Mission Villa Senior Living

Care and supervision as defined by statute and rules

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on interviews and records reviewed, R1 was a fall risk, required two-persons transfer, escort assistance and close supervision, however despite staff being aware, facility staff did not assist a Vitas Healthcare hospice aide on 12/2/24, leaving the hospice aide alone with R1. In addition, R1 fell on 12/2/24, and based on medical records, R1 had a rotation to his/her left leg and a deformity to his/her left hip, an acute, mildly displaced fracture of the left iliac wing extending to the acetabulum with associated widening of the left femoroacetabular joint space; an acute, comminuted, mildly displaced fracture of the left inferior pubic ramus, and a mild presacral edema without a definite sacral fracture. A hematoma involving the left iliacus and left pelvic sidewall was also present. This poses an immediate health and safety risk to residents in care.

87463 Reappraisals: (f) The licensee shall immediately, or as soon as reasonably possible, communicate with the resident and, if applicable, the resident's representative, about any significant change in condition and the recommendation...This regulation is not met as evidenced by: Based on R1's charting notes reviewed, although the facility did reach out to R1's responsible party on 12/2/24 after the fall and later in the evening, the facility failed to communicate with R1's responsible party on 12/3/24 when R1 was constantly yelling for help and the facility documented a change in R1's condition which poses an immediate health and safety risk to residents in care.

Arrange appropriate medical and dental care

87465 Incidental Medical and Dental Care: (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... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement is not me as evidenced by: Based on documentation reviewed, R1 had a fall on 12/2/24 at 7am and was treated by the hospice nurse. However, it was noted that later in the evening of 12/2/24, R1 was constantly yelling for help. Based on staff interviews, on 12/3/2024, R1 was complaining of pain when changing R1’s diaper and reported it to the med-tech and constantly yelling for help. It was not until the following evening on 12/4/24 that R1 was sent out to the hospital after staff noted R1 complaining of left hip pain. Staff interviewed were unable to state why R1 was not sent out to the hospital earlier which poses an immediate health and safety risk to residents in care.

1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds : (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual...responsible for the fees ...within 15 days after the personal property is removed.This requirement is not met as evidenced by: Based on the admission agreement reviewed and the copy of check provided for review, R1 moved out of the facility on 11/2/24 and all personal belongings were removed, however facility did not issue a refund check until 12/17/24.

Maintain comfortable room temperature at all times

87303 Maintenance and Operation: (b) A comfortable temperature for residents shall be maintained at all times.This requirement is not met as evidenced by: Based on interviews conducted, it was acknowledged that the facility does not have a functioning heating unit on both floors of the facility and the facility is using portable heaters in common areas. In addition, based on observations, LPA observed residents at the facility wearing heavy jackets and wrapped in blankets.

Maintain separate complete record for each resident

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 staffThis regulation is not met as evidenced by: Based on R1's file reviewed, there were no completed reappraisals, no service plans, pre-admission appraisal, functional capacilities in the file.

Care and supervision as defined by statute and rules

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on medical records reviewed, the resident was found to have a diganosis of dehydration and UTI when admitted to the hospital which resulted in the resident needing multiple doses of IV fluids while at the hospital. This finding poses an immediate health a safety risk to the resident in care.

Develop required incidental medical care plan

87465 Incidental Medical and Dental Care - (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.This requirement is not met as evidenced by: Licensee failed to perform care and supervision to the resident to address the care need of a resident who fell and had a change in condition. According to staff interviews, R1 was experiencing pain in his/her right leg or hip, and called R1’s responsible party, however, did not feel that calling 911 was necessary due to R1’s old age even though staff observed R1 moaning and grimacing in pain when R1 moved his/her leg. Furthermore, based on interviews conducted and file reviewed, it was noted that R1 was at fall risk and med-techs interviewed indicated that 911 should have been called but they did not. Nevertheless, R1 was complaining and observed by staff of having pain and the facility did not seek medical attention for R1 which poses an immediate health risks to residents in care.

Submit and maintain current mailing address

Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or...This requirement was not met as evidenced by: Based on filed reviewed, LPA was unable to locate S1's fingerprint clearance and facility association documentation for S1. In addition, the resident care director and the business office manager were unable to provide LPA with confirmation or documentation of S1's fingerprint clearance and/or S1's facility association documentation

Care and supervision as defined by statute and rules

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on documents reviewed and interviews conducted, R1 was fell and was found on the bathroom floor and facility staff failed to ensure care and supervision was provided as documents reviewed identified R1 as fall risk, however there was no individualized fall prevention place for R1. In addition, based on staff interviewed, due to short staffing, there was a lack of supervision.

1569.69 Employees assisting residents with self-administration of medication; training requirements (a) 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: (5) To complete the training requirements set forth in this subdivision, each employee shall pass an examination that tests the employee’s comprehension of, and competency in, the subjects listed in paragraph (4). This requirement has not been met as evidenced by: Based on a complaint investigation conducted in relation to complaint # 14-AS-20240514090937, it was discovered that the memory care director was passing medications to residents in care but did not pass the examination regarding med-tech training. This poses an immediate health and safety risk to residents in care.

87101(c)(3)(H) "Care and Supervision" means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. "Care and Supervision" shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (H) Monitoring food intake or special diets. This regulation has not been met as evidenced by: Based on documentation reviewed, the resident lost weight while at the facility. It is not apparent that regular food intake records were being made to track any changes in food intake. Some meals may have been missed or the resident not receiving enough food caused the resident to lose weight at the facility from 120lbs to 111lbs at time of weighing at the emergency room. This finding poses an immediate health a safety risk to the resident in care.

87464 Basic Services(f)(5) - (f) Basic services shall at a minimum include: (5) Regular observation of the resident's physical and mental condition, as specified in Section 87466, Observation of the Resident. This regulation has not been met as evidenced by: Based on records reviewed, the resident was found to have a condition as a result of dehydration which resulted in the resident needing fluids provided intravenously while at the hospital. Additionally there was a change in the resident's mental condition also found at the hospital . This finding poses an immediate health a safety risk to the resident in care.

Ensure hazardous items are locked and not unattended

87309 Storage Space - (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by: Based on interviews conducted, a cleaning solution was left in a resident's room where they were able to access it, open it, and had some of the solution on their face. This poses an immediate health and safety risk to residents in care.

Care and supervision as defined by statute and rules

87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requriement has not been met as evidenced by: Based on documentation reviewed, the resident lost weight going from 120lbs to 111lbs during the resident's stay at the facility of approximately 5 weeks, additionally the resident was found to have a condition as a result of dehydration which resulted in the resident needing fluids provided intervenously while at the hospital. These finding pose an immedate health a safety risk to the resident in car.

§1569.69 Employees assisting residents with self-administration of medication; training requirements (a) 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: (1) 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 regulation has not been met as evidenced by: Based on file review, the memory care director's file showed that she is not fully trained at this time and has passed out medications to residents as a reulst of the facility not having enough med-tech's on duty or on the schedule. This violation poses a health and safety risk to residents in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements - General - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This regulation has not been met as evidenced by: Based on observations made and interviews conducted, there currently is only one med-tech handling AM and PM medications as well as 4 caregivers assiting residents at LPAs arrival. Per interviews and staffing schedule observed there is also only 1 med-tech for AM and PM for the next day, and 3 caregivers for AM and PM shfit for 57 residents. This violation poses a health and safety risk to residents in care.