily Atropine and a copy of the medication destruction record for the Atropine. The LPA also requested a copy of the documentation indicating the electronic MAR error for R1’s Atropine on 5/26/2020. Administrator agreed to email all requested documentation by the end of business on 5/27/2020. Documentation was later discussed with the facility Executive Director, but no additional documentation was received. Therefore, based on record review and observation, the allegation that "Staff mishandling resident's medication" is deemed SUBSTANTIATED at this time. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D) Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were issued via email.

Citations

6 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87217(b)Type B

    87217 Safeguards for Resident Cash, Personal Property, and Valuables (b)Every facility shall take appropriate measures to safeguard residents'...personal property... which have been entrusted to the licensee or facility staff...articles or cash resources.This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that had been left by a skilled nursing professional, as well as a remote left by family, which posed a potential health and safety risk to residents in care.

  • 87303(i)(1)(A)Type B

    87303 Maintenance and Operation. (i)Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.This requirement is not met as evidenced by: Based on interviews and record review, R1's call button was not working on 8/24/2020. In addition, other call button alerts went unresponded for other residents during the period of August 2020 - September 2020, which poses a potential health and safety risk to residents in care.

  • 87465(d)(1)Type A

    87465 Incidental Medical and Dental Care (d) If the resident is unable to determine...PRN medication and is unable to communicate his/her symptoms clearly...shall be permitted to assist the resident with self-administration provided (1) Facilty staff...dose of medication.This requirement is not met as evidenced by: Based on interviews and records review, R1 was in obvious pain, however staff failed to contact hospice or a physician for authorization to administer any PRN pain medication 8/21/20-8/23/20, which posed an immediate health and safety risk to residents in care.

  • 87466Type A

    87466 Observation of the resident. The licensee shall ensure that residents are regularly observed for changes...appropriate supervision is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented...This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to observe, document and communicate R1's pressure injuries/wounds which contributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents in care.

  • 87465(a)(4)Type A

    87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on medication review, the facility did not assist R1 with their medications as prescribed, as medications were waiting for refill and unable to be administered, as well as discontinued medication was marked as administered, which poses an immediate health and safety risk for residents in care.

  • 1569.312(a)Type A

    1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as the licensee failed to provide adequate care and supervision to R1 which contributed to R1 sustaining pressure injuries and R1's clothing observed with dried fecal matter, which posed an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the March 25, 2022 inspection of VISTAS AT OXNARD SENIOR LIVING,THE?

This was a complaint inspection of VISTAS AT OXNARD SENIOR LIVING,THE on March 25, 2022. 1 citation were issued: 1 Type A (serious).

Were any citations issued to VISTAS AT OXNARD SENIOR LIVING,THE on March 25, 2022?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87217 Safeguards for Resident Cash, Personal Property, and Valuables (b)Every facility shall take appropriate measures t..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.