Atria Hillcrest

Based on observation and interview, the licensee did not comply with the section cited above in 4 out of 10 resident centrally stored medication and destruction record did not have start dates which poses/posed a potential health, safety or personal rights risk to persons in care.

87208 (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility...significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval...This requirement is not met as evidenced by: Based on interview and record review, the facility has changed it's policies and Admission Agreement as it relates to care services offered to residents, however no approval was obtained from the Department, which poses a potential health and personal rights risk to persons in care.

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary...to note significant changes in condition...and to keep the appraisal accurate...updated pre-admission appraisal shall be referred to as reappraisalThis requirement is not met as evidenced by: Based on interview and record review, R1 had a change of condition on or around 12/02/2024 (hospitalization, UTI, catheter, medication change and increased anxiety/depression) however, the facility did not conduct a reappraisal, which posed a potential health risk to persons in care.

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.

Based on record review, the licensee did not comply with the section cited above as one staff (S1) was not associated to the facility which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above, as the kitchen drawer in the memory care unit needs repair, the cabinet under the aquarium in the memory care unit needs repair, the towel rack in the shower for room # 242 in memory care was broken and needs repair, a bin in the main kitchen on the 1st floor containing sugar was broken, which poses a potential health and safety risk to residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(2) Occurrences, such as..outbreaks..which threaten the...or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile.. This requirement is not met as evidence by:Based on interview, the licensee failed to comply with the section cited above, as the Administrator failed to report to CCL a COVID-19 outbreak which poses a potential health, safety, and personal rights risk to residents in care.

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.

87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident.This requirement is not met as evidenced by: Based on interviews and documents received, Administrator failed to ensure the incident reports of four (4) residents during the period of two (2) weeks be received by CCL within 7 days of occurrence which poses a potential health & safety risk to residents in care.