Rancho Mesa Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours for 15 sampled days during the fiscal year Quarter 4 of 2024 (July 1 - September 30) and Quarter 3 of 2025 (April 1 - June 30). This failure had the potential for all residents living in the facility to not receive services and advanced care activities specifically performed by a registered nurse including resident assessments, administration of intravenous medications, and general oversight of the residents' clinical needs either directly by the RN or indirectly by the Licensed Vocational Nurses or Certified Nursing Assistants for whom the RN was responsible for overseeing resident care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 10) reviewed for pressure ulcers (injury to skin and underlying tissues that develops as a result of prolonged pressure, shear, or friction) had a low air loss mattress (LAL mattress - a specialized mattress which is air filled and is designed to help prevent and treat pressure ulcers) which was programmed for Resident 10's weight. Additionally, documentation regarding verification for the settings the low air loss mattress was incomplete in Resident 10's clinical record. These failures resulted in the low air loss mattress to not have the most therapeutic effect for the prevention and treatment of pressure ulcers and for Resident 10 to have increased risk for the development of new pressure ulcers and a delay in wound healing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 6) reviewed for accidents had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) on both sides of her bed as was specified in the resident's care plan (an individualized plan for the medical care of a resident), and physician's orders. In addition, documentation verifying the placement of the fall mats was inconsistent in Resident 6's clinical record. This failure had the potential for Resident 6 to sustain a serious injury during a fall in which the severity of the injury may have been lessened if the fall mat had been in place. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered medications within 1 hour of their scheduled administration time for one of twelve (12) sampled residents (Resident 57) reviewed for medication administration when Resident 57 received two medications (omeprazole - a medication used to decrease the amount of acid in the stomach, and empagliflozin - a medication used to treat diabetes [condition characterized by high blood sugar] or heart failure) one hour and twenty five minutes before they were scheduled to be administered on September 16, 2025. This failure resulted in the medications to not be administered in accordance with the facility's policy and procedure and for the omeprazole to not be administered as specified by the physician's orders (30 minutes prior to a meal). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% when the medication error rate was 7.69%, with two errors in 26 opportunities, when Licensed Vocational Nurse 1 (LVN 1) administered two medications (Omeprazole - a medication used to help prevent acid reflux [condition where stomach contents flow back up to the esophagus causing irritation and inflammation] and Jardiance - a medication used to treat people with heart failure or diabetes [condition characterized by high blood sugar] to one of 12 sampled residents observed for medication administration (Resident 57). This failure resulted in the medications to not be administered in accordance with the facility's policy and procedure and for the omeprazole to not be administered as specified by the physicians' orders (30 minutes prior to a meal). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one discontinued medication was removed from the Intravenous (IV) medication cart when one box of Bio Patches (specialized disc dressings that are used to prevent insertion site infections) were expired and available for use. This failure had the potential for the medication to be administered incorrectly which may cause harm to 56 residentsFindings:During a concurrent observation and interview on [DATE], at 2:20 PM, with a Licensed Vocational Nurse (LVN), the LVN inspected a box of Bio Patches from the IV medication cart. The box contained 10 patches, and the label indicated an expiration date of [DATE]. The LVN stated, Yes they are expired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control policies and procedures when:1) Licensed Vocational Nurse 2 did not perform hand hygiene (hand washing or the use of alcohol-based hand rub [ABHR]) between the administration of medications to two Residents (Residents 53 and 47). In addition, Resident 47 was on Enhanced Barrier Precautions (EBP - a set of infection control practices designed to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to follow its policy and procedure for activities of daily living (ADL) to provide care and services for residents who are unable to carry out ADLs independently for one of four sampled residents. This failure has the potential to put clinically compromised resident (Resident 1) health and safety at risk when Resident 1 ' s request for a diaper change was approximately delayed for 3 hours. During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses that hemiplegia ( is a condition that causes paralysis or weakness on one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu on Monday August 5, 2024, for lunch for 45 residents when: 1. The cook served 1/2 cup of mashed potatoes instead of 1/3 cup as indicated on the menu for the CCHO (carbohydrate controlled- diet involves eating the same number of carbohydrates every day, and the purpose is to help people manage their blood sugar levels) diets. 2. Facility did not have a way to ensure 4 oz (ounce - unit of measure) of meat was served for residents on the CCHO and regular diets, for lunch on August 5, 2024, as indicated on the menu. These failures have the potential for 45 of 52 highly vulnerable residents to have altered nutrition intake and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored/prepared under sanitary conditions when: 1. Shelf under coffee maker had crumbs and dust and this had the potential to attract pests and for microorganism (bacteria) growth. 2. Floor under shelves in the dry storage had a build-up of food crumbs, white crumbs under one shelf and a liquid spill which can attract pests and cause microorganism growth. 3. Old food and dust under the fridges stored in the staff lounge and this had the potential to attract pests and microorganism growth. 4. Ice machine had some black and yellow discoloration in the area where ice is formed which can potentially contaminate the ice. These failures had the potential to contaminate resident's food and cause food illness to 52 out of 52 vulnerable residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs when the regular diet (no modifications) meatloaf was not served to 26 residents who are on a medically prescribed mechanical soft diet (designed for people who have trouble chewing and swallowing) instead of meatloaf that is mashable and topped with gravy. This failure had the result to increase the risks of choking and aspiration (process when swallowing food enters the lungs) for 26 out of 52 highly vulnerable residents.

Inspectors wroteBased on interview and record review, facility failed to ensure that a Minimum Data Set (MDS- a computerized assessment instrument) Discharge Assessment was completed and transmitted in accordance with federal guidelines for one of three residents (Resident 53) reviewed for residents assessment. This failure resulted in Resident 53's assessment not completed upon discharge on [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one of 55 sampled residents (Resident 58) when tube feeding (process where food is delivered into the stomach by a machine) was not administered based on physician order. This failure had the potential to result in decline in function and unplanned weight change to Resident 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have nursing staff with appropriate competencies and skills set to provide nursing services to Resident 58 when he only received 940 ml (milliliters - unit of measure) of tube feeding (supply of food delivered via tube to the stomach) but should have received 1200 ml (millimeters) of medically prescribed enteral tube feeding formula as ordered by his physician on August 6, 2024. This failure had the potential to result in altered nutrition status for one of 55 medically compromised residents.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure medication for one of seven sampled residents (Resident 42) observed for medication administration, was administered according to the physician's orders, when Resident 42 received Omeprazole [medication prescribe to minimize the acid reflex] after breakfast, on August 7, 2024. This failure has the potential to cause less effective management of Resident 42's condition, as the medication may not work as intended when taken after meal.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications under proper temperature control, as specified by the manufacturer when two vaccine solutions were found inside the medication cart (used to transport medication between patients' rooms), instead of the refrigerator. This failure had the potential to increase the risk of residents receiving vaccine medications with decreased efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a representative (ensures residents wishes are respected) was in place for two of three sampled residents (Resident 1 and Resident 2). Resident 1 and Resident 2 had impaired decision making abilities and did not have a representative in place to give consent for medical decisions. This failure resulted in two clinically compromised residents making medical decisions in which resident 1 and resident 2 were unable to understand or comprehend based on their History and Physical.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a repeated resident to resident altercation, for one of three sampled residents (Resident 2) when Resident 2 had been placed on 1:1 (one-to-one) monitoring (one-to-one monitoring uses continuous staff observation to safeguard patients judged likely to harm themselves or others) and the monitor stepped away from Resident 2 leaving him unattended. This failure had the potential to cause Resident 2 to begin an altercation with another resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Three oranges and seven onions with mold were found in the kitchen inside of a plastic box. 2. A box of 14 yellow squash was wet and leaking inside of the refrigerator, that was stored in the central supply room. 3. Thirty two ounces (unit of weight) of plain yogurt container found inside the refrigerator expired. 4. The ice machine was found dusty outside and inside with dark black stain seen on both sides of the ice maker tray. 5. A shelf storing clean water pitchers were stored in the Central Supply room, near the laundry room. These failures had the potential to contaminate resident's food and cause food -borne illness to a population 56 medically compromised residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their infection control practices were implemented in accordance with their policy and procedure when: 1. One of the kitchen sink air gaps (a form of backflow prevention device) had black, brown grime. 2. Two bar guns (a device used to serve types of carbonated drinks and non-cabonated drinks) were found to contain red residual fluid and were not clear. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to 56 medically compromised residents and staff in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (Residents 10, 54, and 64) of five sampled residents received care in accordance with the facility's policy and procedure. 1. For Resident 10 and 64, the facility failed to ensure their blood sugar levels were monitored and documented prior to administering insulin (medication used to lower blood sugar) according to physician's order. 2. For Resident 54, the facility failed to ensure weekly weights monitoring were carried out per physician's order. These failures had the potential to result in harm or death of the resident from medical complications caused by elevated or decreased blood sugar levels and resident harm from complications of nutritional deficiencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the privacy of personal information for five of five sampled residents (Resident's 40, 6, 42, 10, and 19) when Licensed Vocational Nurse 1 (LVN 1) left the electronic health record (EHR) exposed to public view during medication administration. This failure had the potential to violate Resident 40, 6, 42, 10, and 19's right to privacy and confidentiality of medical information.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) assessments were completed accurately to reflect the residents' current health status, care, and services for one of eight residents' (Resident 4) reviewed for antibiotic therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- a screening done upon admission into a facility to determine if a resident with serious mental illness and/or intellectual/development disability require nursing facility services and/or specialized services) was completed accurately for one resident reviewed for PASSR (Resident 12). This failure had the potential to delay identification and treatment of Resident 12's mental disorder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure secure storage of medications when: 1. The central supply medication storage cabinet was found open and unattended on June 26, 2023, at 9:55 AM. 2. The medication storage room was found open and unattended on June 26, 2023, at 10:01 AM and June 27, 2023, at 12:42 PM. 3. The treatment cart #3 was left unlocked and unattended on June 26, 2023, at 11:30 AM. These failures had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 56 residents.

Inspectors wroteBased on interview and record review the facility failed to designate a qualified Director of Food Services to provide oversight of the dietary department which includes, implementing menus, purchasing food, training of staff, and ensuring compliance with all state and federal regulations. This failure had the potential to result in a lack of effective oversight in the operations of the dietary department and supervision which could lead to poor quality of services in the dietary department.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and serve food that conserved flavor and appearance when: 1. Five packages of flour tortillas were found dry and had expired 10 days ago. This failure had the potential to cause food-borne illness (stomach issues from expired and contaminated food) and less palatable.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the antibiotic stewardship program (a program to measure and improve how antibiotics are prescribed by clinicians and used by patients) was implemented in accordance with facility policy when the monitoring of antibiotic usage and resistance data (monitoring the effectiveness of the antibiotics) were not documented for two consecutive months (May and June 2023). This failure had the potential to inaccurately monitor the use of antibiotics for 56 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure equipment was maintained in safe operating condition when: One of three refrigerators observed, had condensation (water) dripping from the top of the refrigerator to the bottom area. This failure had the potential for the refrigerator to not function properly to cool the food and/or contamination of the food stored inside the refrigerator which could cause foodborne illnesses to a population of 56 medically compromised residents who received food from the kitchen.