Avondale Villa Post-Acute

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an injury of unknown origin was reported as required by law for one of three sampled residents (Resident 1). This failure resulted in Resident 1' s facial bruise, which was of unknown origin, not being reported to California Department of Public Health (CDPH), local law enforcement and Ombudsman. Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 12/29/25, indicated, Resident 1 was severely cognitively impaired. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection prevention and control practices when: 1. Shared Hoyer Lift used by 7 of 7 sampled residents was not maintained in the designated clean and dirty area in Utility Room. 2. The facility failed to properly clean and disinfect the glucometer (a device used to measure blood sugar) according to the manufacturer's guidelines, and facility's policies and procedures (P&P) between resident use. 3. Enhanced Barrier Precautions (EBP) protocol was not followed when providing direct care to Resident 239. These failures had the potential to result in transmission of infection to Residents and Staff throughout the facility.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure nursing staff safely handled hazardous drug (HD-drugs that pose short- or long-term harm upon exposure to human via skin or inhalation) in accordance with Centers for Disease Control and Prevention (CDC- a federal agency leading the science-based, data-driven, service organization that protects the public's health) and National Institute for Occupational Safety and Health (NIOSH-a federal agency that is part of the CDC; NIOSH conducts research and makes recommendations for the prevention of work-related hazards, injury and illness) guidelines and facility's Policies and Procedures (P&P) for the safe handling of Hazardous Drugs with resident census of 35. This failure had the potential to pose health risk to the nursing staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to document disposition and destruction of the non-narcotic (non-opioid) prescription medications with resident census of 35. This failed practice could contribute to the risk of drug diversion (unlawful use of prescription drug by unauthorized individuals) and unsafe disposition practices.

Inspectors wroteBased on interviews and record reviews the facility failed to address and prevent duplicate use of two similar medications used to treat severe form of stomach heartburn known as Gastro-Esophageal Reflux Disease (GERD-a condition of stomach acid flowing back into the esophagus and can contribute to stomach bleeding) in one out of five sampled residents reviewed for unnecessary drugs (Resident 28) when: Resident 28 received two drugs called pantoprazole (or Protonix) and omeprazole (or Prilosec) simultaneously, which had belonged to the same class of drug called Proton Pump Inhibitors (PPIs-medications that reduce the production of stomach acid and help relieve symptoms like heartburn or GERD). The duplicate use of two PPI could contribute to adverse drug consequences and cause further health problems.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 35. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 43 opportunities which resulted in a facility wide medication error rate of 9.52% in three out of 7 residents (Resident 26, Resident 29, and Resident 31) observed for medication administration as follows: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe storage of medication and medical supplies in the active storage areas of treatment cart (a mobile cart where medication and supplies for wound and skin care are stored) and the medication room (a locked room used to store medications and supplies) with census of 35 when: 1. Facility's medication room stored expired vaccine, expired testing products, expired supplies, and co-mingled supplies for IV (Into the Vein) medication use on residents that were no longer in the facility. 2. Treatment cart stored expired supplies and opened products that were marked sterile and for one time use in the active storage areas. These failures could contribute to unsafe storage and use of spoiled medication and supplies that could affect the well-being of vulnerable elderly residents.

Inspectors wroteBased on interview and record review the facility failed to implement their policy regarding food for residents brought in by family or other visitors for one of 27 sampled residents (Resident 31) when Resident 31's two bottles of outdated apple juice were stored in the facility refrigerator. This deficient practice had the potential for Resident 31 to consume drinks that were out of date which could cause avoidable gastrointestinal upset.

Inspectors wroteThis requirement is NOT MET as evidenced by: Based on observation and interview, the facility had two resident rooms (rooms [ROOM NUMBERS]) that measured less than 80 square feet (sq. ft.) per resident for the eight residents (Resident 3, 5, 22, 9, 25, 8, 19, and 14) who occupied the rooms. This failure had the potential to result in a lack of adequate space for the delivery of care to each of the residents in room [ROOM NUMBER] and 18, or for storage of these residents' belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a qualified nutrition professional to manage the food and nutrition services when; 1. The Dietary Services Supervisor (DSS) did not work in the facility on a full-time basis and the Registered Dietitian (RD) worked part-time. 2. DSS did not know the cool down method for a leftover meat sauce and Pozole soup. 3. DSS did not ensure that time and temperature monitoring was performed by kitchen staff during thawing of frozen food items. 4. DSS did not ensure residents were served palatable food when food was served at a low temperature, tasted bland, and was a poor texture. 5. DSS did not ensure food was fortified (adding protein, fat, and/or carbohydrate to foods) for 15 out of 15 residents on fortified diet. 6. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food and nutrition staff had the appropriate competencies and skills set when: 1. Staff did not follow correct procedure for thawing frozen food item. 2. Staff did not appropriately demonstrate how to check the sanitizer strength used for the dish machine. 3. Staff recorded dish wash machine temperature inaccurately. These failures had the potential for inappropriate food preparation and dishwashing procedure that could result in food borne illness.

Inspectors wroteBased on observation and record review, the facility failed to provide food items according to the menu when nine of 30 sampled residents receiving a regular diet order (Residents 4, 6, 13, 15, 16,17, 29, 186, and 188) were not served with one teaspoon (tsp) of margarine at lunch. This failure had the potential for residents to receive and/or consume inadequate caloric intake. See also tag F 808.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were served palatable food when food was served at a low temperature, tasted bland, and had poor texture. These failures had the potential for 30 of 30 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve foods in a sanitary manner that prevents foodborne illness for the facility when: 1. Cool down method was not performed for a leftover meat sauce and Pozole soup in the refrigerator. 2. Frozen food items were incorrectly thawed and refrozen. 3. A box of cherry tomatoes in the refrigerator was covered with white fuzzy material and dark spots. 4. A bag of cooked chicken was stored together in the same compartment with frozen raw meat and poultry. 5. Multiple unlabeled and undated food items were found in the freezer. 6. Staff did not handle drinkware in a manner to protect the drinkware from contamination. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent falls and implement appropriate interventions for one (Resident 16) of 12 sampled residents when, Resident 16 had repeated unwitnessed falls. The facility did not implement Resident 16's need for supervision with stand-by assistance during transfers. These failures caused Resident 16 to sustain repeated falls and had the potential to result in injuries.

Inspectors wroteBased on observation and record review, the facility failed to ensure pureed food was the appropriate consistency for six out of 30 residents. This failure had the potential for residents on pureed diet to aspirate (draw food into the lungs) and/or negatively impact the resident's dining experience resulting in poor food intake and compromising their nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Offer a substitute of equal nutritive value when milk on the planned menu was routinely not provided when milk was on the planned menu for all diets. 2. Effectively maintain a system to ensure the resident's food preferences were accurately recorded on their individual tray cards. These failures had the potential for 30 of 30 residents who received food from the kitchen to not receive the nutrients intended by the planned menu and not receive foods according to resident preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the physician- prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) when: 1. Six of six sampled residents (Residents 4, 6, 13, 15, 16,17) on a Fortified diet (a diet with added protein, fat, and/or carbohydrate to increase calories) did not receive supplemental food items as ordered. 2. Three of three sampled residents (Residents 5, 28, 21) on a Consistent Carbohydrate diet (CCHO - a diet that promotes stable blood sugar levels) received a regular diet instead of the CCHO diet. 3. One of one sampled resident (Resident 16) with a diet order for extra protein did not receive extra meat as ordered. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure accurate documentation of medication administration for three (Residents 5, 13, and 16) of five sampled residents when two nursing staff (Director of Nursing and Licensed Vocational Nurse 3) failed to document multiple medications' administration on four separate days (2/2/24, 2/11/24, 2/14/24, 2/17/24) These failures had the potential to result in unnecessary duplication of medication administration, and prevented accurate analysis of effectiveness of medication due to lack of clarity as to whether or not the medication was administered.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of the one facility dishwashing machine was able to maintain water temperatures during the wash and rinse cycles within the manufacturer's recommended water temperature range of 120 degrees Fahrenheit (ºF) and 140 ºF. This failure had the potential for dishware used by residents to not be sanitized sufficiently to prevent food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to complete a baseline care plan within 48 hours of admission and provide three (Resident 187,185, and 188) of 12 sampled residents and their representatives with a summary of the baseline care plan. This failure did not ensure the residents or their representative were informed of the plan for the provision of care.

Inspectors wroteBased on observation, interview and record review, for one (Resident 6) of two sampled resident, the facility failed to implement its Care Plans, Comprehensive Person-Centered policy and procedure when there was no care plan developed to address Resident 6's risk of aspiration with appropriate interventions This failure had the potential to result in Resident 6 develop aspiration, pneumonia and respiratory infection and for residents' not receiving appropriate care and treatment.

Inspectors wroteBased on record review and interview, the facility failed to assess one sampled resident (Resident 16) when the resident experienced a severe weight loss. This failure had the potential to result in continuous, unplanned weight loss for one of 13 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (Resident 2, 16 ) of five sampled residents were free from unnecessary drug when psychotropic medications were administered without adequate clinical indication and monitoring for its use when; 1. Resident 2 was administered Ziprasidone HCL (hydrochloride), an antipsychotic medication at bedtime for dementia and depression manifested by hitting, striking out during care and mobility. Resident 2 was administered Ziprasidone without adequate monitoring of target behaviors. 2. Resident 16 was administered Zyprexa, an antipsychotic medication for altered sensorium (inability to think clearly or concentrate), throwing objects, hitting/punching staff. Resident 16 was administered Trazadone, an antidepressant for sleep without adequate monitor of hours of sleep. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consider alternative recommendations for the use of the provale cup assistive device (helps prevent choking by delivering a measured amount of liquid. Cups vary with different delivery amounts) while allowing the patient to eat and drink independently, for one (Resident 6) of 12 sampled residents. Resident 5 was identified at risk for aspiration (food or liquids enters the windpipe). This failure resulted in staff not using an assistive device with meals or consulting with the Speech Therapist for recommendations when Resident 5 refused using the provale cup. This had the potential to result in aspiration and the development of pneumonia.

Inspectors wroteBased on observation and interview, the facility had two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) with multiple beds that provided less than 80 square feet (sq ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was provided supervision when staff were unaware of Resident 1's whereabouts for two eight-hour shifts (16 hours). This failure had the potential to result avoidable accidents while Resident 1 was not in the facility unsupervised.

Inspectors wroteBased on interview and record review, for one of three sampled residents (Resident 1), the facility failed to maintain medical records on Resident 1 that were accurately documented and complete when; - Licensed Vocational Nurse (LVN) 1 did not document Resident 1's whereabouts for the entire afternoon/evening shift. - LVN 1 signed off Medication Administration Record (MAR) indicating medications were administered to Resident 1 while Resident 1 was actually not in the facility. These failures resulted in inaccurate medical records and falsification of medication administration.

Inspectors wroteBased on interview and record review the facility failed to ensure the recommendations from the January 2022 medication regimen review (MRR, a review of all medications prescribed to each resident to check for provision of pharmaceutical services not consistent with accepted professional standards) for five (Resident 5, 6, 7, 11, 12) of 13 sampled residents were reviewed by the attending physician. This failure had the potential to result in the administration of unnecessary medications for the five residents during January 2022.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control policies and procedures were followed when: 1. Two scheduled nursing staff (Licensed Vocational Nurse 1, Certified Nursing Assistant 1), had no documented completion of pre-entry screening for symptoms of COVID-19 (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death. Symptoms include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea). Licensed Vocational Nurse 1 had no documented screening for 3/15/22, 3/16/22, 3/17/22, or 3/20/22. Certified Nursing Assistant 1 had no documented screening for 3/17/22. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Have a prescribed medication available for one (Resident 14) of eight residents. 2. Ensure one pill crusher and one pill cutter were cleaned after use. The failure to administer two consecutive doses of Resident 14's medication for reduction of fluid inside the eye had the potential to result in increased fluid pressure inside the eye causing nerve damage and impaired vision. The failure to remove medication residue from the pill crusher and cutter after use had the potential for administration of unordered medications or incompatible medications due to the mixing of different medications used in the pill crusher and pill cutter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two kitchen staff wore a head covering while working in the kitchen. This failure had the potential to result in food contamination from hair shed by staff and cause food to be less palatable and/or spread food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide seven of seven residents in multiple resident rooms [ROOM NUMBERS] with at least 80 square feet per resident. This had the potential to result in inadequate space for resident needs and care provision.