VI at La Jolla Village

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtained written consent for the use of a bed/chair sensor alarm (a device that detects movement or pressure changes to alert staff for residents at risk of falling) [Resident 51] and for the use of an antipsychotropic medication (treats mental health illnesses such psychosis and schizophrenia) [Resident 1] for two of seven residents reviewed for Resident Rights. This failure had the potential for residents and their responsible parties (RP-a designated person chosen by the resident to represent them in medical and financial decisions), to be uninformed of the risk versus the benefits, for the recommended treatment.1. Resident 51 was admitted to the facility 7/25/2025, after multiple falls at home per the facility's admission Record. Resident 51 had an RP listed on the admission Record. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure non-pharmacological interventions (NPI) were done related to the use of an antidepressant (medication used to treat depression) for one of five residents (Resident 1) reviewed for unnecessary medications. This failure had the potential for Resident 1 to receive unnecessary medications, or more medication than necessary to treat depression (feelings of sadness, hopelessness, and loss of interest in activities).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an activity program to meet the interests of one of one residents reviewed for activities (Resident 3). As a result, Resident 3 was at risk for psychosocial isolation and boredom.

Inspectors wroteBased on interview and record review the facility did not ensure medications were documented according to professional standards of practice for two of five Resident (8,36) sampled residents reviewed for pharmacy services when:1. Documentation of controlled medication (drugs with high abuse potential) was not documented the same time as it was administered to Resident 36.2. Controlled medication prescribed to Resident 8 could not be accounted for when a controlled medication was wasted without a second nurse signature.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled resident (Resident 31) were free of unnecessary medications when Resident 31 received anticoagulant (blood thinner) medications without monitoring for signs and symptoms of side effects. This deficiency had the potential to cause harm due to lack of monitoring for negative side effects of anticoagulant therapy, including excessive bleeding or bruising.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure medication storage cabinet was free from an expired medication. This failure had the potential for medication to have reduced effectiveness and/or medication misuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect one (Resident 1) of four Residents' PHI (protected health information) when Resident 1 was sent out to the emergency room with wrong resident information and documents. As a result, HIPPA (Health Insurance Portability and Accountability Act- a U.S. federal law protecting sensitive patient health information from disclosure without the patient's consent or knowledge) was violated and allowed unconsented disclosure of another resident's PHI.

Inspectors wroteBased on interview and record review, the facility failed to administer medications to the correct resident for one of two sampled residents (1). This failure placed Resident 1 at an increased risk of low blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of neglect (a type of abuse that involves failing to provide care and services to a resident) for one of one resident (Resident 1) within the 24-hour timeframe to the State Survey Agency (SA, where the state law provides for jurisdiction in long term care facilities) of the reported incident. This failure resulted in the delay of facility's abuse investigation and potentially expose Resident 1 and other residents for further neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident-centered care plans were developed for six residents when: 1. Four residents had symptoms of vomiting and/or diarrhea (Resident 2, Resident 3, Resident 4 and Resident 5); 2. Two residents had fall incidents (Resident 1 and Resident 6); 3. A resident ' s bladder incontinence was not addressed (Resident 1) These failures could potentially affect these residents in the care areas that were not care planned. These included proper attention and assessment for dehydration and infection control for Resident 2, Resident 3, Resident 4 and Resident 5; avoiding further falls for Resident 6; preventing injury from further falls for Resident 1; and interventions to address bladder incontinence for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide the needed care for one of three residents (Resident 46) when Resident 46's thoracentesis (procedure to drain fluid out of the lungs) incision site was not monitored. This failure had the potential for nursing staff to not identify any deterioration on Resident 46's incision site which could result in delay of treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 of 29 medication opportunities was administered per standard of practice when Resident 11's Lidocaine patch (medication for pain) was administered without date and time.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage of medications were followed when: 1. 1 of 2 medication rooms (Medication Room # 1) stored 2 expired residents' medications. 2. 1 of 12 sampled residents (Resident 155) had an unattended medication in Resident 155's bedside table. As a result, using expired medications had the potential to affect the medications' action and effectivity. In addition, leaving medications unattended could result in other residents ingesting another resident's medications which could affect the resident's health and safety.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the facility's policy and procedure for infection control were implemented for 2 of 12 residents (Resident 10 and Resident 46) when: 1. Resident 10's breakfast meal tray, that had been placed on the resident's bedside table, was brought back to kitchen and meal items were re-stored back in respective storage (food warmer and refrigerator). 2. Resident 46's used nasal cannula (tubing to deliver oxygen) was not stored in a bag. These failures could result in the spread of infection and cross contamination that could affect the 48 residents in the facility, the facility staff, as well as the visitors.

Inspectors wroteBased on interview and record review the facility failed to consistently use the pain scale when assessing resident pain. The facility also failed to ensure pain medication was administered based on the resident's pain assessment. As a result, residents pain may not have been well controlled.