Arcady Villa

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.