St Jules Care Villa

Based on observation, the licensee did not comply with the section cited above. Oxygen tank was observed in share bedroom and "No Smoking - Oxygen in Use" sign was posted outside resident room doors, which poses/posed a potential health, safety or personal rights risk to persons in care.

Infection control plan required in operations plan

Based on record review, the licensee did not comply with the section cited above facility did not have infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on record review, the licensee did not comply with the section cited above Administrator did not have file at facility. which poses/posed a potential health, safety or personal rights risk to persons in care.

Resident record must include minimum required items

Based on record review), the licensee did not comply with the section cited above in two (2) out of two (2) residents were missing (R1)LIC 601,conset form, personal rights LIC 613, and appraisel needs and service. (R2) missing LIC 602 current physicians report,appraisel needs and service, and LIC 613 personal rights 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 facility did not have any drill conducted 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 R1 did not have physicians order for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review when LPA Calderon asked to review Emergency Disaster Plan Administrator informed LPA the Emergency Disaster Plan was not maintained at the facility, the licensee/facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain personnel records at facility location

Based on observation and interview with Administrator, Administrator stated not having any staff files at the facility, the licensee/ facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on observation during physical tour LPA Calderon observed half bed rails/ hospital beds for resident #1 and resident #3, interview with Administrator, Fernan David informed not having records / not having physician order in place for residents and LPA did not obtain , during resident file record review LPA did not observe physician orders, the licensee did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview with Administrator, Administrator stated not having training in-services logs for each staff at the facility, the licensee/ facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview with Administrator Fernan David informed LPA Fire Drill in-service training are not documented , the licensee did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview with Administrator Fernan David , the licensee/facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview with Administrator Fernan David and during record review of staff files, no files were made available for LPA's review , the licensee did not comply with the section cited above in [3] out of [3] persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and interview with Administrator Fernan David, Administrator stated not having a list of centrally stored medication for residents, the licensee/ facility did not comply with the section cited above in [3] out of [3] persons, which poses/posed a potential health, safety or personal rights risk to persons in care.