Villa Del Rio Gardens

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 76 and 179) received care to prevent pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) development, by failing to: 1. Implement Resident 179's care plan which indicated staff were to check the resident's skin for presence of sores, breakdown, impairment, and skin trauma, and use pressure reducing devices. 2. Implement its policy which indicated to initiate a care plan to address Resident 76's newly developed deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel, obtain treatment orders, and monitor the effectiveness of the treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in the kitchen when: 1. The foods were not labeled with opened dates, there was no received dates, foods were stored in bins, refrigerator, and freezer without removing from original packaging. 2. The ice machine was not maintained in a clean and sanitary condition to ensure the ice was safe to consume. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 80 of 81 medically compromised residents who received food and ice from the kitchen. Findings. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess two of eight sampled residents' skin integrity (Residents 76 and 179). Cross Referenced F686. This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) on the sacrococcygeal (base of the spine, tailbone) area and Resident 76 developing a deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) on the left heel.

Inspectors wroteBased on interview and record review, the facility failed to perform psychotropic assessments and provide non-pharmacological interventions to Residents 6, 33, 43, and 49 prior to start of psychotropic medications (medication that affects brain activities associated with mental processes and behavior) to ensure the use of psychotropics were necessary to treat a specific condition; and perform a gradual dose reduction ([GDR] an attempt to decrease or discontinue psychotropic medication after no more than three months after starting on the psychotropic medication) for Resident 49. These deficient practices had the potential to result in Residents 6, 33, 43, and 49 receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of the coronavirus disease ([COVID-19 a disease caused by virus called SARs-CoV-2}) an illness caused by a virus that can easily spread from person to person) by failing to: 1. Ensure housekeeping that was assigned to clean the hallway at the green zone (a room or group of rooms designated for residents who do not have nor were exposed to Covid-19) was wearing an N-95 (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air] and prevent infections). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to enhance a resident's dignity and respect by failing to ensure for one of eight residents (13) that Resident 13's wet clothes and bedding were changed timely to prevent strong urine odors. This deficient practice had the potential to negatively affect the resident's psychosocial and physical wellbeing by feelings of being neglected and possible skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Ensure the facility offered/implemented non-pharmacological interventions for one of one Residents 33, before starting Anti-Psychotic (a type of psychiatric medication which is used to treat psychosis [a mental disorder characterized by a disconnection from reality]) medication. b. Ensure that Residents 33 was assessed for the appropriateness of anti-psychotic medication before starting the medications. These deficient practices had the potential to result in Resident 33 receiving unnecessary medications, and adverse effects from those medications.

Inspectors wroteBased on interview, and record review, the facility failed to develop a person- centered care plan for two of two sampled residents (46 and 43), who were taking anti- psychotic (a type of psychiatric medication which is used to treat psychosis [a mental disorder characterized by a disconnection from reality]) medication. This deficiency had the potential to result in a delay in delivery of care and services.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure Resident 20 received the necessary care and services needed to attain the highest practicable level of physical, mental, and psychosocial well-being. These deficient practices had the potential to result in Residents 20 not receiving the quality of care that was needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's physician took an active role in supervising the skin impairment of one of eight sampled residents (Resident 76), who was admitted to the facility with intact skin integrity, as per their policy. This deficient practice had the potential for delay in necessary services, poor continuity of care and follow up on Resident 76's deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Maintain the correct concentration of chlorine (a chemical sanitizing agent) sanitizing agent used in the low-temperature dishwasher, according to the manufacturer's guidelines. b. Ensure one Kitchen Staff performed hand washing before starting work, and prior to handling foods, when in the kitchen area. These deficient practices had the potential to increase the risk of food contamination, which could cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for the residents.

Inspectors wroteBased on interview, and record review, the facility failed to report a change of condition to the attending physician for one of 19 sampled residents (23), when the saturation levels (oxygen level in the blood) registered below the average normal range of between 95 to 100 percent (%). This deficient practice had the potentially caused a delay of medical treatment for Resident 23.

Inspectors wroteBased on interview, and record review, the facility failed to develop a plan of care for the use of Depakote (medication used as a mood stabilizer), for major depression disorder manifested by self-isolation for one of 19 sampled residents (66). This deficient practice placed Resident 66 at increased risk for adverse reactions for the use of Depakote and psychological harm related to isolation.

Inspectors wroteBased on interview, and record review, the facility failed ensure a Registered Nurse (RN) was on duty, for at least eight consecutive hours a day, for three consecutive days (August 11, 12 and 13, 2019). This deficient practice had the potential for the residents not be provided with the appropriate nursing observations, and assessments, which could only be performed by an RN.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare the appropriate consistency of a breaded chicken for a residents who was on a mechanical soft diet (a diet that involves only foods that are physically soft, with the goal of reducing or eliminating the need to chew the food), per the menu, and the physician order. This deficient practiced of not grinding, but cutting the breaded chicken in to one-inch or bigger size, had the potential to place the residents who was to receive mechanical soft diet, at increased risk for choking.

Inspectors wroteBased on interview, and record review, the facility failed to follow its protocols for antibiotic stewardship program (a program designed to optimize the use of antibiotics and reduce the adverse events usually associated with antibiotic use), when administering ciprofloxacin (an antibiotic used to treat infections), to one of 19 sampled residents (47), who did not meet the criteria for antibiotic use while being treated for a urinary tract infection ([UTI] an infection in any part of the urinary system). This deficient practice had the potential to place Resident 47 at risk for the developing antibiotic-resistant organisms (a strain of infectious organisms that developed resistance to antibiotics), and suffer side effects of unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain Refrigerator #2 in safe operating condition. This deficient practice placed the foods kept in Refrigerator #2 at increased risk for spoiling and the resident's at increased risk of foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review the facility failed to identify risks, and hazards by providing a safe living environment for the resident residing in rooms 70, 72, 76, 77, 78, 79, 81, that had long television (TV) cords, that extended down the wall in to an outlet. This failure had the potential for the residents in rooms 70, 72, 76, 77, 78, 79, and 81 to cause accidents, or to induce harm to themselves.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper handling of clothes were followed, when clothes was dropped on the floor, folded, and then placed in the resident's closet. This failure had the potential to cause spread of infection to the residents of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents were treated with respect and dignity for four to five residents sitting at the same table during meals, by being served at the same time. The failure to provide the necessary care left the residents hungry for extended periods of time while looking at others eat, picking at other residents foods, making them anxious, and frustrated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 17 sampled residents (59) was covered and not exposed during incontinence (accidental or involuntary loss of urine from the bladder or bowels) care, skin care and a wound treatment. The failure to provide the necessary care created the potential to make the resident feel embarrassed, uncomfortable and disrespected.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment ([POLST] approach to improving end-of-life care in the United States, encouraging providers to speak with patients and create specific medical orders to be honored by health care workers during a medical crisis) form was completely filled out for one of 17 sampled residents (47). The failure to provide the necessary services did not show communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan with concerns/problems, including measurable goals and interventions for one of 17 sampled residents (26), receiving Tylenol #3 with codeine, without including location of the pain. This deficient practice had the potential of contributing to further pain leading to mismanaged, when the location of the pain was not identified by the staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 17 sampled residents (47) splint was applied to the right upper extremity on a daily basis as ordered by the physician and that his fingernails were cleaned, trimmed and well groomed. The failure to provide the necessary care created the potential for the resident to have increased contractures of his fingers.

Inspectors wroteBased on interview and record review, the facility failed to identify drug irregularities (rationale) during the monthly Medication Regimen Review (MRR), when two anticonvulsant ([seizure] a sudden surge of electrical activity in the brain, a seizure usually affects how a person feels or acts) medications Carbanazepine and Levetiracetam without a documented clinical rationale for one of 17 sampled residents (18).

Inspectors wroteBased on interview and record review, the facility failed to monitor one of 17 sampled residents (18) baseline tegretol levels (medication to treat seizure disorder [ sudden surge of electrical activity in the brain, a seizure usually affects how a person feels or acts]). This deficient practice had the potential for adverse consequences that includes dizziness, fatigue, depression including suicide and worsening of seizures.

Inspectors wroteBased on observation, interview and record review, the facility failed to wash hands while providing incontinence care for one of 17 sampled residents (59), that had a bowel movement. The failure to provide care in a sanitary manner created the potential for the spread of harmful bacteria and the development of disease and/or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one of 17 sampled residents (31) safety by: The resident overhead bed light cover was not left open to prevent the residents from removing the electrical light bulbs from the light socket. This deficient practice had the potential of causing physical harm to the resident.