Crest Villa

Based on observation and record review, the licensee did not comply with the section cited above by not ensuring an updated reappraisal for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #5 (R5), and Resident #7 (R7) was completed,which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by not ensuring an updated needs and services plan for R1, R2, R5 was completed, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by not ensuring medication for Resident #2 (R2) was documented and maintained on Medication Administration Record (MAR),which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care....(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 evidence by: Based on interviews, record review the licensee did not follow " Incidental Medical and Dental Care" resulting on Resident #1 to have controlled substance on their possesion, which poses an immediate Health, Safety, or Personal Rights risk to residents in care.

Personnel Requirements - General....(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.This requirement is not met as evidence by: Based on interviews, record review the licensee did not follow "Personnel Requirements" to Resident #1 to observe residents change of condition, which poses an immediate Health, Safety, or Personal Rights risk to residents in care.

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency... (1) A written report shall be submitted to licensing agency... (D) Any incident which threatens the welfare, safety or health of any resident... Based on record review, the licensee did not comply with section cited above by not ensuring a written report was submitted to licensing for incident regarding Resident #1 (R1) within seven days of occurence, which poses a potential health, saftey or personal rights risk to persons in care.

Maintenance and Operation 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not met as evidenced by Based on observations, the licensee did not comply with the section cited above by not ensuring all smoke detectors were in working ability, 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 by not ensuring bleach, cleaning solutions, scissors and a hammer were locked inacessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by not ensuring Resident #1 (R1) has an updated Physician Report, which poses a potential health, safety or personal rights risk to persons in care.

1569.31 Basic Services Requirement (e)Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. Based on interviews, licensee failed to meet this requirement by not ensuring staff were properly supervising residents, which poses an immediate health, safety or personal rights risk to persons in care.

Based observation and record review, the licensee did not compy with the section cited above by not ensuring Resident #5 (R5) has a completed and signed Admission Agreement, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record reivew the licensee did not comply with the section cited above by not ensuring Resident #1 (R1) has a completed Reapprasial form.which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by not ensuring Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #5 (R5), Resident #6 (R6) and Resident #7 (R7) do not have a Functional Capabilities Assessment. which poses a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above by not ensuring Resident #1 (R1), Resident #2 (R2), Resident #3 (R3) and Resident #5 (R5) to have a Pre-Placement Apprasial completed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by not ensuring Resident #4 (R4), Resident #5 (R5), Resident #6 (R6) and Resident #7 (R7) have a completed Needs and Services plan, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by not ensuring Resident #1 (R1) Medication Administration Record (MAR) was documented correctly, which poses an immediate health, safety or personal rights risk to persons in care.

87211 Reporting Requirements(1) A written report shall be submitted to the licensing agency..seven days of the occurrence of any of the events specified..(D)..unexplained absence of any resident. Based on record review, licensee failed to meet this requirement by not ensuring disapperance of resident was reported to licensing agency within seven days of occurence, which poses a potential health, saftey or personal rights risk to persons in care.

Maintenance and Operation 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times...This requirement is not met as evidenced by: Based on observations, the facility administrators did not comply with the section cited above by not ensuring all smoke alarms were in working ability. This poses a potential health, safety or personal rights risk to persons in care.