Valencia Gardens Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that medications were administered according to physician ordered parameters for two of three residents reviewed (Resident 2 and 8) when:1. For Resident 2, the licensed nurse administered the medication Losartan (high blood pressure medication) 25 mg (mg - unit of measurement) outside of the physician ordered parameters of hold for SBP (systolic [top number of blood pressure] blood pressure) less than 140 mmhg (mmhg - unit of measurement); and2. For Resident 8, the licensed nurse administered the medication Carvedilol (high blood pressure medication) 3.125 mg outside of the physician ordered parameters of hold for SBP less than 110 mmhg. This failure had the potential for Resident 2 and 8 to experience undesired hypotension.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. For Resident 7, Certified Nursing Assistant (CNA) 2 failed to use the disposable gown provided for Enhanced Barrier Precautions (EBP - infection prevention practices using gowns and gloves during high-contact resident care activities to reduce the spread of multidrug resistant organisms [MDRO] - a germ that is resistant to many antibiotics) when providing direct care; and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents reviewed for accommodation of needs (Resident 11) was offerred access to his wheelchair for daily activities and a shower chair on shower days. This failure had the potential to result in Resident 11 feeling a loss of independence, dignity, and continued well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment and evaluation for self-administration of medication for Orajel (a topical treatment for the mouth and gums to relieve pain) was completed, and had a physician order, for one of 55 residents reviewed (Resident 7). In addition, the facility failed to ensure the medication was stored properly and securely. This failed practice increased the potential for unsafe self-administration of medication for Resident 7, and the potential for visitors, and other residents to have access to the medication, which was stored at the bedside of Resident 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one resident of two residents (Resident 6) when:1. The physician was not contacted when Resident 6 blood sugar was below ordered parameters.2. Resident 6 received hypertension (high blood pressure) medication when blood pressure was below physician ordered parameters. This failure had the potential for Resident 6 to have adverse effects of hypoglycemic (low blood sugar) and hypotension (low blood pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the required bedroom space, measuring at least 80 square feet per resident, in 12 resident rooms (Rooms: 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34).

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the discharge notice to the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) the same time the notice of the discharge was provided to the resident or resident ' s representative for two of six sampled residents (Residents 1 and 3). This failure has the potential for the Ombudsman not be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure the interventions provided to Resident 1 when she had a low blood sugar level of 37 (hypoglycemia), was documented in the medical record. This failure had the potential to affect Resident' 1's health and make it harder for nursing staff to communicate effectively and provide proper care.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) for three of four random sampled residents (Residents 1, 18, and 247) when a random controlled medication audit did not reconcile. The controlled medications were signed out of the Medication Count Sheet (a controlled drug record, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability of controlled medications, which had the potential for misuse or diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to hold the administration of the the medication Hydralazine Hydrochloride (medication used to control high blood pressure) for the systolic blood pressure (top number) less than 130 for one resident reviewed (Resident 35). This failure resulted in Resident 35 receiving the medication multiple times below the prescribed parameter as ordered by the physician from May 11, 2024 through June 3, 2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Dietary Aide (DA) 3 did not follow the facility cleaning procedure to clean food preparation surface and stationary equipment (Cross referred F 812); 2. Two kitchen staff did not document the cooling process on June 2, 2024 for making boiled eggs (Cook 2) and on June 2, 2024, for making tuna salad (Dietary Aide 1); 3. [NAME] 3 did not know how to calibrate a thermometer; 4. [NAME] 1 did not follow the time length according to manufacturer's guidelines for dipping the test strip in the sanitizer (sanitizing solution used for sanitizing food contact surfaces); and 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritional needs for three of eight sample residents (Residents 297, 25, and 26), was met, when the meal was not served in accordance with menu guidance for lunch when: 1. Resident 297, who was on a physician prescribed Fortified diet (diet with added extra nutrients to increase calories and/or protein density to promote improvement in residents' nutritional status), received diet Jello instead regular Jello on June 3, 2024, lunch and received 1 package of dressing instead of 2 packages of dressing on June 4, 2024, lunch; 2. Resident 25, who was on a physician prescribed Controlled Carbohydrate Diet (CCDO: a meal plan for diabetic residents), received regular dessert instead of diet dessert on June 4, 2024; and 3. [...]

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. Food service workers did not follow the facility cleaning procedure to clean food preparation surfaces; 2. Dust found in several areas in kitchen, ice machine room and dry storage room; 3. Poor quality produce found in walk-in refrigerator; 4. Can opener and base had buildup; 5. Blender had buildup; 6. Floor in the kitchen and dry storage room found dust and food particles; 7. The hot water spout on the coffee maker had hard water buildup; 8. One food container stacked wet in dry storage room; 9. Bottom of small oven found black particles; 10. Two opened food items exposed to air in reach-in freezer; 11. A container which stored Margarine did not have an identification label and date; and 12. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control and prevention practices were observed when: 1. For Resident 147, there was no enhanced barrier precaution (EBP - an infection control method that use personal protective equipment [PPE - medical equipment for protection] to reduce the spread of infection) sign posted and there was no container found in the room to dispose the used cloth gowns and linens to care for the resident who had a urinary catheter (a flexible tube used to empty the bladder [body organ that stores urine]) in place; 2. Nursing staff failed to properly clean and disinfect a shared automatic blood pressure (BP - pressure of blood in blood vessels) cuff machine after use according to the facility's policy for Resident 101; 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure equipment in the kitchen was clean and maintained in a safe operating condition when: 1. There was ice buildup in reach-in freezer; 2. Three out of three cracked white shelves in reach-in freezer; 3. The bottom shelf of the prep table corrosion; 4. Two out of two silver storage shelves found had rust in dry storage room at kitchen; 5. One blue cutting board a rough surface; and 6. The drying dome rack had cracked coating with exposed rusting metal. These failures had the potential for equipment not functioning in the way they were intended and in turn cause contamination of food which could lead to food borne illnesses for 48 out of 50 residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure an effective pest control program was in place for the kitchen, when a gnat was observed in a storage room on June 3, 2024, and four house flies were observed flying and landing in the kitchen on June 4, 2024. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in the facility residents who eat food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident reviewed (Resident 297) was treated with respect and dignity by failing to ensure Resident 297's indwelling urinary catheter (medical device that helps drain urine from your bladder) drainage bag (holds the urine) had a dignity bag (a bag used to cover a urinary drainage bag, so it was not visible). This deficient practice had the potential to cause Resident 297 psychosocial harm and for the resident to feel embarrassed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs for one resident reviewed (Resident 30), when the call light button was observed not within reach. This failure had the potential for Resident 30 not to be able to call staff for assistance which could result in the resident's needs going unmet.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's family member (FM) of the change in condition and transfer to the acute hospital for one of three residents reviewed for closed record (Resident 45). This failure resulted in Resident 45's FM looking for Resident 45 two days after Resident 45 had a change in condition and was transferred to the acute hospital on March 10, 2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the resident's care plan when one resident reviewed (Resident 8) was transferred to the hospital for chest pain. This failure had the potentail to delay the necessary care and services for Resident 8 when the care plan was not updated with specific measurable goals and interventions for his chest pain when he returned to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain the pacemaker (a device used to treat irregular heart beats) information and include the information in the plan of care for two of three residents reviewed (Residents 8 and 97). This failure resulted in Resident 8 and 97 not being seen and evaluated by their cardiologists (doctor specializing in the heart) and the facility staff not having information about the residents' pacemaker, which could delay the necessary care and services if the pacemaker malfunctioned.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment in accordance with the facility's policy and procedure for one of three residents (Resident 147) reviewed for oxygen administration when Resident 147 was administered oxygen without a physician's order. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in Resident 147's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 13.89% when five medication errors occurred out of 36 opportunities during medication administration for two out of four residents (Residents 32 & 101). This failure resulted in medications not given according to physician's orders and had the potential for Resident 32 and Resident 101 to not receive the full therapeutic (relating to the healing of disease) effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the required bedroom space, measuring at least 80 square feet per resident, in 12 resident rooms (Rooms 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure COVID-19 (an infectious disease caused by SARS-CoV-2 Virus) outbreak was reported when a resident with symptom had tested positive for COVID-19 infection on September 4, 2023. The facility failure had delayed early intervention to monitor and prevent virus spread and proliferation as reporting was intended to facilitate timely intervention.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the required bedroom space, measuring at least 80 square feet per resident, in 12 resident rooms (Rooms: 16, 17, 19, 21, 23, 24, 27, 29, 30, 32, 33, and 34).