El Rancho Vista Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate medical record was maintained in accordance with accepted professional standards, for one of three sampled residents (Resident 1), who received rehabilitative services from Certified Occupational Therapy Assistant (COTA) and Physical Therapist Assistant (PTA). This deficient practice resulted in incomplete treatment encounter notes and the potential for inappropriate clinical reasoning for PT and OT services provided to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when:1. Three frozen packs of ham were unlabeled.2. [NAME] 1 wore a cuff bracelet (a band with an open back that slides onto the wrist without a clasp) during lunch preparation and trayline (meal assembly system).3. Food in the resident's refrigerator was not labeled properly.4. Non-Resident drinks were stored in the resident's refrigerator. These deficient practices had the potential to result in incorrect use of the unlabeled ham and placed the residents at risk for exposure to bacteria and contaminants, increasing the risk of foodborne illness, infection, and compromised health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 70) clothing protector (garment worn over clothing during meals to protect against spills) was not referred to as a bib. This deficient practice had the potential for Resident 70 to feel embarrassed and to feel as if being treated as a baby.

Inspectors wroteBased on interview and record review, the facility failed to submit a referral to the Office of the Long-Term Care Patient Representative (OLTCPR- office that provides a trained public representative for specified long-term care residents who may need medical treatment but lack decision-making capacity and have no legally authorized decision-maker) for one of eight sampled residents (Resident 28). This deficient practice resulted in delaying the process of obtaining a representative for Resident 28, who did not have the capacity to understand and make decisions. Cross Reference F552 and F578.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for the use of Zyprexa (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]) from an individual with decision-making capabilities for one of four sampled residents' (Resident 28), who did not have the capacity to consent. This deficient practice resulted in Resident 28 making uninformed decisions about his care and unable to understand the use, side effects, and risks of taking Zyprexa. Cross Reference F551.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents' (Resident 28) Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) was reviewed and completed by an individual with decision-making capacity. This deficient practice had the potential to result in Resident 28, who did not have the capacity to make medical decisions, not understanding his decision of Do Not Resuscitate (DNR- a medical order written by a doctor to instruct health care providers not to do cardiopulmonary resuscitation [CPR- lifesaving procedure performed when the heart stops beating]) if breathing stops or the heart stops beating). Cross Reference F551.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely physician and resident representative party notification following a change of condition for one of six sampled residents (Resident 5). This deficient practice resulted in a delay in medical evaluation and intervention and had the potential to result in worsening neurological status, permanent deficits, or death for Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advance Beneficiary Notice (a notice notifying that Medicare may deny payment for specific treatments, and provides residents the opportunity to accept or refuse services if Medicare denies payment) forms were provided when Medicare Part A (insurance that primarily covers inpatient skilled nursing facility stays) coverage ended for two of three sampled residents (Resident 53 and Resident 58). This deficient practice had the potential to result in residents not being informed of items and services not covered under Medicare, and the transfer of financial responsibility to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for one of six sampled residents (Resident 2), when they failed to ensure Resident 2's closet was organized and the closet doors were able to close. This deficient practice had the potential to place Resident 2 at risk of an unsafe and unclean environment.

Inspectors wroteBased on interview and record review, the facility failed to revise one of five sampled residents' (Resident 4) care plan to reflect Resident 4's use of Mirtazapine (medication to treat major depressive disorder [disorder that causes a persistent feeling of sadness and loss of interest]). This deficient practice had the potential to result in a delay in the delivery of Resident 4's necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff followed professional standards of practice by failing to obtain an accurate and timely blood pressure assessment prior to the administration of a blood pressure medication for one of five sampled residents (Resident 24) This deficient practice had the potential to result in a hypotensive (low blood pressure) episode for Resident 24.

Inspectors wroteBased on interview and record review, the facility failed to perform weekly weights for one of two sampled residents' (Resident 70), after Resident 70 experienced a three-pound (lb, unit of weight measurement) weight loss in one week. This deficient practice resulted in the uncertainty whether Resident 70's 4 lb weight loss in a month period was gradual or sudden.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nursing staff demonstrated competency to prioritize and respond to signs and symptoms consistent with a possible cerebrovascular accident (CVA- stroke, loss of blood flow to a part of the brain), including left-sided weakness and facial drooping for one of one sampled residents (Resident 5). This deficient practice had the potential to result in delayed medical evaluation and interventions for time-sensitive conditions, which could lead to worsening neurological status, permanent deficits, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual evaluations were completed for two of five employees (Certified Nursing Assistant's [(CNA) CNA 3 and CNA 4]). This deficient practice had the potential to place residents at risk of not receiving quality care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided in accordance with accepted professional standards and facility policies to meet the needs of residents when the facility failed to ensure the following for two out of six sampled residents (Resident 16 and Resident 46):1. Ensure controlled medications (medications that the use and possession of are controlled by the federal government) were securely maintained and effectively destroyed.2. Ensure Resident 46's lisinopril (blood pressure medication) was available for timely administration.3. Ensure Resident 46's dose of lisinopril was accurately documented. 4. Ensure Resident 16's famotidine (a medication that treats conditions where the stomach produces too much acid) was administered at the correct time, per the physician's order. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered in accordance with physician orders for one of six sampled residents (Resident 73). This deficient practice had the potential to result in hypotension (low blood pressure), decreased cardiac perfusion (blood oxygenation), and potential cardiac complications for Resident 73.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an unused and unopened NovoLog Flex Pen (a medication device that contains insulin aspart [a medication used to control blood sugar]) was stored in accordance with manufacturer's specifications and per facility policy for one of six sampled residents (Resident 37). This deficient practice had the potential to compromise the medication effectiveness, which could result in uncontrolled blood sugar levels and serious complications for Resident 37.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record for one of six sampled residents (Resident 5) was complete and accurately reflected care provided after a change of condition. This deficient practice had the potential to result in incomplete communication among healthcare providers, delayed or inappropriate clinical decision-making, and inability to verify that appropriate assessment and interventions were performed for Resident 5. Cross Reference F580 and F726.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely replacement and sanitation of water pitchers for two of six sampled residents (Resident 10 and Resident 53). This deficient practice had the potential to result in bacterial growth and contamination of the water pitchers, and subsequent infection for Resident 10 and Resident 53, who were both diagnosed with dysphagia (difficulty swallowing) and impaired cognition (ability to think and reason).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents' (Resident 52) responsible party's (RP- decision maker when an individual does not have the mental capacity to do so) refusal of the coronavirus (COVID-19- a highly contagious respiratory illness) vaccine (a medical treatment to help the body's immune system to recognize and fight disease) was documented. This deficient practice had the potential to result in RP 3 being unaware of the risks involved in refusing the COVID-19 vaccine and potential for the facility to not track Resident 52's vaccination status and reoffer at another time.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized care plan for one of three sampled residents (Residents 1) after Resident 1 had a change of condition, exhibited behavior of kneeling and placing self on floor, and was a high risk of falls. This failure had the potential to result in Residents 1's needs not being met, unidentified interventions and falls for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary practices in the kitchen that affected 67 residents out of 67 sampled residents when: 1. The refrigerator contained food with no in date (the date when the food was placed in the refrigerator) and no use by date (date the food item must be consumed by). 2. The freezer had food that was not labeled with an in date and a use by date. 3. Food items in the refrigerator and freezer that were removed from original packaging were not labeled with what it was. 4. Refrigerator and freezer temperatures were not within acceptable range. 5. Dietary [NAME] (DC) 1 did not remove gloves when moving to another task. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in residents that are medically compromised residents.

Inspectors wroteBased on interview and record review, the facility failed to inform one of three sampled residents' (Resident 34) Family Member (FM) 3, who was Resident 34's emergency contact, of an unwitnessed fall on 2/22/2025. This deficient practice resulted in FM 3 being unaware of Resident 34's fall which resulted in Resident 34's family being concerned of Resident 34's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 34) had a safe discharge by failing to follow Resident 34's care and whereabouts after Resident 34 was transferred to general acute care hospital (GACH) 1 after an unwitnessed fall. This deficient practice resulted in the facility being misinformed of Resident 34's whereabouts and had the potential to result in Resident 34's discharge needs being unmet.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan addressing a resident's diagnosis of clostridioides difficile ([C. diff], a germ that causes diarrhea and inflammation of the colon [organ in the digestive system that stores and processes waste before it's eliminated from the body]) for one out of eight sampled residents (Resident 56). This deficient practice had the potential to delay and negatively affect the delivery of care for Resident 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care per the physician's orders for three residents (Residents 35, 55, and 124) out of 16 sampled residents by failing to ensure: 1. Resident 124's blood sugar level was monitored. 2. Resident 55's surgical dressing was changed. 3. Licensed Vocational Nurse (LVN) 3 administered regular insulin (a hormone that removed excess sugar from the blood, could be produced by the body or given artificially via medication) 30 minutes prior to Resident 35's meal. These deficient practices had the potential to not meet Resident's 35, 55, and 124's overall healthcare needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the interventions to prevent formation and/ or worsening of pressure ulcers/injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were implemented for two of two residents (Resident 54 and 56) when the following occurred: 1. Resident 54's low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) did not reflect the resident's correct weight on 3/10/2025. 2. Resident 56's LALM did not reflect the resident's correct weight. This deficient practice placed Resident 54 and 56 at risk for worsened condition of their exiting pressure injuries, and/ or the development of new pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label one of one sampled resident's (Resident 69) peripheral intravenous line's ([IV], a soft, flexible tube placed inside a vein to administer medications or fluids) dressing with the date and time of insertion and the initial of the inserting nurse. This deficient practice had the potential to result in Resident 69's IV to be left in place longer than seven days, which could cause preventable infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to display a No Smoking sign on the inside and outside of the resident's room for one of eight sampled resident's (Resident 14) use of an oxygen concentrator (a medical device that extracted oxygen from the air and delivered it to resident for breathing). This deficient practice had the potential to cause fire hazards to all residents, families, visitors, staff, and residents' properties, and result in serious harm and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe administration of medications for two of 20 sampled residents (Residents 125 and 29) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 did not leave medications at Resident 124's bedside and failing to ensure Resident 124 took all his medications. This deficient practice had the potential to result in Resident 124 self-administering his own medications unsafely or potentially leading to another resident self-administering medications not prescribed to them. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 46 and 65) were free from significant medication error (one which caused the resident discomfort or jeopardizes his or her health and safety) when: 1. Staff did not instruct Resident 65 to rinse his mouth thoroughly after administering Budesonide-Formoterol Fumarate inhaler (a medication to relax airway muscles, making breathing easier). This deficient practice had the potential to result in mouth discomfort and development of oral thrush (a fungal infection of the mouth, resulting in white, raised patches, that could be painful and cause discomfort) for Resident 65. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove three bags of expired intravenous (IV -given directly into the blood stream) fluid solution from inside the IV emergency kit (e-kit), in one of one inspected medication room (Medication Room Nursing Station 1). This deficient practice increased the risk that residents could have received medications that were expired and/or ineffective, possibly leading to health complications such as infection (the invasion and multiplication of microorganisms [like bacteria, viruses, etc.] in body tissues, potentially causing illness or harm) and electrolyte imbalance (an abnormal level of electrolytes in the body fluids, like blood and urine, which could disrupt vital functions like nerve and muscle activity, and fluid balance).

Inspectors wroteBased on interview and record review, the facility failed to notify the primary care physician (PCP), when one of three sampled residents (Resident 1), refused insulin (medicine for diabetes (DM], - abnormal blood sugar levels) administration, as ordered by the PCP. This failure placed the resident at risk for potential complications from diabetes such as diabetic ketoacidosis (a life-threatening complication that can occur if blood glucose levels are high) leading to hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan to one of 3 residents (Resident 1), who refused to receive insulin (medicine for diabetes mellitus ([DM], abnormal blood sugar levels) injection on 9/24/2024, for the high blood sugar levels, as ordered by the physician. This failure had the potential that interventions Resident 1 would need will not be provided, resulting in poor quality care and complications.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of practice by failing to ensure one of three sampled residents (Resident 1), who was diabetic and who refused insulin (medicine for diabetes) injection, was monitored for any possible diabetic reactions which could be life-threatening. This failure had the potential for Resident 1 to suffer complications from uncontrolled blood sugar levels that could lead to hospitalization and/or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's responsible parties (RP) were informed of the utilization of bedrails and informed consent was given for two of 24 sampled residents (Resident 32 and Resident 66) by failing to: These deficient practices did not allow the Resident 32 and Resident 66's RP's the right to be fully informed in advance of the bedrails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a change in condition of a resident's refusal of monthly weights to the physician for one out of three residents (Resident 6). This deficient practice had the potential for Resident 6 to have continued weight loss without facility awareness and intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the person-centered care plan's (document that helps nurses and other team care members organize aspect of resident care) interventions for one of six sampled residents (Resident 39) when Certified Nursing Assistant (CNA) 1 only wore a gown when providing feeding assistance to Resident 39, who was on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms [MDRO]). This deficient practice had the potential to result in Resident 39 contracting an MDRO and potentially spreading the MDRO to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to revise the person-centered care plan (document that helps nurses and other team care members organize aspect of resident care) for one of six sampled residents (Resident 59) who had nonstop bleeding of their arteriovenous shunt (AVS, a connection between an artery and vein that is a commonly used access site in patients receiving regular hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally]) and was sent to the general acute care hospital (GACH). This deficient practice had the potential to result in Resident 59's needs not being met due to staff being unaware on how to care for Resident 59's bleeding AVS.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders for one out of three residents (Resident 19) by not getting Resident 19 out of bed. This deficient practice had the potential to negatively affect Resident 19's psychosocial well-being due to lack of socialization and stimulation.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assist residents who were unable to carry out their activities of daily living (ADLs, self care activities performed daily such as grooming, personal hygiene, and dressing) for two out of 24 sampled residents (Resident 32 and Resident 43) by failing to: 1. Ensure Resident 32's and Resident 43's teeth were routinely brushed. 2. Ensure Resident 32's and Resident 43's clothes were changed daily. 3. Ensure Resident 32 and Resident 43 got out of bed daily. These deficient practices had the potential to result in a negative impact on Residents 32's and Resident 43's quality of life and self- esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) development for one out of three residents (Resident 19) by not turning Resident 19 as needed. This deficient practice resulted in Resident 19 developing a Stage II (partial thickness loss of the top layer of the skin presenting a shallow open ulcer with a red, pink wound bed) pressure ulcer, and had the potential to negatively affect Resident 19's skin by potentially becoming infected and spreading to the bone or blood stream.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their oxygen administration policy for one resident out of 24 sampled residents (Resident 7) by not ensuring Resident 7's nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils) was labeled. This deficient practice increased the risk for Resident 7 to acquire a respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consents were signed by the physician prior to the use of administering two antipsychotic (used to treat various mental disorders) medications, and for the utilization of bedside rails for one out of 24 sampled residents (Resident 32). This deficient practice had the potential of delay of necessary services, poor continuity of care and poor follow-up on the resident's status.

Inspectors wroteBased on interview and record review, the facility failed to document medication administration of a Schedule II-controlled substance (drugs with accepted medical use but with a high abuse potential), Norco (medication used to treat moderate to severe pain), when administering medication to one out of three residents (Resident 9). This deficient practice had the potential for harm due to an inaccurate record of narcotic medication use, and the loss of accountability, which affected the controls against drug loss, diversion (transfer of a legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use), or theft.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective infection prevention measures for one of six sampled residents (Resident 39) when Certified Nursing Assistant (CNA) 1 only wore a gown when providing feeding assistance to Resident 39, who was on Enhanced Standard Precautions (ESP, infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms [MDRO]). This deficient practice had the potential to result in Resident 39 contracting an MDRO and potentially spreading infection to other residents and staff.