Villa Las Palmas Healthcare Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat one of 12 sampled residents (Resident 1) with dignity during toileting and brief care. This failure could lead to the emotional and psychosocial trauma of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse for one of three sampled residents (Resident 1) to the Department of Public Health (DPH) within twenty-four (24) hours from the time the facility learned of the allegation. This deficient practice had the potential for Resident 1 to experience continued abuse and negative psychosocial outcomes.

Inspectors wroteThe following reflects the findings of the California Department of Public Health during an investigation of two complaints. Complaint Number: 2564745Complaint Number: 2566052 The inspection was limited to the complaints investigated and does not represent the findings of a full inspection of the facility. One deficiency was identified for the complaint number: 2564745 and Complaint Number: 2566052 (Refer to Ftag 694). Resident 1 was readmitted to the facility on [DATE] with diagnoses which included pneumonia (lung infection), per the facility's admission Record. A review of Resident 1's clinical record was conducted. Resident 1's physician's order dated 7/16/23, indicated Resident 1 was to receive an antibiotic (anti-infective) medication and PIV line care. The physician's order was for the Licensed Nurses (LNs) to flush the PIV line every shift (three shifts in a day). [...]

Inspectors wroteBased on interview and record review, the facility failed to revise and implement a preventative fall risk plan of care for 1 of 3 sampled residents (1) with a known history of falls and severe cognitive impairment. Resident 1 sustained an unwitnessed fall which had the potential to be prevented.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items stored in the residents' refrigerator were labeled and dated and discarded within two days per the facility policy. This deficient practice had the potential to affect who stored items in the residents' refrigerator.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASRR) when the resident was diagnosed with a new mental illness diagnosis for 1 (Resident #134) of 3 sampled residents reviewed for PASRR.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #134) of 5 residents reviewed for unnecessary medications was free of significant medication errors. Specifically, facility staff failed to hold spironolactone (a diuretic/water pill which promotes the removal of fluid [edema] from the body) when Resident #134's systolic blood pressure (SBP) was below 120 millimeters mercury (mmHg) as outlined in the physician's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was free from verbal and mental abuse when: Certified Nursing Assistant (CNA) 2 yelled at Resident 1 and made disparaging comments to the resident about their ability to perform bed mobility while also making humiliating comments to the resident regarding their weight and size. Cross reference F607. As a result: Resident 1 cried, experienced depressed mood, psychosocial (the influence of social factors on an individual's mind or behavior) distress, and felt unsafe in the facility and worthless.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were fully trained to correctly identify mental, emotional, and verbal abuse when: 1. Certified Nursing Assistant (CNA) 2 yelled at Resident 1 and made disparaging comments to the resident about their ability to perform bed mobility while also making humiliating comments to the resident regarding their weight and size. Staff considered CNA 2 ' s behavior as rudeness instead of abuse. 2. Charge Nurse (CN) 3 was not adequately trained to collect pertinent information to make an accurate determination of abuse during the incident regarding CNA 2 and Resident 1. As a result, CNA 2 was permitted to finish her eight-hour shift providing care to residents after the incident involving Resident 1. This failure had the potential for other residents to experience abuse. Cross reference F600.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was developed for two of three residents (Resident 6 and 7), reviewed for fall care plans. This failure to develop the baseline care plan for fall risk within 48 hours of admission placed Resident 6 and 7 at risk for falls.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified Social Services Director (SSD) on a full- time basis that met the qualifications specified in the regulation. This deficient practice placed all 151 residents at risk of not receiving medically-related social services necessary to attain their highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to address the nutrition and hydration need of one of three residents (Resident 1) when: • Resident 1's nutrition and hydration need, as recommended by the registered dietician (RD), was not implemented. • The interdisciplinary team (IDT - team of individual with different specialties) did not address Resident 1's weight loss. As a result, Resident 1 was found lethargic (lack of mental and physical energy) and hard to arouse (wake up). Resident 1 was sent to the hospital and diagnosed with acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), metabolic acidosis (a condition when the body produces too much acid) and dehydration (when a body does not have as much fluids as it needs; can lead to kidney damage, brain damage and even death). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 3) was provided privacy during wound care when the resident's privacy curtain was not closed all the way. During Resident 3's wound treatment, a staff member came into the room when the resident ' s private areas were exposed. As a result, Resident 3 was not provided care in a private and dignified manner which had the potential to cause the resident emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three residents ' (Resident 1 and Resident 3) written care plans were developed and implemented, when: 1. Resident 1 did not have an individualized care plan developed to address his multiple wounds. 2. Resident 3 ' s written care plan for activities of daily living (ADL, self-care activities) which required two staff to perform bed mobility (how a resident moves in bed) was not implemented. As a result of these failures, there was a potential for Resident 1 ' s wounds to deteriorate and for Resident 3 to experience discomfort and possible injury during care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three residents (Resident 2 and 3) reviewed for pressure injuries (damage to the skin and underlying tissues as a result of sustained pressure over long periods of time), had: - Physicians ' orders for pressure injury wound treatments that were followed. -Infection control practices that were adhered to during pressure injury treatments. As a result, there was the potential for Resident 2 and Resident 3 ' s pressure injuries to deteriorate and/or become infected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurse (LN) 1 performed wound care/treatment in a competent manner. In addition, the facility did not assess LN 1 ' s competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) prior to LN 1 providing wound treatment to two residents (Resident 2 and Resident 3). This failure had the potential to cause the residents ' wounds to worsen and/or become infected.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control standards of practice when: 1. A dedicated blood pressure cuff, stethoscope and thermometer were not available for eight residents who were on contact isolation precautions for a multi-drug resistant organism (MDRO-bacteria that developed resistance to one or more classes of antibiotics). 2. Face shields or eye protection were not available for staff to use upon entering a resident room with a diagnosis of Coronavirus (COVID-19 an infectious respiratory infection). These failures had the potential to expose other residents, staff, and visitors to infection.

Inspectors wroteBased on observation, interview and record review the facility did not notify the attending physician in a timely manner regarding weight loss for three of three sampled residents. (Resident 10, 5 and 12). This failure had the potential to result in delayed care for the residents and were not given appropriate interventions to correct weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' nutritional status were monitored and meal intakes were accurately maintained for three residents with weight loss when: 1. Resident's weights were not taken weekly. (Resident 10, Resident 5 and Resident 12) 2. Staff did not know how to take and record residents' meal percentage. These failures had the potential for residents to experience further weight decline and risk for functional decline, pressure sores and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the MDS (a clinical assessment tool) were accurately coded for: 1. Two of two sampled residents (343, 446) and five of nine unsampled residents (12, 112, 115, 124, 137) who smoked; 2. One of three residents (34) reviewed for pressure ulcer/injury (PUI, damage to an area of the skin caused by constant pressure on the area). This failure had the potential to affect the provision of care and provided inaccurate information to the Federal database.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop person-centered care plans to meet the needs for: 1. Two of two sampled residents (343, 446) and seven of nine unsampled residents (15, 79, 112, 115, 124, 125, 137), when there was no care plan with specific interventions for smoking safety. This failure had the potential for inadequate monitoring of the residents who smoked. 2. Two of five residents (40, 452) with indwelling urinary catheters (a tube to drain urine). These failures had the potential for complications such as blockage of the catheter, infection, or dislodgement. 3. Two residents (73, 100) with behavior issues. This failure had the potential for disruptive behaviors to not be appropriately addressed. 4. One resident (60) with a hip abduction pillow (an orthopedic device placed between the legs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Smoking assessments were consistently conducted to determine the residents' ability to safely use tobacco products for two of two sampled residents (343, 446) and eight of nine unsampled residents (12, 14, 15, 79, 112, 125, 137, 343). This failure had the potential to place residents at risk for accidental burns and injuries. 2. Resident 18 was adequately supervised to prevent falls. This failure had the potential to place Resident 18 at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed when urinary catheter (a tube to collect urine) collection bags and drainage tubing were in contact with the floor for three of three sampled residents, (40, 449, 452) and two unsampled residents (47, 444), reviewed for catheter care. As a result, Residents 40, 449, 452, 47, and 444 were at risk for urinary tract infections (an infection in part of the urinary system) from cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 27 residents (Residents 62, 94, 100, 118) were treated in a dignified manner when: 1. Resident 62 was provided assistance with eating while CNAs stood over the resident. 2. Resident 94 was provided peri-care (washing of the genital region after an incontinence episode) while the resident's privacy curtain and door to the room was open. In addition, Resident 118 observed her roommate's (Resident 94) peri-care take place. 3. Resident 100's room and person had a pungent odor that permeated the hallway on the residential unit. As a result of these deficient practices, residents had the potential to experience shame and embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a quiet atmosphere was promoted for three of three unsampled residents (24, 58, 102). As a result, the environment was disruptive to the residents. Cross-reference to F656 no.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a comprehensive assessment and care screening tool) for one of two sampled residents was transmitted in a timely manner to the Centers for Medicare and Medicaid Services (CMS, an agency which oversees federal health care programs) following a resident's death (Resident 2). This failure resulted in noncompliance with regulatory requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed when one of five residents (Resident 449) reviewed for urinary catheters (a tube to drain urine from the bladder ) had a physician's order. As a result, there was the potential for Resident 449 to have urinary complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 27 sampled residents (Resident 60) reviewed for quality of care, had a hip abduction pillow (orthopedic device placed between the legs) consistently applied and monitored as ordered by the physician. As a result, Resident 60 was at risk for further hip injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess the clinical necessity of a urinary catheter (a tube inserted into the bladder to drain urine) for one of three residents reviewed for catheters (113). This failure had the potential to increase Resident 113's risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the staff followed physician's orders for tube feeding (feeding through a tube into the stomach) for one of six residents reviewed for tube feeding (21). As a result, there was a potential Resident 21 was fed more than what was prescribed.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered according to the physician's order to meet the needs of the residents when: 1a. Resident 14's insulin glargine (long-acting insulin to decrease the level of blood sugar in diabetic person) doses were held against the physician order; 1b. Resident 14's metoprolol (blood pressure lowering medication) doses were given despite the parameter to hold when systolic blood pressure (the upper number in a blood pressure reading) was less than 110 and heart rate less than 60; and 2. Resident 30's fosinopril (blood pressure lowering medication) dose was given despite the parameter to hold when systolic blood pressure was less than 110. These had the potential to expose the residents to side effects from elevated blood sugar (BS) and low blood pressure.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from unnecessary medications when Resident 30 was placed on apixaban (an anticoagulant; blood thinner) 5 mg without the careplan that included monitoring for signs and symptoms of bleeding. This had the potential to cause harm to the resident from bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate for medication pass observation did not exceed 5 percent. There were 27 opportunities. Two medication errors were identified. The error rate was 7.4 percent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Scheduled II controlled substance (legally prescribed dangerous medication with the highest addictive potential) was administered as ordered by a physician for one unsampled resident, Resident 61. The resident received twice the ordered dose. This had the potential for the resident to experience dangerous side effects such as unable to wake up due to respiratory depression and sedation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Residents' medication labels on the blister packs included the date of expiration; and 2. An open date was written on the insulin glargine (medication to control blood sugar level in diabetics) 3-ml pen when it was removed from the medication refrigerator and stored in the medication cart at room temperature. These failures had the potential for residents receiving expired medications. 3. Medications were secured and locked for one (sub-acute medication cart) of six medication carts, reviewed for medication storage. As a result, the was the potential for unsecured medication to be diverted (stolen) by residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the correct therapeutic diet to one of four residents, (Resident 44), reviewed for nutrition. This failure had the potential for Resident 44 to aspirate (food enters the airway) food during meal service.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (29) with a urinary catheter (a tube to help drain urine) was provided with a dignity (cover) pouch for the drainage bag. As a result, Resident 29's dignity was not respected.

Inspectors wroteBased on interview and record review, the facility failed to ensure informed consent was verified and documented in the clinical record, for the use of an antipsychotic medication for one of six residents (34) selected for unnecessary medication review. As a result, the facility staff was not able to verify the ordering practitioner had discussed the psychotropic medication's use, risks, and benefits to Resident 34's RP.

Inspectors wroteBased on observation, interview and record review, the facility failed to safeguard confidential medical records for one unsampled resident (129). As a result, there was a potential for Resident 129's confidential medical records to have been viewed by non-medical staff, other residents and visitors.

Inspectors wroteBased on observation and interview, the facility failed to provide a home like environment when the shower rooms and residents' rooms were not well maintained. This failure had the potential to affect residents' comfort and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from verbal abuse (harsh and insulting language directed at another person) for one of two sampled residents (115). As a result, Resident 115 did not feel safe in her room and experienced fear.

Inspectors wroteBased on observation, interview and record review, the facility failed to create a plan of care for aggressive behaviors for one of one sampled resident (101). As a result, there were no goals or interventions to address Resident 101's aggressive behavior.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan related to activities for four of four sampled residents receiving one-to-one visits (16, 131, 72, 97). These failures had the potential to negatively affect the residents' physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's environment remained free of accidental hazards when staff did not store cigarettes in a secured area for one of four residents (112). As a result, there was a risk to resident's safety from burns and fire.

Inspectors wroteBased on interview, and record review, the facility failed to monitor specific target behaviors for the use of an antipsychotic medication for one of six residents (18) selected for unnecessary medication review. As a result, this placed the resident at increased risk for receiving unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the dietary department failed to maintain sanitary conditions in the kitchen in accordance with professional standards when an employee failed to wear a beard restraint (a cover for facial hair). As a result, there was a potential for contamination of the residents' food.