The Village Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was developed for resident's discharge plans, for one of three residents reviewed (Resident A). This failure had potential for the staff not to be aware of discharge plans for Resident A.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen were observed, when: 1. Dust was found in multiple areas of the kitchen and on several kitchen equipment; 2. Grime buildup was found on the bottom of the cold storage shelves and on the walk in Refrigerator's (Ref) # (number) 1 inner door; and 3. Multiple residents' food items were stored in the nurses' station refrigerator undated and out of date. These failures had the potential to place residents at risk for food-borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and/or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the residents' wishes regarding their care were maintained, for four of six residents reviewed for Advance Directives (AD - a written instruction relating to the provision of health care when the individual is incapacitated) (Residents 3, 13, 93 , and 26) , when: 1. Resident 3, 13, and 93's ADs were not readily available in their charts; and 2. For Resident 26, there was no documented evidence information was provided to the resident regarding AD formulation. These failures had the potential for the resident's decisions regarding their healthcare and treatment to not be honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medical supplies and medication conformed to national standards and the facility policy and procedure when: 1. During medication administration observation, Resident 95's furosemide (medication used to help the body get rid of extra fluid and salt) bubble pack label did not include the blood pressure holding parameters (instructions for when the medication should not be given). This failure had the potential for the medication to be administered outside of holding parameters. 2. During medication storage inspection, the following were observed: a. Three bottles of iron tablets, with expiration dates of April 2025, were stored in the medication cabinet readily available for use; b. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Food and Nutrition Services associates were trained and competent to carry out the functions of the department safely and effectively when: 1. Food Service (FS) staff did not use three separate steps (wash, rinse and sanitize) to clean and sanitize work surfaces and soiled equipment, according to the facility's policy and procedure; and 2. FS staff did not follow the manufacturer's guidelines for the length of time required for dipping the test strip into the sanitizer (sanitizing solution used for sanitizing food contact surfaces) when testing the concentration of the sanitizer. These failures had the potential for food utensils and dishes to be improperly sanitized, and may result in food-borne illnesses in the vulnerable resident population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Food and Nutrition Services staff followed the Cook's spreadsheet when: 1. For Residents 14 and Resident 25, the appropriate dessert was not served during lunch on June 9, 2025; and 2. For Residents 14, 18, and 25, the pot roast meat was not served with gravy during lunch on June 9, 2025. These failures had the potential for residents on oral diets to not receive the adequate nutrition which can further compromise their medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided, for nine of nine residents reviewed (Residents 14, 142, 2, 3, 93, 20, 241, 18, and 17), when: 1. Residents on mechanical soft diet did not receive ground pork and chopped vegetables according to the cook's spreadsheet during lunch on June 9, 2025; and 2. Residents on mechanical soft diet were served with potatoes skin during lunch on June 9, 2025. These failures had the potential for the residents to choke on the food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented, when Licensed Vocational Nurse (LVN) 1 was observed removing one tablet of Metoprolol (a blood pressure medication) from the medicine cup using bare forefinger, during medication administration observation. In addition, LVN 1 was observed not disinfecting the blood pressure (BP) apparatus before and after resident use. These failures had the potential to spread infection among the vulnerable residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper maintenance of essential equipment, when water was found dripping from the condenser unit (removes heat from the refrigerator and cooling it down to a liquid state) of Refrigerator (Ref) #3 . This failure had the potential to place residents at risk for food-borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner, in accordance with professional standards for food service safety, when: 1. Stacks of dirty pots, pans, and dishes in the three-sections sink area, several with food on them and more dirty dishes noted on a metal shelf across from the three-section sink, one filled with an egg like mixture. 2. Food particles, crumbs, a cookie, broken eggshells, a plastic bowl, and various wrappers were under the stoves and ovens. This failure had the potential to attract further rodents in the kitchen who could transmit disease to 43 of 44 medically compromised residents by contaminating food and food contact surfaces.

Inspectors wroteBased on interview and record review the facility failed to ensure three (Resident D, E, and F) of 13 residents (Residents D, E, and F), received treatment and care in accordance with professional standards of practice to meet each resident's highest practicable physical, mental, and psychosocial well-being, when: 1. Resident D did not receive antibiotic (used to treat infection) medication as ordered by the physician. In addition, the topical treatments for Resident D's moisture associated skin damage (MASD - skin inflammation that occurs when the skin is exposed to moisture for a long time); 2. Resident E's neurocheck (a series of tests to check the brain, spinal cord, and nerve function) was not conducted according to the physician's order after the resident fell; and 3. Resident F was not administered medication to address constipation according to the physician's order. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure accurate skin assessments and wound care treatment were provided to promote the healing and prevention of new pressure injuries from developing, for three of 13 residents (Residents A, B, and C). These failures have the potential to result in delayed wound healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of physical abuse, for one of three residents (Resident G), was reported to the California Department of Public Health (CDPH - State Agency) immediately or within two hours after the facility was made aware of the alleged abuse. This failure resulted in a delayed investigation by CDPH and had the potential to expose the resident to further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation of an allegation of physical abuse was conducted, for one of three residents (Resident G), after the facility was made aware of the allegation of abuse. This failure had the potential to result in further abuse for Resident G, which could affect the resident's emotional and psychosocial well-being.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure, for four of six residents reviewed (Residents A, B, C, and D), wound management to treat pressure ulcers (localized area of skin and tissue damage caused by prolonged pressure on the skin) was provided according to the plan of care, when: 1. For Resident A, there was no comprehensive assessment (indicating measurement, color, tissue appearance, presence of drainage, odor, appearance of surrounding tissue) of the re-opened sacral wound; 2. For Resident B, there was no comprehensive assessment of the wound on the bilateral buttocks upon admission. In addition, there was no weekly re-evaluation of the bilateral buttocks wound the week of September 18 to 20, 2024; 3. For Resident C, there was no treatment provided to the left buttock pressure ulcer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, for two of three sampled residents (Resident 17 and 28), when: 1. The facility's Registered Dietitian (RD) failed to: a. Follow the facility's policy titled, Nutritional Assessment, to assess Resident 17's nutritional status; and monitor the effectiveness of nutritional interventions for Resident 17; and b. Follow the facility's policy titled, Weight Assessment and Intervention, to identify an unplanned severe weight loss in a timely manner for Resident 17. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was obtained from the resident or resident representative for the use of psychotropic (medications that affect the mind, emotions, and behavior) medications, for four of five residents reviewed for unnecessary medications (Residents 12, 15, 17, and 19),when the facility's informed consent forms were not properly completed and signed by the resident or resident representative and the physician who obtained the informed consent. This failure resulted in the resident and/or resident's representative to not be informed of the risk and benefits of the proposed care and treatment regarding the use of the psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Three of five emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened. This failure had the potential for emergency medication to be unavailable when needed. 2. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Drug Control Receipt Record/Disposition Form (count sheet - an inventory sheet that keeps record of the usage of controlled medications), for two of four residents reviewed (Residents 17 and 19). This failure had the potential to not have an accurate accountability of controlled medications and the potential for abuse or misuse of these medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the temperature in the medication refrigerator was monitored twice daily, according to the facility's protocol. This failure had the potential for the medications stored in the medication refrigerator to not be stored in a proper temperature to maintain its efficacy and/or full therapeutic effects in which can lead to unsafe administration of medications to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food service employees were able to carry out the functions of food and nutrition services safely and effectively when: 1. Prep [NAME] did not document the cooling process for tuna salad made on May 20, 2024; 2. Prep [NAME] and [NAME] 2 were unable to demonstrate the cooling process for tuna salad; 3. [NAME] 2 did not know how to calibrate thermometer; 4. Dishwasher 2 did not know how long kitchenware need to immerse into sanitizer; 5. Dishwasher 1 and Dishwasher 2 did not follow manufacturer guideline instruction time length for dipping test strip in sanitizer to check the concentration of sanitizer; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were implemented when: 1. Prep [NAME] did not monitor the cooling process for tuna salad prepared on May 20, 2024; (Cross reference 802) 2. Dishwasher 1 did not cover his mustache; 3. Can opener base had residue buildup; 4. Rusted shelves were found in the kitchen; 5. Dust was found in the kitchen; 6. Trash were found on the walk-in freezer floor; 7. The ice machine's deflector (a piece of plastic cover inside ice bin to prevent harvested ice from filling up in the front of the storage bin) had residue buildup; 8. [NAME] shelves' plastic coating in refrigerator number (#) 4 was worn off; 9. The vent above the stove was covered with grease and dust; 10. Opened food items exposed to air in the walk-in freezer; 11. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated for the use of apixaban (medication that helps prevent blood clots), for two of five residents (Residents 8 and 12). This failure had the potential to result in the delay in treatment and care for Residents 8 and 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), for one of five sampled residents (Resident 19), when: 1. Zoloft (another name for sertraline [a psychotropic medication for depression]) was administered without adequate behavioral and manufacturer's specified monitoring documented during use; and 2. Escitalopram (a psychotropic medication for depression) was administered without adequate behavioral monitoring documented during use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four residents (Residents 8 and 12) who were receiving Eliquis (another name for apixaban [medication to prevent clots]) were free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of side effects related to the use Eliquis. This failure had the potential for the side effects of Eliquis (such as bleeding, excessive bruising, and others) medication to be undetected or unrecognized for timely intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of five sampled residents (Resident 19) was free from unnecessary psychotropic (affects brain activities associated with mental processes and behavior) medications when: 1. Resident 19 was receiving Zoloft (another name for sertraline [a psychotropic medication for depression - mood disorder]) and was administered without adequate behavioral and manufacturer specified monitoring documented; 2. Resident 19 was receiving Escitalopram (medication for depression) and was administered without adequate behavioral monitoring documented; and 3. Resident 19 was receiving PRN (as-needed) Xanax (another name for alprazolam (medication for anxiety [feeling of restlessness) and was administered without prescriber-documented rationale and specified duration for extended use beyond 14 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rates are below 5 percent, for two of ten residents (Residents 131 & 138), observed during medication administration. These failures resulted in medication error rate of 19.23 percent in which resulted in medications not to be given according to the physician orders. In addition, these failures had the potential for the residents to not receive the full therapeutic (relating to the healing of disease) effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided, for two of two residents (Resident 135 and 281) who had a physician-prescribed pureed diet (food that has been grounded, pressed and/or strained to a soft smooth consistency like pudding). This failure had the potential to place the residents at risk of aspiration (accidentally inhaling food or liquid into the lungs), choking, and decreased meal intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the diet order was followed according to the physician's order, for two out of nine sampled residents (Residents 12 and 15) when: 1. Resident 12, did not receive large portions on May 21,2024 lunch meal tray according to the diet ordered by the physician; and 2. Resident 15, did not receive fortified food items (food items enriched with high calories to help gain weight) on May 21, 2024 lunch meal tray according to the diet ordered by the physician. These failures had the potential to result in not improving Resident 12 and 15's weight, further compromising Resident 12 and 15's nutritional and medical overall condition.

Inspectors wroteBased on observation, interview, and record review, the facility did not implement and maintain infection control procedures when the licensed nurse did not disinfect a shared stethoscope between each resident use. This failure had the potential to spread infection that could risk the health and well - being of 2 of 37 medically compromised residents (Residents 138 and 181).

Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment was provided for three of the six residents (Residents 2, 4 and 5) as evidenced by the following: 1. For Residents 4 and 5, intravenous (IV - given through the veins) medication was not administered in accordance with the physician order. This failure had the potential to result in infection not resolving and could lead to hospitalization; and 2. For Residents 2 and 4, wound treatment was not provided as ordered by the physician. This failure had the potential to result in delayed wound healing for the resident's skin condition to achieve their highest practicable level of physical and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to do a dressing change on a peripherally inserted central catheter (PICC-is a thin flexible tube that is inserted into a vein in the upper arm and used to give intravenous fluids and other drugs) as ordered by the physician, for one of six sample residents (Resident 4). This failure increased the potential for Resident 4 to acquire an infection to the area where the catheter was placed which can spread to the resident's blood and other parts of the body.

Inspectors wroteBased on observation, interview, and record review, for one (Resident 1) of three residents, the facility failed to admit Resident 1 to the facility when a bed was not made readily available for an arranged admission on [DATE]. The facility's failure to make a bed readily available for a pre-arranged admission resulted in a denial of Resident 1's entry and admission on [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of three residents reviewed for nutrition (Resident 22), when: 1. Weekly weights monitoring were not completed as ordered by the physician; and 2. There was no assessment and interventions initiated to address Resident 22's continued poor food intake and weight loss. In addition, there was no follow up assessment conducted by the Registered Dietitian (RD) to address Resident 22's poor food intake and weight loss. These failures resulted in Resident 22 to have a weight loss of 16.1 pounds (lbs.)/10% (percent) from December 16, 2021 to January 12, 2022 (27 days), which could subsesquently cause further decline in the health status of Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The food service department had no system for ambient food (food that can be safely stored at room temperature in a sealed container, for example, canned tuna fish) cooling down process; 2. Improper labeling for thawing meat; and 3. A tray of diced chicken was found in the walk-in refrigerator, and was passed the used-by-date and not discarded. These failures had the potential to cause foodborne illnesses in a medically vulnerable population of 20 out of total census of 21 residents who received food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean environment for the residents and visitors when one garbage disposal bin located outside by the kitchen was overflowing and was not securely closed with the dumpster lid. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and rcord review, the facility failed to ensure range of motion (ROM) exercises were provided according to the physician's orders, for three of four residents reviewed for limited ROM (Residents 2, 8, and 12). This failure had the potential to result in a decline in the residents' ROM and could affect the residents' activities of daily living for Resident 2, 8, and 12.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed during the lunch meal on January 10, 2022, when the menu item, zucchini, was substituted by the yellow squash without notifying the Food Service Director or facility Registered Dietitian (RD). This failure had potential to compromise residents' intake when the planned menu was not followed. There were 20 out of 21 residents received meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when multiple facility staff did not wear proper PPE (Personal Protective Equipment - mask, gown, gloves, face shield or goggles) when surgical mask was placed on top of the N95 mask (a mask to filter airborne particles) while providing care to the residents inside the PUI Unit (Person Under Investigation - a resident suspected of having or exposed to COVID-19 [coronavirus-an illness caused by a virus that can spread from person to person]). This failures had the potential to result in the transmission of infection to an already vulnerable population of residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure information regarding formulating an Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions) was provided to the resident, for one of nine residents reviewed for AD (Resident 20). This failure had the potential for Resident 20, to not be able to exercise their rights to formulate an Advance Directive.