The Villas at Poway

Inspectors wroteBased on interview and record review, the facility failed to obtain residents' weight upon admission for seven of 18 sampled residents (36, 280, 282, 430, 19, 9, 3). In addition, the facility did not ensure input and outputs (I & Os) were documented accurately for one sampled resident (Resident 73) on intravenous (IV - giving medications, fluids, or nutrients directly into the bloodstream through a needle or tube inserted into a vein) medications. These failures had the potential to delay identification of risk factors related to nutrition and hydration for Resident 2, 36, 280, 282, 430, 19, 9, 3, and 73.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure infection control procedures were followed when: A. Resident 36 and Resident 282 were not identified and placed on enhanced barrier precautions (EBP - involves gown and glove use during high-contact resident care activities for residents [example: residents with medical devices]), and licensed staff did not wear a gown when providing care to Resident 36 and Resident 282. B. Licensed Nurses (LN) did not perform hand hygiene (a process of washing hands or using a hand sanitizer) while dispensing medications, when changing gloves in a contact precaution room, and did not sanitize stethoscope and pulse oximeter after resident use. C. A bottle of body spray was found in the drawer of respiratory cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of seven residents reviewed for resident rights, in a dignified manner when one resident (Resident 47) waited for 30 minutes to be served her meal while the other residents ate their meals. This deficient practice had the potential for Resident 47's self-esteem and self-worth to be devalued.

Inspectors wroteBased on interview and record review the facility failed to ensure Advance Directive information was provided to a resident (Resident 10). This failure had the result for Resident 10 to not have the opportunity to express wishes for care if capacity for decision making was lost.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect confidential information for one unsampled resident (Resident 15). This failure had the potential for Resident 15's confidential health information to be accessed by unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (the process of cleaning the blood through a machine) access site was properly cared for one of one resident reviewed for dialysis (Resident 19). This deficient practice had the potential for Resident 19's dialysis access to clot.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four license nurses were knowledgeable in assessing the thrill and bruit (thrills are palpable, vibratory sensations felt on the skin, while bruits are abnormal, audible sounds heard through a stethoscope) related to dialysis (the process of cleaning the blood through a machine) access. This failure had the potential for dialysis access to develop complications that may not be identified timely and addressed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the controlled drug record (CDR- an accounting of controlled medications, drugs with a high abuse potential) reconciled with the medication administration record (MAR- documentation that a resident received a medication) for one of three residents (Resident 3 ). As a result, this failure had the potential for the facility to be unable to readily identify drug diversion (illegal distribution or abuse of prescription drugs) of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications in carts were properly stored and labeled when the following was found in two of twenty medication carts: 1. An expired insulin pen. 2. A use by sticker on a medication bottle was illegible. 3. There was a white pill in an unlabeled medication cup. As a result, medications had the potential to be improperly administered.

Inspectors wroteBased on interview and record review the facility failed to ensure the Medical Director (MD) participated in the development and implementation of written policies and procedures, related to the care of residents receiving dialysis services. This had the potential to affect the effectiveness and quality of care delivered to residents on dialysis. (Cross reference to F698 and F726)

Inspectors wroteBased on interview and record review the facility failed to ensure accurate documentation related to: 1. Advance Directives for two residents (10, 131). 2. A documentation for a resident's capacity to understand and make decisions was missing for one resident (40) 3. Resident's consent for treatment was incomplete (40). This failure resulted in conflicting records regarding the presence of Advance Directives (10, 31) and did not provide an accurate representation of the care provided and had the potential to cause confusion amongst care providers (40).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 7 was not abused. As a result, Resident 7 experienced abuse from two staff members. In addition, other residents who were cognitively impaired (problem with the ability to think, learn, remember, use judgement, and make decisions) had the potential to suffer abuse from the two staff members.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement policies and procedures for abuse when: a licensed nurse (LN) did not report a witnessed abuse of one resident. (Resident 7). This failure resulted in an incomplete investigation and protection of residents from the perpetrators.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff reported a witnessed physical abuse of a resident (Resident 7) who was cognitively impaired (problem with the ability to think, learn, remember, use judgement, and make decisions) to the facility's administration. This deficient practice had the potential for actual and/or alleged abuse incidents to be unreported and not investigated. In addition, this failure had the potential for residents to be unprotected from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a person-centered care plan was updated for one of three residents (Resident 1) reviewed with osteoporosis (bone disease; weak, brittle bones). This failure had the potential to miscommunicate care related to Resident 1 ' s health and safety when providing care, assistance, and repositioning for Resident 1.

Inspectors wroteBased on observation, interview and record review the facility failed to implement transmission based infection control measures when Licensed Nurse (LN) 2 entered the room of a resident (Resident 1) who tested positive for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) without the required personal protective equipment (PPE, equipment worn to minimize exposure to infection and injury in the workplace). This failure had the potential to increase the risk of COVID-19 transmission to all residents, staff, and visitors at the facility. Findings Include: Resident 1 was admitted to the facility on [DATE] with a diagnosis of respiratory failure, per the residents admission record. On 12/5/23 at 11:31 AM an interview was conducted with LN 1 in the hallway outside Resident 1's room. [...]

Inspectors wroteBased on interview and record review the facility failed to offer bed hold for two residents who were transferred to the acute hospital. (Resident 5 and Resident 6) This failure had the potential for the residents to not be aware of their choice to hold a bed at the facility when transferred to the hospital.

Inspectors wroteBased on observations, interviews, and document reviews, the facility failed to ensure the menu was designed to meet the nutritional needs of the residents on pureed diets. This failure led to twelve (12) residents on pureed diets to receive fewer calories and nutrients which had the potential to further impair their nutrition and health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation protocols were maintained in the kitchen according to standards of practice and facility policy when: 1. Loading dock area, dumpster cart, and area in front of the dumpster were not free of kitchen waste. 2. Ten (10) kitchen floor sink drains were dirty and filled with food waste. 3. An Ice Machine was not properly maintained and cleaned per manufacturer guidelines. 4. An expired supplement was found in a nourishment room refrigerator in the facility nursing station. These failures exposed residents to unsanitary practices in the kitchen, which had the potential to contaminate the food and place residents at risk of developing a foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Loading dock, dumpster cart, and area in front of the dumpster were free of kitchen waste. 2. Food and Nutrition department floor sink drains were free from food waste. These failures provided an unsanitary environment in the kitchen that harbored pests and had the potential to contaminate resident food. The nursing home census was 109 residents.

Inspectors wroteBased on observations, interviews, and document reviews the facility failed to ensure: 1. One ice machine in the main kitchen was maintained in a safe operating condition. 2. One ice machine in the skilled nursing facility (SNF) was maintained and cleaned according to manufacturer's guidelines and standards of practice. This failure created the potential for residents to receive and consume ice from machines that were contaminated with substances resembling mold and other hazardous chemicals, that could lead to foodborne illness and impair health status. The facility census was 109.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the main kitchen area and the skilled nursing home (SNF) were free of pests. This failure had the potential to contaminate food prepared, stored and served to facility residents, which could lead to widespread foodborne illness. The facility census was 109.

Inspectors wrote4. Resident 39 was admitted to the facility on [DATE], with diagnoses which included respiratory failure, per the facility's Patient Information record. On 3/20/23 at 1:53 P.M., and 3/21/23 at 8:26 A.M., an observation was conducted of Resident 39 as she laid in bed. A urinary catheter bag was attached to the right side of the bed frame. The urinary catheter drainage bag contained pale yellow urine and was visible from the hallway. A dignity bag (a dark colored bag, used to promote dignity of catheterized patients by concealing urinary drainage bags from public view) was not present. On 3/20/23, Resident 39's clinical record was reviewed: According to the physician's order, dated 7/20/22, .Foley (brand name) Catheter FR #16 (size) monitor every shift . [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written summary of the baseline care plans for three of five residents and/or their representatives (Resident 58, 85 and 402), reviewed for comprehensive care plans. This failure had the potential for residents and/or their representatives of not being informed of the resident's initial plan of care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were revised and/or updated for three of five residents (Resident 58, 87 and Resident 402), reviewed for comprehensive care plans when: 1. Resident 58's care plan was not developed for the use of oxygen. 2. Resident 87's care plan for skin integrity did not indicate the current pressure ulcer status, and the use of Negative Wound Pressure Therapy (NWPT- wound vac-suction tubing, and wound dressing to remove excess fluid and any infectious material present in the wound), and Resident 87's wound center follow up appointments. 3. Resident 402's care plan was not updated when Resident 402's current pain medication was ineffective. Failure to revised and/or update the care plans had the potential for delayed care, miscommunication among caregivers, and decreased physical well-being.

Inspectors wroteBased on observation, interview, and record review, the Quality Assessment and Improvement Plan (QAPI-a plan to improve the overall quality of life and quality of care and services delivered to nursing home residents), failed to identify areas of improvement related to: 1. Weight loss (F-692) 2. Kitchen (F-803, F-812, F-814, F-908, F-925 3. Infection control (F-880) As a result, there was the potential to affect the safety and quality of care for residents.

Inspectors wrote2a. Resident 83 was admitted to the facility on [DATE], with diagnoses which included right hip fracture with surgical repair, per the facility's Patient Information record. On 3/20/23 at 10:20 A.M., and on 3/21/23 at 8:11 A.M., an observation was conducted of Resident 83 as she laid in bed. Resident 83 was receiving oxygen at 2 liters (Al) via nasal annular, (NC-a flexible plastic tube that delivers oxygen via the nasal cavities). The oxygen tubing had a handwritten label, dated 3/5/23. On 3/20/23, Resident 83's clinical record was reviewed: According to the physician orders, dated 3/4/23, .O 2 at 2 LP (liters per minute) via NC . There was no physician's order of when to change the oxygen tubing and there was documented evidence on Resident 83's MAR or TAR that oxygen tubing had been changed. On 3/21/23 at 12:03 P.M., an interview was conducted with the ICN. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a sensitive (touch pad) call light was available for one of one resident, (Resident 13) reviewed for accommodation of needs. This failure resulted in Resident 13 not getting his needs met.

Inspectors wroteBased on interview and record review, the facility failed to conduct a quarterly (every three months) MDS assessment (a clinical tool which is submitted to Centers for Medicare & Medicaid Services [CMS]) and submit it to CMS in a timely manner for one of four residents (Resident 74) reviewed for Resident Assessments. As a result, the facility and CMS were delayed in knowing Resident 74's current health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the manufacture's guidelines for low air loss (LAL- a special mattress that provides alternating airflow within the mattress, to relieve pressure), to maintain skin integrity for three of five residents, (Resident 64, 80, 83) reviewed for pressure ulcers. As a result, Residents 64, 80 and 83, had the potential to develop pressure ulcers from incorrect mattress settings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with very low body weight and severe malnutrition risk was assessed according to the facility policy and standards of practice. This failure had the potential to cause additional weight loss and further compromise the one of 22 sampled residents (Resident 85) nutrition and health status.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of five residents (Resident 46 and 92) were monitored for side effects of unnecessary drugs. These failures had the potential for Resident 46 and 92 to have side effects that went undetected by staff.

Inspectors wroteBased on observation, resident and staff interviews and review of facility documents, the facility failed to ensure that residents meals were served at a palatable and appetizing temperature. This finding had the potential to cause reduced food intake and affect nutrition status among medically vulnerable residents on therapeutic diets. The facility census was 109.

Inspectors wroteBased on interview and record review, the facility failed to ensure to have a full-time, certified infection control nurse (ICN-a professional who ensures healthcare workers and patients are doing all the things they should be doing to prevent infections and the spread of infections), who provides assessment, monitoring, development, implementation and management of the facility's infection prevention and control program. This failure had the potential of negatively affecting the quality of care provided to all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents reviewed for dignity, was assisted with meal service in a respectful, and dignified manner (87). As a result, there was the potential for Resident 87 to experience decreased self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for one of three residents (78), reviewed for hearing needs. As a result, there was a potential for Resident 78 to experience decreased socialization and isolation.

Inspectors wroteBased on interview and record review, the facility failed to review, evaluate and document Ativan (a medication to treat anxiety) prn (as needed) in the 14 day time frame for continued usage for three of 13 residents reviewed for psychotropic (mind altering) medications (37,54,57). This failure had the potential for residents to receive unnecessary medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor one of two residents meal preferences for a cola beverage (70). This failure had the potential to decrease fluid intake by not honoring resident's preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu related to Tuscan vegetables and 2% milk. This failure had the potential to not meet the nutritional needs of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove expired food from one of three refrigerators, and there was no process in place to determine freshness of produce. This failure had the potential to expose residents to foodborne illness.