Villa Mesa Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and monitoring were maintained for two of two sampled residents (Resident 23 and 4) reviewed for pressure ulcers (injury to skin and underlying tissues that develop because of prolonged pressure, shear (skin tissues slide in opposite directions when sticks to a surface), or friction) when: 1. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure one of one sampled resident (Resident 61) was provided with a dignified experience when the Infection Preventionist (IP) nurse was standing while assisting Resident 61 to eat. This failure has the potential to cause Resident 61 to feel disrespected and negatively affect their psychosocial well-being and individuality. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set Assessment (MDS- a computerized assessment instrument) for one resident (Resident 92) reviewed for history of falls. This failure had the potential to cause inaccuracy in identifying Resident 92's care and support needs. During a review of Resident 92's clinical record, the admission Record (contains demographic and clinical data), the admission Record indicated Resident 92 was admitted to the facility on [DATE], with diagnoses which included generalized (overall body) muscle weakness, Dementia (noticeable, worsening loss of brain function, including memory, thinking, language, and judgment, that goes beyond normal aging), and adult failure to thrive (downward spiral of health and ability). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a summary of a resident's health conditions, specific care needs, and current treatments) addressing identified medical needs for two of two sampled residents (Residents 11 and 14), when:1. Resident 11's care plan for intravenous (IV) therapy (a method of giving fluids or medications directly into a vein), initiated on January 12, 2026, did not address monitoring, nursing interventions, or measurable goals.2. Resident 14, admitted on hospice services (specialized care that provides physical comfort and emotional, social and spiritual support for people nearing the end of life) since June 10, 2025, did not have a comprehensive care plan addressing hospice service, including goals of care, palliative interventions, or coordination of services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional status was monitored for one of eight sampled residents (Resident 47) reviewed for weight loss, when Resident 47's weight loss was not addressed from November 6, 2025, through January 19, 2026. This failure had the potential to result in delayed treatment, increased risk for unmet nutritional needs, further weight loss, decline in function status, and compromised overall health and well-being. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its intravenous (IV) therapy (a method of giving fluids or medications directly into a vein through a small tube) policy and procedures was followed for one of eight sampled residents (Resident 61) when Resident 61's IV dressing (the bandage place over the IV site to protect it) on the right arm was not labeled to indicate the date when it was changed. This failure prevents staff from properly monitoring the IV site, increasing the risk of infection and infiltration (where fluid leaks into the surrounding tissue causing pain or damage). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) were maintained in accordance with their own policy and procedure for one of three Medication Carts (Medication Cart B). This failure had the potential to result in inaccurate count of narcotic drugs and drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff in a highly vulnerable population of 93 residents. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain effective infection prevention and control practices (steps used to prevent the spread of germs, including proper cleaning, storage, and handling of medical equipment) for three of seven sampled residents (Residents 4, 14, and 68) when:1. For Resident 4, the urinary catheter bag (a medical bag used for collection of urine) was resting on the floor, on January 20, 2026.2. For Resident 14, an oxygen tubing (a flexible plastic tube to deliver oxygen from the oxygen concentrator to the resident) was hanging from underneath the bed and touching the floor.3. For Resident 68, a breathing treatment face mask (a medical device that covers the nose and mouth to deliver medication directly to the airways and lungs) was on top of the nightstand, uncovered and unlabeled, while not in use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate record of Norco (a controlled medication that combines two types of drugs, acetaminophen and hydrocodone, for pain management) for one of five sample residents (Resident 4) when a Licensed Vocational Nurse (LVN1) administered Norco to Resident 4 and failed to document. This failure had the potential in delaying the recognition of possible diversion of a control medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of three sampled residents (Resident 1) was not adequately supervised following two fall incidents within 48-hour period. This failure resulted in Resident 1 sustaining a pelvic fracture during the latest fall incident.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PAASRR) screening was completed prior to admission to the facility for 3 (Residents #22, #42, and #86) of 5 sampled residents reviewed for PASARR screening.

Inspectors wroteBased on interview and record review the facility failed to report a change of condition and document in the medical records for one of four clinically compromised residents (Resident 1). This has the potential to exclude the family and responsible party of (Resident 1) to actively participate in the plan of care related to the resident's change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication administration policy and procedure when the facility: 1. Failed to ensure Resident 39's insulin medication (medication to treat high blood glucose) was readily available for use. This failure had the potential to cause delay of treatment, which can cause negative effects to the overall health of Resident 39. 2. Failed to implement their policy and procedure involving special handling and storage for protecting and securing resident's-controlled medications (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) for one of two sampled residents reviewed for pain (Resident 38) when a licensed nurse did not immediately document when she administered a controlled drug to Resident 38. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control and prevention measures when: 1. Resident 56's soiled Nasal Canula (NC- a tubing to deliver oxygen in small amount through nostrils) was not properly disinfected or cleaned before applying back to the resident. 2. Resident 437's peripheral intravenous catheter (PIV, a small hollow tube inserted into a vein for administration of medication, fluids, or blood products) and dressing were not replaced. 3. Trash bins overflowed, and soiled isolation gowns stuck out from the trash bin lid covers in three out of six rooms in the yellow zone (a designated area for symptomatic, suspected COVID-19( a viral infection affecting the respiratory system), and residents awaiting test results; COVID-19 exposed residents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity, respect, and privacy for one of two sampled residents reviewed for urinary catheters (Resident 80) when Resident 80's urinary catheter (flexible tube inserted into the bladder to drain urine) bag, was not covered with a dignity bag. This failure had the potential to compromise Resident 80's dignity and violate his right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's needs were accommodated for one of two sampled residents when Resident 11's call light was not within reach. This failure had the potential to negatively affect Resident 11's health and safety.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS - facility care assessment tool), for one of two residents reviewed for resident assessment (Resident 12) when Resident 12's MDS, dated [DATE], did not indicate Resident 12's correct first name. This failure had the potential to result in unmet care needs for Resident 12 which can negatively affect her health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate competency in administration of medication when a Licensed Vocational Nurse (LVN 1) administered multiple medications via Gastrostomy Tube (G Tube - a tube used for feeding and medication administration) was performed for one of five residents on tube feeding (Resident 9). This failure can result in an occlusion of the feeding tube, a reduced drug effect, or drug toxicity. These potential adverse (serious) outcomes can jeopardize the health and safety of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was below five percent when a Licensed Nurse crushed all medications together and administered via Gastrostomy Tube (G Tube - a tube that is placed directly into the stomach through an abdominal wall incision for the administration of medications, food and fluids) together for one of five residents on tube feeding (Resident 9). This failure had the potential to alter the desired effect of the medication to the resident by causing occlusion of the G Tube and jeopardize her health and safety.

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate documentation on discharged arrangement was provided for one of four sampled residents reviewed for closed records (Resident 20). This failure had the potential for Resident 20 to receive inconsistent care coordination and unmet care needs.