Rose Villa

Infection control plan required in operations plan

Based on record review, the licensee did not comply with the section cited above by not ensuring that the facility has an updated infection control plan LIC9282 which poses a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above by not ensuring that the side gate is functioning properly and resident can exit the facility during emergency 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 by not ensuring that hte facility has an updated emregency disaster drill 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 that the facility has the 72 hour emergency food which poses/posed a potential 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 by not ensuring that the facility has an updated emrgency diasater pla 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 that the faciliyt has an updated first aid manual which poses a potential health, safety or personal rights risk to persons in care.

Onsite food stock levels for nonperishables and perishables

Based on observation, the licensee did not comply with the section cited above by not ensuring that the facility has the seven day supply of non perishable food 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 by not ensuring that staff #1 (S1) has an updated CPR certificate which poses a potential health, safety or personal rights risk to persons in care.

Use slip-resistant surfaces in bathing areas

Based on observation, the licensee did not comply with the section cited above by not ensuring that the batroom has the non-slip mat 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 by not ensuring that resident #2 (R2) and resident #3 (R3) have a needs and services plan. which poses a potential health, safety or personal rights risk to persons in care.

Include required health screening documents

Based on record review, the licensee did not comply with the section cited above by not ensuring that staff#2(S2) has the health screening performed by a license professional on file which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, the licensee did not comply with the section cited above by not ensuring that the facility is equipped with the 72 hour emergency food or emergency kits 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 by not ensuring that the staff conduct the emergency/fire/disaster drill 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 by not ensuring that resident #1 (R1) and resident #2(R2) has the needs and services plan on file which poses a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above by not ensuring that the side door handle by the garage is in good repair which poses a potential health, safety or personal rights risk to persons in care.

Include required health screening documents

Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having a physicians report for Staff #1 which poses an immediate health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation the licensee did not comply with the section cited above by not having sharps locked and inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Store disinfectants separately from food supplies

Based on observation, the licensee did not comply with the section cited above by not having the garage and kitchen drawers properly locked inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Request a transfer of criminal record clearance

Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having Staff #2 associated to facility which poses an immediate health, safety or personal rights risk to persons in care.

RCFE complaint poster posting requirements

Based on observation, the licensee did not comply with the section cited above by not having a CCLD complaint poster posted which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA staff file review, the licensee did not comply with the section cited above by (3) staff not having record of required care training and/or hours which poses/posed a potential health, safety or personal rights risk to persons in care.

Address and clearance obligations before facility work

Based on LPA file review, the licensee did not comply with the section cited above with (1) staff not having proper background clearance prior to employment which poses an immediate health, safety or personal rights risk to persons in care.

(1) Ensuring that the administration of enemas or suppositories or manual fecal impaction removal is performed by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by:LPA Bueno reviewed medication records showing that facility staff were administering suppositories.

Dispose of unused medications with required witness

Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy...or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years... This requirement is not met as evidenced by:LPAs and lead staff observed exipred as needed medication in resident's basket mixed with current medications.

Keep prescriptions in original containers

Incidental Medical and Dental Care: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: LPAs and lead staff observed one pill box with pills inside days marked TUE, WED, THU.

Maintain facility in clean, safe, sanitary condition

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:Based on LPAs observation and records review, the licensee did not comply with the section cited above as LPAs observed live pests in the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observations, the licensee did not comply with the section cited above as PUB 475 was not posted in the facility which poses a potential safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on LPAs observation and records review, the licensee did not comply with the section cited above as LPAs observed live pests in the kitchen area which poses/posed a potential health, safety or personal rights risk to persons in care.