Vista Del Mar Senior Living

Allegation investigated: Resident sustained serious injury while in care resulting in hospitalization. Resident sustained many unwitnessed falls while in care. Resident has mulitple unexplained scab wounds.

On 08/18/2021 around 02:00 pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. Today’s complaint investigation was conducted face to face with Administrator James Bender. The Investigation consisted of the following: LPA Calderon conducted a tour of the physical plant. LPA obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Dermatology medical records, Physicians Report and Medication list) On 02/08/2021 LPA Calderon submitted facility records and client records and initial investigation report to the Department Investigation Branch (IB). On 02/11/2021 IB Investigator Lorraine Patterson conducted record reviews on the facility records, client records and initial investigation report submitted by LPA. On 05/11/2021 IB interviewed (W1). On 05/07/2021 IB interviewed (C3), On 5/17/2021 IB Investigator interviewed (S2), On 5/17/2021 IB Investigator interviewed (S2) and on 5/17/2021 IB investigator Administrator(C3). Unsubstantiated The investigation revealed the following: Regarding the allegation “Resident sustained serious injury while in care resulting in hospitalization. All the parties IB interviewed W1, C1-C3, S1-S3 on 05/17/2021 denied any abuse and stated that R1’s injury was unwitnessed. IB was not able to interview R1 due to R1’s dementia. IB reviewed all hospital medical records did not report suspected neglect or abuse and could find any fault with facility. Regarding the allegation: “Resident sustained many unwitnessed falls while in care”. All the parties IB interviewed on 05/17/2021, 5/17/2021, 5/17/2021 denied any abuse and stated that R1 has sustained unwitnessed falls. IB was not able to interview R1 due to R1’s dementia. IB reviewed records and interviews revealed that R1 needed reminders to call for help with transfers and R1 often tried to transfer alone and had unwitnessed falls. Safety plans and interventions such as physical therapy, bed rails, fall pad and alarm pendant, increase monitoring was agreed on with R1 family to aid in fall prevention. Based on the inform ion obtained and records review R1 has had multiple falls but the facility, family and doctor have fall risk plans in place to prevent falls. Regarding the allegation: “Resident has multiple unexplained scab wounds”. All the parties IB interviewed on 05/17/2021, 5/17/2021, 5/17/2021 denied any abuse and stated that R1’s injury was unwitnessed. IB was not able to interview R1 due to R1’s dementia. IB reviewed records and interviews revealed R1 was ambulated with wheelchair and would sustain accidental bumps, bruised and skin tears from hitting the wheelchair. IB reviewed all medical records from the facility and hospital and could not find evidence of neglect from the facility. 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. An exit interview was conducted with Administrator James Bender, and a hard copy was provided.the state’s words, verbatim · CDSS document, Aug 19, 2021 · control 11-AS-20210209153410

Allegation investigated: Lack of supervision resulting in resident being physically assaulted by another resident in care. Facility did not seek medical attention in a timely manner.

On 07/29/2021 around 10:00 am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Brad DeHaan, Administrator and the purpose of the visit was explained. The Investigation consisted of the following: On 07/23/2021 LPA Calderon interviewed witness for the complaint. On 07/23/2021 LPA Calderon interviewed Administrator Brad DeHaan and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Resident 1 &2, Physicians Report, copy of Torrance Memorial Hospital Notes, SIR report on incident and viewed facility video or altercation. On 07/26/2021 LPA Calderon interviewed staff S1 regarding complaint and on 07/26/2021 LPA Calderon interviewed R1-R4 for complaint. On 07/27/2021 LPA Calderon interviewed S2-S3 for complaint. The investigation revealed the following: Unsubstantiated Allegation: Facility did not seek medical attention in a timely manner. It is alleged that Facility did not seek medical attention in a timely manner. On 07/23/2021 LPA Calderon interviewed witness for the complaint and confirmed R1 had cuts and bruises on his face. Witness states that another resident attacked resident and video from facility clearly shows resident 2 attacking resident 1. Witness took resident 1 to the hospital for evaluation. Witness states that the facility did not take incident seriously and told witness that there was nothing wrong with resident. On 07/26/2021 LPA Calderon interviewed S1 who confirms the video of the fight between resident 1 and resident 2. S1 states that resident 1 attacked resident 2 due to resident 2 sitting on a sofa and words were exchanged and punches were thrown. S1 states that neither resident was injured, but a SIR report was taken, and confirmed both men stated that they were not injured from the altercation. On 07/26/2021 LPA Calderon interviewed R1-R4, resident 1 and 2 confirm the other resident started the fight for unknown reason, and that neither one has ever had any issues with the other one they are not clear what started the fight. Both resident 1 and 2 confirm no injuries and the police never spoke to them. Residents 3 and 4 also did not know what started the fight, but that resident 1 punched first and neither one was injured. On 07/27/2021 LPA Calderon interviewed S2-S3 and all confirm that resident 1 started the fight for unknown reason. Both staff members confirmed no injuries to either men and the fight was broken up by staff. On 07/27/2021 LPA Calderon received and reviewed: Physician's report which indicated R1 and R2 primary diagnosis is dementia. Reviewed Torrance Memorial Hospital reported dated 7/23/2021, hospital report does not support resident 1 was injured from the altercation with resident 2 but did have a heart issue not associated with the incident. Reviewed SIR report which does support staff breaking up the fight when they were aware of the issue between both men. Allegation: Lack of supervision resulting in resident being physically assaulted by another resident in care. It is alleged that Lack of supervision resulting in resident being physically assaulted by another resident in care. On 07/23/2021 LPA Calderon interviewed witness for the complaint and confirmed R1 had cuts and bruises on his face. Witness states that another resident attacked resident and video from facility clearly shows resident 2 attacking resident 1. Witness took resident 1 to the hospital for evaluation. Witness states that the facility did not take incident seriously and told witness that there was nothing wrong with resident. On 07/26/2021 LPA Calderon interviewed S1 who confirms the video of the fight between resident 1 and resident 2. S1 states that resident 1 attacked resident 2 due to resident 2 sitting on a sofa and words were exchanged and punches were thrown. S1 states that neither resident was injured, but a SIR report was taken, and the police were called. S1 states police would not take a report due to both residents having dementia. On 07/26/2021 LPA Calderon interviewed R1-R4, resident 1 and 2 confirm the other resident started the fight for unknown reason, and that neither one has ever had any issues with the other one they are not clear what started the fight. Both resident 1 and 2 confirm no injuries and the police never spoke to them. Residents 3 and 4 also did not know what started the fight, but that resident 1 punched first and neither one was injured. On 07/27/2021 LPA Calderon interviewed S2-S3 and all confirm that resident 1 started the fight for unknown reason. Both staff members confirmed no injuries to either men and the fight was broken up by staff. On 07/27/2021 LPA Calderon received and reviewed: Physician's report which indicated R1 and R2 primary diagnosis is dementia. Reviewed Torrance Memorial Hospital reported dated 7/23/2021, hospital report does not support resident 1 was injured from the altercation with resident 2 but did have a heart issue not associated with the incident. Reviewed SIR report which does support staff breaking up the fight when they were aware of the issue between both men. 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. An exit interview was conducted with Administrator Brad DeHaan, and a hard copy was provided. On 07/29/2021 around 12:00 pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Brad DeHaan, Administrator and the purpose of the visit was explained.the state’s words, verbatim · CDSS document, Jul 29, 2021 · control 11-AS-20210722163038

Allegation investigated: Resident wasn’t provided medical care in a timely manner

On 07/26/2021 around 10:00 am Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA Calderon met with Administrator Brad DeHaan, Administrator and the purpose of the visit was explained. The Investigation consisted of the following: On 07/13/2021 LPA Calderon interviewed witness for the complaint. On 07/22/2021 LPA Calderon interviewed Administrator Brad DeHaan and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Physicians Report and pest control documentation for the facility. On 07/22/2021 LPA Calderon interviewed staff S1-S6 regarding complaint and on 07/22/2021 LPA Calderon interviewed R1-R3 for complaint. On 07/23/2021 LPA Calderon interviewed facility doctor for complaint. The investigation revealed the following: Unsubstantiated Allegation: Resident wasn’t provided medical care in a timely manner It is alleged that Resident wasn’t provided medical care in a timely manner. On 07/13/2021 LPA Calderon interviewed witness for the complaint and confirmed R1 had an rash on the chest area and believes R1 has scabies, and witness has taken R1 to see a dermatologist and will have test results within 2 weeks. On 07/22/2021 LPA Calderon interviewed S1 who confirms R1 does have a rash on the chest area and when they were made aware of the rash by his caregivers, they treated the rash with ointment for rash and scabies. S1 confirms this was done quickly and they informed R1 family by phone. On 07/22/2021 LPA Calderon interviewed S2-S6 and all confirm that medical care was given to R1 on time and when the rash first showed up on R1 chest. On 07/22/2021 LPA Calderon interviewed R1-R3 all have some cognitive issues/dementia and they were unable to answer LPAs questions fully. All were able to communicate they are happy living in the facility. On 07/23/2021 LPA Calderon received and reviewed facility paperwork: Physician's report which indicated R1 primary diagnosis is dementia. Cleaning schedule 2021, extensive cleaning schedule for facility, Reviewed Orkin paperwork, service 7/22/2021 inspected for bugs none were found, treated new room 290 to confirm no bugs and no scabies found. On 07/23/2021 interviewed facility doctor and confirmed R1 had a rash, unclear at this time if scabies or not, but R1 was treated when rash was first noticed by caregivers. 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. An exit interview was conducted with Administrator Brad DeHaan, and a hard copy was provided.the state’s words, verbatim · CDSS document, Jul 26, 2021 · control 11-AS-20210713143552

Allegation investigated: Licensee did not bathe resident\ Licensee did not groom resident

On 05/24/2021 around 1pm Licensing Program Analyst (LPA) Jose Calderon initiated a complaint investigation to deliver the investigation findings for the allegation listed above. LPA met with Brad DeHaan, Administrator and the purpose of the visit was explained. The Investigation consisted of the following: On 05/18/2021 LPA Calderon interviewed Administrator Brad DeHaan and conducted a tour of the physical plant. LPA Calderon obtained copies of Staff and Resident rosters, Resident #1’s record (Needs and Service Plan, Pre-Placement Appraisal, MARS (3 months), Dermatology medical records, Physicians Report and Medication list) and housekeepers training documentation and cleaning procedures. On 05/18/2021 LPA Calderon interviewed staff S2-S8 regarding complaint and on 05/18/2021 LPA Calderon interviewed R1-R10 for complaint. The investigation revealed the following: Unsubstantiated Allegation: Licensee did not bathe resident It is alleged that R1 family pays extra money for R1 to be given a shower 2 or 3 times a week, and that is not being done since every time resident is visited, R1 is dirty and wearing dirty clothes. It is also alleged R1 has scabies and that she is paying for cleaning services. On 04/05/2021 LPA Calderon attempted to interview R1 but was unsuccessful as R1 has dementia and was unable to answer questions. On 04/05/2021 LPA Calderon interviewed R2-R10, 9 out of 10 residents stated they have no issues with showering, some get assistance from staff, most can shower on their own. All residents deny the presence of scabies, all their rooms are cleaned weekly and service is good. On 04/05/2021 LPA Calderon interviewed S1-S5 deny scabies in the facility and stated they have schedule for showering and that there are no issues reported. On 04/09/2021 LPA Calderon received and reviewed facility paperwork: Physician's report which indicated R1 cannot self-bath. Clean schedule 2021, extensive cleaning schedule for facility, Reviewed Orkin paperwork, service 1/11/2021 treated rooms 132, 259, 271,303 no scabies found. On 2/1/2021 treated facility and no bugs, scabies found, 3/1/2021 treated rooms 126138, 271,322 no bugs or scabies found. 3/21/2021 doctors’ script for R1, appears to be infect bite. reviewed MAR, extensive information notes no issues noted. Allegation: Licensee did not groom resident It is alleged that R1 family pays extra money for R1 to be given a shower 2 or 3 times a week, and that is not being done since every time resident is visited, R1 is dirty and wearing dirty clothes. It is also alleged R1 has scabies and that she is paying for cleaning services. On 04/05/2021 LPA Calderon attempted to interview R1 but was unsuccessful as R1 has dementia and was unable to answer questions. On 04/05/2021 LPA Calderon interviewed R2-R10, 9 out of 10 residents stated they have no issues with showering, some get assistance from staff, most can shower on their own. All residents deny the presence of scabies, all their rooms are cleaned weekly and service is good. On 04/05/2021 LPA Calderon interviewed S1-S5 deny scabies in the facility and stated they have schedule for showering and that there are no issues reported. On 04/09/2021 LPA Calderon received and reviewed facility paperwork: Physician's report which indicated R1 cannot self-bath. Clean schedule 2021, extensive cleaning schedule for facility, Reviewed Orkin paperwork, service 1/11/2021 treated rooms 132, 259, 271,303 no scabies found. On 2/1/2021 treated facility and no bugs, scabies found, 3/1/2021 treated rooms 126138, 271,322 no bugs or scabies found. 3/21/2021 doctors’ script for R1, appears to be infect bite. reviewed MAR, extensive information notes no issues noted. 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 Brad DeHann, and a hard copy was provided.the state’s words, verbatim · CDSS document, May 28, 2021 · control 11-AS-20210323090543