Villa Marin

Inspectors wroteBased on interviews and record review, the facility failed to ensure sufficient staff to fulfill the responsibilities of a full-time supervisor of the Skilled Nursing Facility food and nutrition service. This failure had the potential to place residents at risk for impaired nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a safe and sanitary manner when:1. Multiple food items were not discarded after their use-by-date.2. Opened food items were not properly labeled with open and use-by-date. These failures had the potential to cause food-borne illnesses in an already medically fragile population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent when six identified medication errors out of 27 opportunities were observed for three of five sampled residents (Resident 2, Resident 16 and Resident 21). These failures resulted in an overall facility medication error rate of 22.22% and had the potential to result in negative health outcomes for Resident 2, Resident 16 and Resident 27. Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent when six identified medication errors out of 27 opportunities were observed for three of five sampled residents (Resident 2, Resident 16 and Resident 21). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure housekeeping staff donned personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when handling 14 out of 15 resident's soiled laundry. This failure had the potential to negatively impact the residents.

Inspectors wroteBased on interview and record reviews, the facility failed to transmit the Minimum Data Set (MDS - an assessment care - planning tool) to the Centers for Medicare and Medicaid Services (CMS) within 14 days after the completion for two of 15 sampled residents (Resident 1 and Resident 6). This failure resulted in the delay of information to CMS for payment and quality measure purposes and for potential changes in Resident 1 and Resident 6's condition to be missed or go unaddressed.1

Inspectors wroteBased on interviews and records review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) in accordance with Federal requirements for one of two sampled residents (Resident 1). This failure resulted in a delayed investigation of the alleged abuse by CDPH and had the potential for other residents to be at risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to one of two residents at risk for falls (Resident 117) when Resident 117 was left unsupervised on her wheelchair after lunch. This failure resulted in Resident 117 getting up from the wheelchair unassisted, falling, injuring her head, right knee, elbow, and being sent to the hospital for evaluation and treatment of her injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a program supporting the residents choice of activities with activities supporting the residents physical, mental, and psychosocial well-being, and encouraging interaction with the community, for one of eight sampled residents (Resident 2), when the activities provided by the facility to Resident 2 were limited to having the TV turned on in her room, despite activity assessments which indicated Resident 2 enjoyed reading, listening to music, being around pets, and spending time outdoors. This failure resulted in Resident 2 not having her activities needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely documentation of resident assessments for the risk of entrapment from bed rails and obtaining informed consent prior to installation of bed rails for 15 of 15 residents. This failure placed residents at risk of entrapment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Agency/Registry (staffing agencies that hire and train staff and place nursing professionals in a variety of nursing positions) Licensed Nurses and Certified Nursing Assistants (CNAs) had the competencies and skills necessary to care for its residents' needs when: 1) the facility did not verify that Agency/Registry Licensed Nurses and CNAs had valid and complete competency/skills checks to meet resident needs prior to working at the facility; 2) an Agency/Registry Licensed Nurse (Licensed Nurse E) did not perform hand hygiene per facility policies prior to medication administration to five residents (cross-reference to Tag F880 - Infection Control); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow best practices for infection prevention and control when three of three Licensed Nurses (Licensed Nurses D, E and F) did not perform hand hygiene (washed hands or used hand sanitizer) before preparing medications and administering them to eight of eight residents (Residents 1, 3, 4, 5, 6, 9, 10 and 11) and when one Certified Nursing Assistant (CNA) provided care to a resident without performing prior hand hygiene. These failures placed Residents Residents 1, 3, 4, 5, 6, 9, 10 and 11 at risk of the spread of infections.

Inspectors wroteBased on interview and record review, the facility failed to review and revise at least quarterly the comprehensive care plan (a document that lays out the care and services to be provided to the resident) of one of two residents (Resident 2). This failure placed Resident 2 at risk of not having her needs met.

Inspectors wroteBased on observation, interview and record review the facility did not follow the procedure when they stored an oxygen tank, which was empty per the gauge, in the Resident's room (one of fifteen residents, Resident 10.) This failure, storing oxygen tanks in residents' rooms, was a potential safety and/or fire hazard. The failure of having an empty oxygen tank puts the residents at risk of not getting supplemental oxygen in an emergency.

Inspectors wroteBased on interview and record review, the facility failed to indicate in its Facility Assessment the use of Agency/Registry (temporary) Licensed Nurses and Certified Nursing Assistants (CNAs). This failure resulted in an incomplete and inaccurate Facility Assessment.

Inspectors wroteBased on interview and record review, the facility failed to monitor bed frames, mattresses, and bed rails for the risk of entrapment by bed rails as part of its regular maintenance program. This failure placed residents at risk of entrapment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: 1. One cook was able to correctly describe the cool down process for food and 2. The kitchen maintained an air gap for kitchen appliances. This failure could potentially lead to food borne illness in a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to provide written information on Advance Directives to two of eight sampled residents. This failure had the potential to keep the residents uninformed of their rights to have their wishes honored in regards to health care decisions during incapacity.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise Nursing Plans of Care and attempt new interventions to prevent falls for 2 of 2 sampled residents at risk for falls. This had the potential to cause severe injuries or death to Resident 6 and Resident 13 during new incidences of falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt new interventions to prevent falls for 2 of 2 sampled residents at risk for falls. This had the potential to cause severe injuries or death to Resident 6 and Resident 13 during new incidences of falls.

Inspectors wroteBased on interview and record review, the facility failed to include a level of supervision on the care plan of one of eight sampled residents (Resident 3) who had fallen repeatedly. This failure could potentially lead to future falls, fractures, or hospitalization when staff had not established how often Resident 3 needed safety checks to prevent him from falling.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain accurate medical records for one of six sampled residents. This had the potential for overmedication, inaccurate medication reconciliation of controlled substances, inappropriate pain control for Resident 7 and diversion of controlled drugs.