ANITA'S CARE VILLA

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as Resident #2 (R2) had Advil in their room in their drawer and R2's physician's report indicates the resident cannot store their own medications and in addition, R2's room remains unlocked rendering R2's Advil accessible to all residents, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2024 Plan of Correction During today's visit, Administrator secured the medications. Administrator agreed to communicate with R2 and their responsible party regarding proper medication storage. Proof of communication with responsible party will be provided to CCL by POC due date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 1 resident (Resident #1 - R1) is using full bed rails, is not on hospice and does not have a valid exception on file which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2024 Plan of Correction Administrator agreed to obtain a doctor's order for the full bed rails, documentation from the resident and/or resident's responsible party, and submit an exception request to CCL by POC due date. Alternatively, Administrator may remove R1's full bed rails and replace with a half bed rail and submit proof to CCL by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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, as smoke detector was removed from room #3 and hallway lightswitch plate was observed to be broken, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2024 Plan of Correction Administrator indicated the maintenance person is unavailable as of today's date, however, facilty staff replaced the smoke detector during today's visit and Administrator will coordinate a visit with the maintenance person as soon as possible. Administrator will provide proof of repaired items to CCL by POC due date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as cleaning supplies were found accessible throughout the facility, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2023 Plan of Correction The Licensee agreed to do the following: 1. Lock all cleaning supplies and accessible items and notify CCL no later than 6/3/2023. All items locked at time of the visit.

Official classification

Type A

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: 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 as 3 out of 5 residents did not have signed resident rights, signed consent forms and 1 out of 5 residents did not have a needs and services plan which poses an immediate personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2023 Plan of Correction The Licensee agreed to the following: 1. To have required forms signed and completed no later than 6/3/2023 and provide proof to CCL.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as there were expired foods and foods exposed to freezer burn found in the refrigerator which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2023 Plan of Correction The Licensee agreed to the do the following: 1. Discard of any expired foods and notify CCL. POC was cleared at the time of the visit.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the centrally stored medication cabinet was observed to be unlocked in the kitchen, prescription mouthwash was observed in hallway bathroom and prescription and over the counter medications were observed unloced in Residetn #4 room which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2023 Plan of Correction The Licensee agreed to the do the following: 1. Lock accessible medicaitons. POC was cleared at the time of the visit.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 as the single latch exit door on the side of the house was not even an not allowing for it to close or open properly. Storage shack door was in disrepair leaving accessible items exposed such as gardening supplies and chemicals which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2023 Plan of Correction The Licensee agreed to the following: 1. Repair side door and stroage shack door and notify CCL no later than 6/9/2023.

Official classification

Type B

Official code

87465(a)(8)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on obsevation, the licensee did not comply with the section cited above as the first aid kit was not complete and missing twezzers, thermometer, first aid manual which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2023 Plan of Correction The Licensee agreed to the following: 1. Replace missing items or obtain a complete first aid kit and notify CCL no later than 6/9/2023.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained...: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as they admitted and retained R1 in the facility with a prohibited health condition, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrators agree to do the following: Review Regulation 87615 and submit a Statement of Understanding, detailing how the facility will maintain in compliance moving forward and submit to CCL by 07/01/2022.

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

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation, the licensee did not comply with the section cited above as two (2) out of two (2) facility restroom faucets delivers hot water measured at 104 and 96.8 degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2022 Plan of Correction The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for seven (7) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit.