VISTA MONTANA SENIOR LIVING

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. based on observations, interviews, and record review, in accordance with the California Code of Regulations, Title 22, see LIC809D—a violation concerning Personal Rights and Procedures for responding to incidents and complaints.

Official plan of correction

The POC will be: Facility is to provide all residents with the required care, supervision and services to meet their individual needs at all times. Additionally, the facility administrator is to review resident records, including physician reports, for all residents in placement and provide training to care staff to ensure they are aware of such needs for each individual by 01/05/2026. Certification that this has been completed must be sent to Antonine.Richard@dss.ca.gov

Deadline recorded: Jan 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.1....(1)To have a reasonable level of personal privacy in accommodations.... This requirement was not being met as evidenced by: Based on observations and interviews, LPA found that residents were not accorded privacy while in care.

Official plan of correction

This deficiency has already been corrected as all staff now knock on the residents' doors and ask for permission to enter.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, record review, the licensee did not comply with the section cited above in four out of ten personnel files which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Executive Director will be notifying the required staff and submit to LPA proof by email the First Aid certification by POC date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in four out of ten personnel records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Executive Director will notify the required staff and will email LPA proof of the health Screening and TB test results by POC date.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...: (1) A written report shall be submitted to the licensing agency... within 7 days of the occurrence of any of the events specified in (A) through (D)... This requirement was not met, as evidenced by: Based on record review the licensee did not ensure a written report was submitted within 7 days regarding R1's elopment from the facility. This poses a potential threat to the health, safety and personal rights of the resident in care.

Official plan of correction

The Interim-Administrator reported staff training regarding reporting requirements will be conducted and proof submitted to the Department.

Deadline recorded: Aug 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

RESIDENT PARTICIPATION IN DECISIONMAKING: Prior to, or within 2 weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident’s condition, or once every 12 months... This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents who did not have a current written record of care. The Appraisal/Needs and Services Plan for R2 was last completed on 02/27/2023. The Appraisal/Needs and Services Plan for R3 and R5 were last completed on 02/24/2023. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/14/2024 Plan of Correction Interim-Administrator reported updated appraisals will be completed and proof submitted to the Department.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

STAFF TRAINING; LEGISLATIVE FINDINGS; CONTENTS: In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff members who did not have the required training. 2 staff members, S3 & S5, did not have proof of Dementia Care training. S2, S3, & S4 did not have Restricted Healthcare training. S2, S3, S4, & S5 did not have postural support training or the complete hours for hospice care training. This poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/21/2024 Plan of Correction Interim-Administrator stated an audit of staff training will be conducted to ensure it is complete. She reported proof of training will be provided to the Department.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

EMPLOYEES ASSISTING RESIDENTS WITH SELF-ADMINISTRATION OF MEDICATION; TRAINING REQUIREMENTS: Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff members who did not have the required training. Initial medication training was not observed on file for S5. This poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/21/2024 Plan of Correction Interim-Administrator stated S5 will complete the initial training and proof of the training will be submitted to the Department.

Official classification

Type B

Official code

87609(b)(4)

Regulation authority

CCR

What the official deficiency says

ALLOWABLE HEALTH CONDITIONS AND THE USE OF HOME HEALTH AGENCIES: Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents who did not have a written agreement on file between the home health agency and the facility. This poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/14/2024 Plan of Correction Interim-Administrator stated copies of the written agreements will be obtained and kept of file for appropriate residents.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: R1 has made threats to physcially harm others, demean others by calling derogatory names and using racial slurs. This poses a potential health, safety and personal rights risk in care.

Official plan of correction

The licensee agrees to conduct a house meeting for all residents where a review of personal rights, and facility expectation will be reviewed. Proof is to be submitted to the department by 5pm on the due date indicated.

Deadline recorded: Jun 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in ...Facilities: (a) In addition to the rights listed ...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff...to meet their needs. This requirement was not met by: Based on interview and record review, the Licensee did not comply with the above regulation with one resident. LPA Colvin observed that R1 went approx. 2 months in consistent denial of bathing and allowing care for rash. Staff did not seek additional means to get resident care. This was immedaite health risk to R1.

Official plan of correction

Licensee agrees to develop a plan of action for situations such as resident self-neglect and refusal of services for when residents are self-responsible. Licensee to consult with mental health professionals regarding options such as involuntary psychiatric holds or considering possible eviction notices. Licensee to provide LPA Colvin with detailed plan, which staff shall be trained on (fLicensee to provide proof of training within 30 days) to LPA Colvin by Plan of Correction date of 11/11/22.

Deadline recorded: Nov 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80019(e)(2)

Regulation authority

CCR

What the official deficiency says

" Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 80019(f)… " This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above with S1 not being associated to the facility. This is a zero tolerance regulation and poses an immediate health, safety or personal rights risk to persons in care. A civil penalty will be assessed in the amount of $500.

Official plan of correction

POC Due Date: 05/26/2022 Plan of Correction Administrator will submit updated LIC500 for S1 to the department by POC date.

Official classification

Type A

Official code

80019(e)(2)

Regulation authority

CCR

What the official deficiency says

" Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f)… " This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above with S2 who was not associated to the facility. This is a zero tolerance regualtion and poses an immediate health, safety or personal rights risk to persons in care. Civil oenalties will be assesed in the amount of $500.

Official plan of correction

POC Due Date: 05/26/2022 Plan of Correction Administrator will submit updated LIC500 for S2 to the deparmtent by the POC date.

Official classification

Type A

Official code

80019(e)(2)

Regulation authority

CCR

What the official deficiency says

" Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 80019(f)… " This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above with S3 not being associated to the facility. This is a zero tolerance regulation and poses an immediate health, safety or personal rights risk to persons in care. Civil Penalties with be assesed in the amount of $500 for this.

Official plan of correction

POC Due Date: 05/26/2022 Plan of Correction Administrator will send the department the transfer request for S3 by POC date.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

FIRE SAFETY: All facilities shall..conformity with..regulations..State Fire.. protection of life and..against fire...This requirement is not being met as evidenced by: Based on observation, LPA noticed several locked exterior doors. This is an immediate health and safety and personal rights risk to residents in care.

Official plan of correction

Licensee agrees to adhere to guidelines of the state marshall by changing all doors so that they cannot be locked. Licensee agrees to provide a memoradum of understanding of the regulation by POC date.

Deadline recorded: Apr 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: (a) Residents... facilities..personal rights: (16) To receive.. This requirement was not met as evidenced by: Based on LPAs review of records, and interviews, Licensee did not adhere to the regulation. This presents a potential health and safety and personal rights risk to residents in care.

Official plan of correction

Administrator agrees to continue allowing Peaceful Heart Hospice to service R1. Upon record review, POC was cleared on date of visit.

Deadline recorded: Mar 7, 2022. A deadline is not proof that correction was completed.