Century Villa, Inc

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nursing staff informed four out of four sampled residents (Residents 11, 22, 23, and 51) of the medications prior to medication administration. These deficient practices violated Residents 11, 22, 23, and 51's right to participate during medication administration. FindingsDuring a review of Resident 11's admission Record, the admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (high blood pressure), and dementia (a progressive state of decline in mental abilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete discharge documents for one of one sampled resident (Resident 84) prior to discharge on [DATE]. This failure has the potential for Resident 84 to not know the appeal process and for the receiving facility to have inaccurate information of Resident 84. FindingsDuring a review of Resident 84's admission record, the admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses including unspecified complicated cataract (a medical condition that causes blurred vision), hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD, a progressive, long-term lung disease that makes it hard to breathe). During a review of Resident 84's History & Physical (H&P), dated 7/10/2025, the H&P indicated Resident 84 had fluctuating capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9) had care plans (a personalized document outlining a resident's health needs, goals, and specific interventions) for diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). This deficient practice had the potential to result in delayed care and services for Resident 9's mental health. FindingsDuring a review of Resident 9's admission Record, the admission record indicated Resident 9 was initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure physician orders for lab work, medical procedures, chest x-ray and dental referral were carried out for one of four sampled residents (Resident 26). This deficient practice had the potential to result in delayed diagnosis, delayed treatment, and/or worsening of Resident 26's condition. FindingsDuring a review of Resident 26's admission Record, the admission Record indicated Resident 26 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 26's diagnoses including bipolar disorder (sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration agreement accurately reflected the residents' right to rescind the agreement within 30 days for three out of three sampled residents (Residents 15, 26, and 41). This deficient practice had the potential to misinform residents of their rights and limit their ability to voluntarily withdraw from the arbitration agreement. Findingsa. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), who was physically attacked by Resident 2, who had a known history of agitation and aggressive behaviors toward others. The facility failed to:1. Implement its policy and procedure (P&P) titled, Abuse, Neglect and Exploitation which indicated each resident had the right to be free from abuse and neglect.2. Implement its P&P titled Behavior Management Plan, which indicated, residents with behavioral concerns will have a behavioral management plan to ensure they received appropriate services and interventions to meet their needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of three sampled residents (Resident 2) by failing to:1. Ensure Resident 2's Depakote (an anticonvulsant used to treat seizure disorder and other psychiatric conditions) medication was encoded as anticonvulsant and reflected in the MDS assessment under Section N (N0415 High-Risk Drug Classes) medication. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on record review and interview, the facility failed to respond to a request for the account balance of personal funds for one of three residents' (Resident 1). This deficient practice resulted in the facility retaining Resident 1's funds after being discharged from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan interventions for two of four sampled residents (Residents 44 and 90) were implemented. The facility failed to implement: 1. Resident 44's care plan interventions regarding skin care for an ankle monitor. 2. Resident 90's care plan interventions regarding the resident leaving the facility temporarily with family. These failures placed Resident 44 and 90 at risk of not having their needs being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure two out of four sampled residents (Resident 57): nasal cannula and humidifiers (a medical device that provides supplemental oxygen to a patient through their nose) were dated, labeled and (Resident 36) GT feeding was changed per physcian orders. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents.

Inspectors wroteBased on observation and interview the facility failed to: 1. Ensure call light device was placed within reach for one of 18 sampled residents (Resident 56). This deficient practice had the potential to result in a delay in or an inability for the residents to obtain necessary care and services.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Conceal a sign containing personal information for one of two residents, (Resident 44), by posting it on the wall above the resident's bed. This deficient practice violated the resident's right to have personal information shielded from public view.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out four sampled residents (Resident 57) had a revised care plan for oxygen therapy (the medical practice of providing a patient with supplemental oxygen). This deficient practice of not having a revised care plan to indicate when to administer oxygen therapy placed Resident 57 at risk of not meeting the care plan goal as indicated.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Properly obtain orthostatic blood pressure (a form of low blood pressure that happens when standing after sitting or lying down) readings for two of four sampled residents (Resident 3, Resident 52). This deficient practice had the potential for Resident 3 and Resident 52 to experience a delay in interventions if they were positive for orthostatic hypotension (low blood pressure).

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Ensure one of four sampled residents (Resident 32) was supervised and wore a smoking apron during smoking break. This deficient practice had the potential to put residents at risk for injury due to lack of supervision and maintain proper safety precautions while smoking.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of four sampled residents (Resident 84) was administered pain medication as needed. This deficient practice of not administering pain medication for Resident 84 had the potential to increase pain and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 39) had an assessment and order for the use of siderails. This deficient practice had the potential to result in inappropriate use of siderails for Resident 39 and could lead to injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Discard a bottle of expired cranberry extract in the medication cart. 2. Label a bottle of opened docusate liquid with the open date. This deficient practice had the potential for the residents to receive ineffective medication dosages.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of four sampled residents (Resident 84) food items stored in Resident 84's room were not dated and labeled. This deficient practice of not having food items dated and labeled had the potential to for Resident 84 to cause a stomach infection (an inflammation of the stomach and intestines caused by bacteria).

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 22), by failing to: 1. Document the correct information on the when the resident transferred to a different facility. This deficient practice had the potential to result in confusion and incomplete assessment of the resident's needs and could lead to a lack of or delay in delivery of necessary care or services to Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure six out of forty-seven rooms met the requirement of the minimum 80 square footage ([sq ft] - a unit of an area measurement equal to a square measuring one foot on each side) per room. This deficient practice to provide adequate space created the potential for adversely affecting the quality of life and safety who may had occupied rooms 22,24,26,27,28 and 29.

Inspectors wroteBased on interview and record review, the facility failed to document medication as given within the ordered administration time for four of four Sampled residents (Residents 1, 2, 3, and 4). This failure had the potential to result in the medication ' s intended therapeutic effect being compromised or possibly leading to inadequate disease management or symptom control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Infection Preventionist (IP), Licensed Vocational Nurse (LVN) 1, LVN2, and Certified Nursing Assistant (CNA) 2 had an annual competency checklist (yearly nursing skills assessment) performed. This deficient practice had the potential to result in staff providing substandard quality of care to residents due to lack of training/assessment.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for three of seven sampled residents (Resident 38, 54, and 46). This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to develop and complete a comprehensive and resident centered care plan for four of 12 sampled residents (Residents 46, 38, 54 and 194) 1. Did not develop a care plan addressing the use of medication Clonazepam for Resident 46. 2. Failed to complete the care plan goals for Residents 38, 54, and 194. This deficient practice had the potential to negatively affect the delivery of nursing care, medical interventions, and goals to Residents 46, 38, 54, and 194.

Inspectors wroteBased on observation, record review and interview, the facility failed to: 1. Discard expired and discontinued medications for four out of four sampled residents (Residents 12, 80, 48 and 36).

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure expired chocolate cookies in the reach in freezer were discarded after expiration date. 2. Ensure turkey lunchmeat, hamburger patties, polish sausages, tamales, and beef hot dogs in the reach in freezer were labeled with received date and use by date. 3. Ensure the ice machine was maintained clean. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to: 1. Notify the physician of an abnormal level of Lithium (a medication to treat mood disorders) for one out of three sampled residents (Resident 54). This deficient practice had the potential for Resident 54 to suffer adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have such as impairment or decline in an individual's mental or physical condition or functional and psychosocial status).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide rooms that meet the required square footage of 80 square feet per resident for 43 out of 48 rooms. This deficient practice placed the residents at risk for injury, lack of privacy, inadequate space during care, emergency services, visitation with family and friends.

Inspectors wroteBased on interview and record review, the facility failed to ensure the 10-foot ladder (steps) was secured in the facility's safe storage location and failed to report the unusual occurrence to the appropriate agencies, for two of 3 sampled residents, (Resident 1, and Resident 2). This failure resulted in an intruder to enter 1 of 3 resident ' s room, placing the residents' safety at risk to danger and resulted in the delay of the investigation by the California Department of Public Health.