Ventura Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure the ice machine was properly and routinely sanitized according to facility policy and procedures (P&P) and manufacturer's service manual. This failure had the potential to result in the growth of harmful microorganisms which can cause foodborne illness to its vulnerable residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure fingernail care was provided for 3 of 16 sampled residents (Residents 9, 43, and 45). This failure had the potential to negatively affect their self-esteem, comfort, and personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one emergency drug supply kit (e-kit) was secured when not in use. This failure had the potential to allow unauthorized personnel access to emergency drug supply.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan interventions were implemented for one of five sampled residents (Resident 6). This failure had the potential to result in Resident 6's needs not being met.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure one of four sampled residents (Resident 14) received consistent professional care as a dialysis resident when the resident's dialysis access site was not assessed pre and post dialysis. In addition, licensed nurses documented in error. This failure had the potential for Resident 14 to have unassessed complications and resulted in an inaccurate medical record.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders were followed and appropriately implemented for one of three sampled residents (Resident 1) when: 1. Blood pressure (BP) parameters were not followed, as ordered, prior to Resident 1 receiving the medication Carvedilol (a medication used to lower BP). 2. The physician was not notified, as ordered, of Resident 1's elevated blood sugar levels on two occasions. These failures had the potential to result in the inappropriate delivery of care and services to the resident affecting health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the exterior metal framed sliding glass door across the hallway that led to outside of the facility opens and closes properly. The sliding glass door partially opens and could not be securely closed . This failure has the potential for cold air from outside to go thru the unclosed glass sliding door, placing residents at risk to have a cold environment /temperature inside the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents rights and dignity for one of 19 sampled residents (Resident 17) was upheld when staff did not document what personal belongings the resident have and did not informed the resident of it's whereabouts . This failure had the potential for the resident to not have access to his own belongings which can result to loss of rights and also may cause some mental anguish .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions in the facility kitchen area was maintained when the back wall of the dishwashing machine and the main drain basin floor were found with build up , uncleaned substance /rust , chipped and worned out tiles. This failure has the potential to harbor the growth of bacteria (microscopic living organisms that effect skin, lungs, brain, blood and other parts of your body) which can be spread to all .

Inspectors wroteBased on record review and interview, the facility failed to ensure the the Minimum Data Set (MDS - a tool used to assess all residents in Medicare or Medicaid certified nursing homes) quarterly assessment was completed on time for 1 of 1 unsampled residents (Resident 18). This failure resulted in the non complaince of the assessment as set by the Centers of medicaid and medicare services (CMS).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS - a tool used to assess all residents in Medicare or Medicaid certified nursing homes) assessment reflected the accurate assessment for 3 of 19 sampled residents (Resident 560, Resident 50, and Resident 2) when: 1. Resident 560's language preference was not accurately reflected . 2. Resident 50's most recent fall was not reflected in the assessment. 3. Resident 2 's assessment did not reflect appropriate skin assessments, treatment, and wound care . This failure has the potential to not create an accurate resident condition which can affect the implementation or creation of a plan of care .

Inspectors wroteBased on interview, and record review, the facility failed to ensure : develop and update the comprehensive care plan, for 2 of 19 sampled residents (Resident 13 and Resident 17) when: 1. Resident 13's care plan did not reflect, a newly discovered medication allergy (Cefazolin- cephalosporin antibiotics - kills bacteria ) as stated in the Hospitalization admission Note (HAN) dated 1/6/23. This failure had the potential to place the resident at risk for an allergic reaction . 2. Resident 17 had no long term stay care plan when discharge plans were changed . This failure has the potential for resident's long term needs to be not met .

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 19 sampled residents (Resident 47) was not served food the resident was allergic to as indicated . This failure had the potential for the resident to have an allergic reaction which be detrimental to the resident's overall condition.

Inspectors wroteBased on observation and interview, the facility failed to safely secure the gas pipe of the oven. This failure has the potential for broken pipes leading to gas leaks resulting to a fire . Findings . During an observation on 12/6/23 on 7:35 a.m., at the kitchen, the gas pipe located at the back of the oven has an inverse T-shaped wooden structure measuring 2X4 inches that supports the gas pipe but was not properly secured. During an interview on 12/6/23 at 8:20 a.m., with the Mainternance Supervisor (MTS), MTS verbalized I have been working here for about 40 years, I could not remember exactly when I placed the wooden stand but that was used to support the gas pipe. I never placed a more permanent fixture. During a review of Policy and Procedure (P&P) titled Safety and Supervision of Residents dated 5/15, the Safety and Supervision of Residents indicated in part: [...]

Inspectors wroteBased on record review and interview, the facility failed to formulate an advanced directive (a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated), for one of 16 sampled residents (Resident 1), and have this information be readily available in the resident's medical record. This failure had the potential for facility staff and emergency personnel to not be informed whether life-sustaining treatments be provided or not to the resident in the event of a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for one of sixteen sampled residents (Resident 47) per regulation and facility policy and procedure (P&P) titled, Activities of Daily Living, Quality of Care, Routine Resident Monitoring, and Scope of Services. This facility failure has the potential for Resident 47 to have complications and difficulty walking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of sixteen sampled residents (Resident 18) received restorative nursing assistance (RNA - person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) services per physician order and facility policy and procedure (P&P), Rehabilitative Nursing Care, dated April 2013. This facility failure resulted in Resident 18 not being out of bed, and has the potential for: 1. loneliness and isolation; 2. worsening stage IV pressure ulcer injury; and 3. Resident 18 not achieving or maintaining optimal level of care.