Vila Monte

(a) Prior to, or within two 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. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not comply with the section cited above wherein 3 residents reppraisals were not completed to indicate the individual care the resident will receive which poses a potential health, safety and personal rights risk to persons in care.

THIS DEFICIENCY WAS INADVERTENTLY AMENDED. Based on observation, interview, and record review, the licensee did not comply with the section cited above wherein the licensee did not ensure the centrally stored medication records contained a start date which poses/posed a potential health, safety or personal rights risk to persons in care.

THIS DEFICIENCY WAS INADVERTENTLY AMENDED. Based on observation, interview, and record review, the licensee did not comply with the section cited above wherein the licensee did not ensure 1 resident was provided their routine medication from 04/08/25 - 04/23/25 which poses/posed a potential health, safety or personal rights risk to persons in care.

80087(a)(1)(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.(1) The licensee shall take measures to keep the facility free of flies and other insects.This is not met as evidenced by: The licensee did not ensure that the facility was free of pests such as bed bugs. It was learned that upon admission the resident room obtained bed bugs and was treated upon notice.This poses a potential health, safety and personal rights risks to persons in care.

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interview, record review, and observation staff (S1) was not competent in providing proper supervision during dinner time by having his/her back turned towards the residents and initially ignoring the resident the first time when R1 began to choke, which poses an immediate health, safety, and personal rights risk to persons in care.

Based on observation, interview, and record review the licensee did not comply with the section cited above in by not providing at least 20 hours of annual training to staff regarding this section which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review the licensee did not comply with the section cited above by not completing the emergency drills quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review the licensee did not comply with the section cited above by not having the infection control plan available for review during LPAs visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above by 1 out of 6 counts for a resident who did not have a physician's report on file which poses/posed a potential health, safety or personal rights risk to persons in care.

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure to document the observation of resident (R1)’s throat condition resulting in R1’s death after choking on food which poses/posed an immediate health, safety, and personal rights risk to persons in care.

(b) The following food service requirements shall apply: (10) Where indicated, food shall be cut, chopped or ground to meet individual needs. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to cut R1’s foods into small portions as indicated on his/her medical discharge summary which poses/posed an immediate health, safety, and personal rights risk to persons in care.

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure the facility was clean, sanitary and in good repair which poses/posed an immediate health, safety, and personal rights risk to persons in care.

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, … : (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. … (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to inform the Department of a death of a resident within 7 days of the occurrence which poses/posed an immediate health, safety, and personal rights risk to persons in care.

Based on observation, interview, and record review licensee did not ensure residents were provided activties which poses/posed a potential health, safety or personal rights risk to persons in care.

(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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or ... This requirement is not met as evidenced by: Based on record review, interview, and observation the Licensee did not comply with the section cited above for staff (S1) working in the facility without association which poses an immediate health, safety, and personal rights risk to persons in care.

Based on observation, record review, and interview resident (R1)'s medical assessment did not include a TB result which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review licensee did not ensure personnel records were maintained at the facility for review which poses/posed a potential health, safety or personal rights risk to persons in care.

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, … : (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. … (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. Based on record review, interview and observation the licensee did not ensure to submit an incident report and death report for a resident (R1) who was sent to the hospital for medical treatment and who later passed away which poses an immediate health, safety, and personal rights risk to persons in care.

Based on observation, interview, and record review licensee did not ensure all needs and services plans were signed and that residents did not obtain an updated physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement was not met as evidenced by: Based on interview and observation, the licensee did not ensure to keep the facility free from pests such as the insect, bed bugs, which poses an immediate health, safety, and personal rights risk to persons in care.