Villa Health Care Center

Inspectors wroteBased on interview and record review, the facility did not ensure timely delivery and administration of the medication Trelegy (medication used to treat Chronic Obstructive Pulmonary Disease {COPD - a progressive inflammatory lung disease that obstructs airflow}) as ordered by the physician for one of three residents reviewed (Resident 1) for pharmacy services. This failure resulted in resident not receiving medication as ordered by the physician to manage and treat the medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely response to call lights for one out of five residents (Resident 2), who waited approximately 15 minutes for assistance. This failure had the potential to place the resident at risk for unmet care needs and increased the risk for unsafe self-mobility and potential falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of seven sampled residents (Resident 1), the medication Eliquis (a prescription medication that functions as a blood thinner to prevent and treat various types of blood clots) was reconciled with the physician. This failure resulted in Resident 1 receiving four doses at twice the strength, placing her at risk for bleeding and other adverse effects.

Inspectors wroteBased on interview, and record review, the facility failed to follow policy and procedure for safe use of the Hoyer lift, (a portable total patient lifting tool to assist in transferring patients in and out of bed), for one of seven sampled residents, (Resident 2). This failure had the potential to cause injury and resulted in Resident 2 feeling unsafe.

Inspectors wrote5. On June 10, 2025, at 11:41 a.m., an interview was conducted with Resident 37. Resident 37 stated she was not sure if she had an AD and would like more information. A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility on [DATE], with diagnoses which included dysphasia (difficulty to speak or understand speech) following cerebral infarction (stroke). A review of Resident 37's Advance Directive/POLST Acknowledgment Form, dated November 6, 2024, indicated, .I have not executed an Advance Directive for Health Care .I do not wish to do so at this time . A review of Resident 37's POLST, dated November 6, 2024, did not indicate Resident 37 had an AD. A review of the Social Services Assessment, dated May 6, 2025, indicated Resident 37 did not have an AD. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when five large plastic basins used for ice and food items were stacked and stored wet. This failure had the potential to cause foodborne illnesses in 52 medically vulnerable resident population who consumed food in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure proper medication administration practices were followed when the licensed nurse did not observe the resident take the medication and left the medication at bedside for one of five residents (Resident 26). This failure had the potential for the resident to not consume the medication as ordered and experience adverse effects as a result of not consuming the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when nursing staff did not clean and disinfect a shared blood pressure cuff and stethoscope according to the disposable wipe manufacturer's specified contact time (the time the resident equipment was to remain wet to kill micro-organisms [germs]) for one of four residents reviewed for medication administration (Resident 31). This failure had the potential to expose vulnerable residents to cross-contamination and increased the risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure multi-resident bedrooms provided the required minimum of 80 sq ft (square feet - unit of measurement) per resident in 16 out of 22 rooms (Rooms 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 21, 22, 23, 24, and 25). This failure had the potential to negatively affect the residents' quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged physical abuse was reported to the California Department of Public Health (CDPH) and other officials immediately, but not later than 2 hours after the allegation was made. The facility was made aware of the alleged physical abuse of a facility staff to a resident on August 26, 2024. This failure had the potential to cause a delay in investigation of the alleged abuse and to expose residents in the facility to further abuse.

Inspectors wroteBased on interview, and record review, the facility failed to review and revise the care plan for one of five residents reviewed (Residents 1) based on the changing needs of the resident who has involuntary twitching and jerking movement related to a disease process. This failure had the potential to result in increased discomfort and possibility of injury to the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, for one of (Resident A) five residents, residents with a multidrug- resistant organism (MDRO-bacteria and other microorganisms that have developed a resistance to one or more classes of antimicrobial drugs) was placed in a single room or cohorted with other residents with the same MDRO infection, according to the facility's policy and procedure. This failure had the potential to exposed Resident A's two susceptible roommates to acquiring an infection.

Inspectors wroteBased on record reviews, interviews, and facility document and policy review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 1 (Residents #37) of 5 sampled residents reviewed for unnecessary medications and 1 (Resident #17) of 4 sampled residents reviewed for accidents. Specifically, the facility failed to ensure Resident #37's use of psychotropic medications and Resident #17's fall event was accurately coded on their MDS assessments.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure pressure injury interventions ordered by the physician were implemented for 1 (Resident #12) of 1 sampled resident reviewed for pressure injury prevention.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 2 medication errors out of 36 opportunities, affecting 1 (Resident #19) of 9 residents reviewed during the medication administration task, resulting in a medication error rate of 5.56%.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure no significant medication errors occurred for 1 (Resident #19) of 9 residents reviewed during the medication administration task. Specifically, staff failed to hold Resident #19's amlodipine when the resident's heart rate was outside the parameters specified by the physician's order.

Inspectors wroteBased on observations, interviews, and facility document and policy review, the facility failed to ensure all multiple-resident bedrooms provided at least 80 square feet (sq ft) per resident for 16 (Rooms 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 21, 22, 23, 24, and 25) of 22 resident rooms observed.

Inspectors wroteBased on interview and record review the facility failed to ensure a written Notice of Discharge (a notice informing the resident of their discharge date , and their rights to appeal the discharge) was provided to the resident and/or resident representative prior to the date of discharge from the facility, for two of three residents reviewed (Residents 1 and 2). In addition, the facility failed to ensure the State Long Term Care Ombudsman (Ombudsman) was provided a copy of the written Notice of Discharge for Residents 1 and 2. These failures could have resulted in Residents 1 and 2 not to be aware of their rights to appeal the discharge and the Ombudsman to not be able to inform the residents of their rights and options to appeal prior to the resident being discharged .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The facility failed to notify the California Department of Public Health (CDPH) of an outbreak of COVID-19 (a contagious respiratory infection) and respiratory synctial virus infection (RSV - a contagious respiratory infection) according to the facility's policy and procedure and CDPH guidelines; 2. The facility staff failed to wear the appropriate personal protective equipment (PPE - equipment used to prevent or minimize exposure to infections) while providing care to a COVID-19 positive resident, in accordance with the facility's policy and procedure and Centers for Disease Control and Prevention (CDC) guidelines; and 3. A licensed nurse reported to work without testing for COVID-19 after exposure to COVID-19 positive residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were provided as ordered by the physician, for one of three sampled residents (Resident 1). This failure had the potential to delay the care and treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents and resident representatives were notified timely of an outbreak of COVID-19 in the facility in accordance with the facility's policy and procedure. This failure resulted in residents and their representatives not informed of the resident's status and placed the residents and representatives at risk for contracting the communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge was provided for one of three sampled residents (Resident 1) when, there was no documented evidence that options for alternative living and resources for home care services were provided upon discharge. This failure had the potential for Resident 1 to not have the care and assistance needed at home, (which placed Resident 1 at risk for not doing ADL's (activities of daily living includes bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet and eating) and increased the risk for Resident 1 to be transferred to the general acute care hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and treatment services were provided, for two of 23 residents reviewed (Residents 32 and 10) when: 1. For Resident 32, the uncontrolled blood sugar levels were not evaluated and referred to the physician for appropriate management. This failure had the potential for Resident 32 to be at risk for complications related to diabetes mellitus (abnormal blood sugar); and 2. For Resident 10, a plan of care was not developed and staff failed to monitor and manage the implantable cardiac defibrillator (ICD - a device placed under the skin to monitor heart rhythm and detect irregular heartbeats). This failure had the potential for Resident 10 to not receive appropriate and timely interventions in the care and management of an ICD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper storage and timely disposal of medications when: 1. Discontinued medications were stored in the medication cart and readily available for use. This failure had the potential for the resident to receive discontinued medication and/or medication administration error to occur; 2. Medications requiring refrigeration, as per the manufacturer's recommendations, were not stored in the refrigerator. This failure had the potential for the residents to receive medications with decreased efficacy; and 3. Medications of discharged residents were not disposed timely and were still stored in the medication room and readily available for use. This failure had the potential for the medications to be administered to other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services and food were stored in accordance with professional standards for food service safety when: 1. Two apple sauce cups were stored in the refrigerator past the use-by-date and readily available for use; 2. 12 gelatin cups were stored in the refrigerator past the use-by-date and readily available for use; 3. 36 cans of cranberry cocktail juice were stored past the use-by-date; and 4. One opened container of chlorine water test strips was observed to be expired. These failures had the potential for the growth of harmful microorganisms which may result in food-borne illnesses in a medically-vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: a. The oxygen tubing was changed every seven days as per the facility's policy and procedure, for one of one resident reviewed for respiratory care (Resident 256); This failure had the potential for the growth of harmful microorganisms and for the resident to develop respiratory infection. b. The staff was wearing the appropriate personal protective equipment (PPE) when she was in the resident's room (Resident 252), who was on required transmission-based precautions for Covid-19 (contagious respiratory infection); c. The resident (Resident 17) was transferred to a non-isolation room after completing the 14 days of quarantine (practice of separating individuals who have had possible close contact with someone with a contagious disease) and multiple negative test results for Covid 19; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-an assessment tool) accurately reflected the resident's status, when the order for hemodialysis (process of cleansing the blood of a person whose kidneys are not working normally) was not coded in the MDS, for one of 23 residents reviewed (Resident 37). This failure had the potential to result in delayed care/treatment or unmet needs for Resident 37.

Inspectors wroteBased on interview and record review, the facility failed to identify and document the mental illness in the Preadmission Screening and Resident Review (PASARR - a federal requirement to ensure individuals are not inappropriately placed in nursing homes for long term care) prior to the resident's admission to the facility, for one of two residents reviewed for PASARR (Resident 26). This failure had the potential for Resident 26 to not receive appropriate care and services in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care (POC), for one of one resident reviewed for respiratory care (Resident 256), when the resident was placed on oxygen (supplemental air administered through a tubing) for shortness of breath (SOB). This failure had the potential for Resident 256 to not receive the appropriate respiratory treatment needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the plan of care (POC) was updated or revised, for one of 23 residents reviewed (Resident 32), when the resident required a fall alarm in the wheelchair to prevent falls or injuries. This failure had the potential to result in a delay of the implementation of appropriate interventions to address the care and treatment for Resident 32. In addition, this failure had the potential to place Resident 32 at risk for recurrent falls and/or injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure metformin (medication used to treat high blood sugar levels) was administered with food, as ordered by the physician and according to current professional standards of practice, for one of five residents reviewed (Resident 27). This failure had the potential for the resident to experience medication adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safety interventions in the prevention of falls and accidents, for one of five residents reviewed for falls (Resident 32), when a fall alarm was not provided to Resident 32 while in the wheelchair, as ordered by the physician. This failure resulted in the occurrence of another fall incident for Resident 32. In addition, this failure had the potential for Resident 32 to have recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and treatment services to manage dementia (memory loss) related mood and behaviors were provided, for two of two residents reviewed (Residents 32 and 26) when: 1. For Resident 32, the psychiatrist's (physician treating mood & mental disorders) order for Depakote (medication to treat mood disorder) was not implemented as ordered. In addition, the Depakote level ordered by the psychiatrist was not referred back to him for appropriate treatment management. This failure had the potential for Resident 32's behavior to not be managed appropriately; and 2. For Resident 26, a plan of care to address dementia was not developed. This failure had the potential for the facility staff to not be aware of interventions to implement in managing behaviors related to dementia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses (LN) implemented the facility's policy and procedure on narcotic drug reconciliation and proper documentation in the narcotic count sheet, for one of 23 residents reviewed (Resident 32), when the narcotic count sheet for lorazepam (medication to treat anxiety [mood disorder]) injectable was not countersigned by another licensed nurse each time the medication was wasted. This failure had the potential for narcotic drug diversion (transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN (as needed) orders for psychotropic medications (medications to treat mood and mental disorders) were limited to 14 days, unless the prescribing practitioner provided rationale to extend the medication, for one of two residents reviewed for psychotropic medication use (Resident 32). This failure had the potential to place Resident 32 at risk for receiving unnecessary psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required 80 square feet (sq ft) per resident was met for 16 of 22 resident rooms (rooms 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 21, 22, 23, 24, and 25). This had the potential to negatively affect the quality of life of the residents.