VISTA DEL LAGO MEMORY CARE

Official classification

Type A

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements... Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents

Official plan of correction

Executive Director shall install an alarm system at exit door if door is open and locked unlawfully without proper keys. Additinally a completion of proper employee retraining regarding the handling and observation of dementia care clients in care is required by the POC due date.

Deadline recorded: Apr 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, R1 was observed with a container of powdered chlorine bleach cleaner. R1 applied the cleaner to hand, face, and in their cup of water. When asked if consumed, R1 initially reported they did. The incident report documents R1 was sent to the hospital via non emergency medical transport rather than activating emergency services, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator Hill reported the facility will receive training from an outside vendor regarding regulation 87465 Incidental Medical and Dental Care by close of business on 6/18/2025. POC will be emailed to LPA by close of business on 6/20/2025.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This poses a potential health and safety risk to residents in care. Based on interviews conducted and records reviewed, the facility failed to secure a powdered cleaning solution by leaving a container unattended and accessible to R1. R1 then applied the cleaner onto their hand, face and in their cup of water. When asked if consumed, R1 initially reported they did. This poses a health and safety risk to residents in care.

Official plan of correction

Administrator Hill reported S1 was counseled regarding the incident and terminated on 2/28/2025. LPA observed the facility's Counseling/Disciplinary Notice for S1 noting their termination of employment effective 2/28/2025. Administrator Hill added the facility conducted an in-service training on 3/3/2025 and 3/13/2025 regarding safety practices for hazardous and potentially toxic substances including cleaning products. LPA reviewed (2) staff sign-in sheets for the reported trainings. POC met.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by: Based on interviews conducted, records and video footage reviewed, S1 physically and psychologically abused multiple residents on November 25, 2024 and November 29, 2024. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee reported the facility will conduct an in-service staff training regarding personal rights of all residents and generate a checklist to include documentation of a reference check for new employees. POC due to LPA by close of business by 1/10/2025. *This is an amended version of the original report

Deadline recorded: Jan 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, R1 sustained a wound that required stitches and RSD instructed facility staff to not activate emergency services and treat the wound instead. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee reported the facility will conduct an all staff in-service training regarding incidental medical care. POC to be submitted to LPA by close of business on 12/20/2024.

Deadline recorded: Dec 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.312(b)

Regulation authority

HSC

What the official deficiency says

Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:(b) Assistance with instrumental activities of daily living in the combinations which meet the needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not ensure resident needs were met for 1 out of 89 residents in care [R1] which posed a potential health and safety risk to persons in care.

Official plan of correction

Executive Director provided recent proof of training regarding caregiver job description, caregiver training checklist to include activities of daily living and observations of residents. In addition, the facility has another training scheduled for 04/23/24 and will be ongoing monthly. POC corrected.

Deadline recorded: Apr 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall... provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange...for medical and dental care appropriate to the conditions and needs of residents. This was not met by: The Licensee did not comply with the above regulation with 1 out of 1 residents. As R1 was not given their medication as prescribed on multiple occassions. This is an immedaite health, safety and personal rights risk to persons in care.

Official plan of correction

The licensee agrees to conduct a medication administration training highlighting the importance of medications being given as prescribed. Proof of POC is to be submitted to the department by 5pm on the due date indicated. The facility has an inservice scheduled 6/26/23.

Deadline recorded: Jun 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(j)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care- (j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives...and for assisting residents as needed with self-administration of medications. This requirement was not met as evidenced by: The Licensee did not ensure assistance was provided with self-administration of medications. Based on records reviewed and interviews conducted, R1 was not provided assistance with their prescription of Plaxovid as ordered. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The facility has already conducted re-training of med tech staff regarding the importance of following up with every unmarked MAR dose or those marked with an exception, notifying the doctor and responsible party if any medication is refused, and ordering refills promptly. Proof of training has been provided to LPA. This deficiency was cleared at the time of the visit.

Deadline recorded: Mar 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

Infection Control Requirements- (c) An Infection Control Plan shall be developed by the Licensee and shall be included in the Plan of Operation required by Section 87208. 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 one (1) of one (1) facility files reviewed which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/16/2022 Plan of Correction Facility has agreed to provide a written Infection Control Plan by POC due date. Facility was advised that form LIC9282 may be used to assist the facility in meeting this requirement.

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

Refund of fees paid: (c) A refund of any fees paid in advance ... covering the time after the resident’s personal property has been removed ... shall be issued ... within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on interviews and record reviews, the licensee did not issue a refund within 15 days in two of ninety residents which posed a potential personal rights risk to residents in care.

Official plan of correction

RSD agreed to provide financial and administrative staff with training on HSC Section 1569.652 and provide signed training logs and training materials. RSD will provide proof of R1's refund. RSD will submit a statement to determine R4's refund status.

Deadline recorded: Aug 31, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(b)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance: (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by: Based on observation and interviews, the Licensee did not comply with the above regulation with at least two staff (S1, S2). LPA George learned that S1 and S2 are not associated to this facility. This is an immediate safety risk to all residents in care.

Official plan of correction

Licensee agrees to complete and submit the LIC9182 by 5/12/22 in order to continue to have S1and S2 work or at the facility. Licensee to provide LPA George with proof of submitted request by 5pm on the due date indicated.

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

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: the facility staff did not have access to the resident's emergency paperwork when needed when a resident was sent out.

Official plan of correction

The licensee agrees to roll out the electronic file PCC program that will give staff access to all resident information and print wha is needed. Proof is to be submitted by 5pm on the due date indicated.

Deadline recorded: Jun 1, 2022. A deadline is not proof that correction was completed.