ARCADY VILLA

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 in three (3) out of five (5) residents not having re appraisals documented which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/13/2026 Plan of Correction The Administrator will conduct re appraisals for Resident #2 (R2), Resident #4 (R4) and Resident #5 (R5) and provide copies to the Department by POC due date 03/13/2026.

Official classification

Type B

Official code

87421(c)

Regulation authority

CCR

What the official deficiency says

87421 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 in one (1) out of two (2) staff did not have documentation of the required annual training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/13/2026 Plan of Correction The Administrator will document all staff training and submit proof of completed training to the Department by the POC due date of 03/13/2026.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 in that the facility failed to conduct an emergency drill at least quarterly for each shift which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Administrator will conduct a drill for each shift and documentation of the drill shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. The documentation will be submitted to the Department by POC due date 03/06/2026.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) medication for resident #1 (R1) that had medication label altered with no documentation which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/30/2025 Plan of Correction Administrator will immediately provide medication with prescription labels only and as indicated on the original prescription label until they obtain medication orders for all residents. Administrator will submit a statement of understanding for the regulation cited and that they reviewed facility's own medication policy and provide statement to LPA by POC due date.

Official classification

Type A

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) resident, resident #1(R1) was provided PRN medication but had no record of PRN medication given which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/07/2025 Plan of Correction Administrator will immediately have staff record when PRN medication is given to resident. Administrator will conduct in-service training for all staff responsible for assisting residents in medication administration. A copy of training material used and sign in sheet of all staff that participated will be submitted to LPA by 02/07/2025.

Official classification

Type A

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. 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 one bedridden resident, resident #6 (R6) residing in a bedroom designated by facility sketch to be for non ambulatory resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/30/2025 Plan of Correction Administrator will move resident to bedroom #3(R3) as that room is designated for bedridden by POC due date. Administrator stated they would submit LIC 200 and facility sketch to designate bedroom #6 and bedridden room or to have inspector add comment that any bedroom is cleared to house the one bedridden resident.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in R3 is on hospice has full bed rail but only has a half bed rail written order, R4 has half bed rail with no written order, R6 is not on hospice and has a full bed rail with no written order, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/30/2025 Plan of Correction Administrator agreed to remove bed rails from three (3) out of five (5) residents and place a half bed rail for R3 until a written order from a physician can be obtained indicating the need for postural support.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one resident's wall having a hole on the wall which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/07/2025 Plan of Correction License will send LPA a picture of the wall after it has been fixed by POC due date.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. 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] out of five [5] admission agreements. Resident #4 (R4's) admission agreement was missing the licensee's or facility representative signature which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2024 Plan of Correction Licensee will review all resident records to ensure records are signed by facility representative and resident or their responsible party. Licensee will submit a copy of R4'a admission agreement signed and dated by facility to LPA by POC due date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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] out of five [5] resident records. Resident #4 (R4) was missing a medical assessment / Physician's report prior to admission which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2024 Plan of Correction Licensee will ensure a Physician's Report / Medical Assessment is completed for R4 and submit a copy to LPA by POC due date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705(c)(5) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. 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) out of five (5) resident records. Resident #3 (R3) who has dementia did not have an annual required medical assessment/ physician's report on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2024 Plan of Correction Licensee will ensure an annual medical assessment/physician's report is conducted for R3 and submit a copy to LPA by POC due date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

87412 (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 record review, the licensee did not comply with the section cited above in two (2) out of two (2) staff records reviewed on todays visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2024 Plan of Correction Licensee will ensure health screening with TB exams are conducted for each staff. Licensee will submit LIC503 to LPA by POC due date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608(a)(3)Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on 12/20/2022 Annual Visit observation and record review the licensee did not comply with the section cited above by utilizing half bed rails for 1 resident without a written order from the physician which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/13/2023 Plan of Correction Licensee/administrator will tour rooms for all residents and identify those who are utilizing bed rails. Licensee/Administrator will contact the physicians and obtain order for postural support for those identified as not having one. Administrator will submit the names of the residents room numbers and dates the orders were obtained as POC.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608(a)(5)(B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on 12/20/2022 Annual Visit observation and record review the licensee did not comply with the section cited above in 3 out of 3 residents by utilizing full bed rails for non-hospice residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/22/2022 Plan of Correction Licensee/administrator will tour rooms and identify those who are utilizing full bed rails. Licensee/Administrator will remove the full bed rails of non-hospice residents. Licensee/Administrator will send a picture of bed with removed full bed rails to LPA by POC date 12/22/2022.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307(d) The following space and safety provisions shall apply to all facilities: (6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one resident bedroom by having a large chair obstructing an indoor passageway exit door which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/22/2022 Plan of Correction Staff removed the chair immediately. Licensee/Administrator will submit to LPA a statement of understanding for the regulation mentioned above by POC date 12/22/2022.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the Licensee/Administrator did not comply with the section cited above in which LPAs observed scissors in the kitchen accessible to residents in care. This poses an immediate health and safety risk or personal rights risk to resdients in care.

Official plan of correction

The Administrator has stated in-house training will be conducted among all staff and a signed written statement will be submitted by the POC due date.

Deadline recorded: Jul 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. Based on an interview and observation, the Licensee/Administrator did not comply with the section cited above in which the Administrator admitted that a credible witness observed medication accessible to residents in care. LPAs also observed a key to the laundry room which stores chemicals accessible to residents in care. This poses an immediate health and safety risk or personal rights risk to resdients in care.

Official plan of correction

The Administrator stated he will remove the key from the location and has stated in-house training will be conducted among all staff and a signed written statement will be submitted by the POC due date.

Deadline recorded: Jul 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(c)(1)

Regulation authority

CCR

What the official deficiency says

87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement was not met as evidenced by: Based on an interview with the Administrator, the licensee/administrator stated that during a previous visit conducted by the credible witness, staff did not comply with the cited section above by not screening visitors for symptoms of COVID 19 upon entry, staff where not wearing masks, and staff did not replenish the paper towel dispenser in a bathroom which poses and immediate Health and Safety and personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator has already conducted in house training with all staff. A written statement signed by all staff regarding such training shall be emailed to LPA no later than 7/23/22.

Deadline recorded: Jul 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(8)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidenced by: Based on an interview with the Administrator, the licensee/administrator stated that during a previous visit conducted by the credible witness, staff did not comply with the cited section above by retaining spoiled milk after the expiration date.

Official plan of correction

Licensee/Administrator has already conducted in house training with all staff. A written statement signed by all staff regarding such training shall be emailed to LPA no later than 7/23/22.

Deadline recorded: Jul 25, 2022. A deadline is not proof that correction was completed.