Villa Rancho Bernardo Care Center

Inspectors wroteThe following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Numbers: The inspection was limited to the specific complaint and Facility Reported Incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for the complaint number: (Refer to Ftag F609).

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- standard assessment to facilitate resident's care) related to hospice (medical care for residents expected to live six months or less) services were coded accurately for one of 3 sampled residents reviewed for hospice (Resident 212). As a result, Resident 212 did not reflect their current health status, which may lead to unmet hospice care needs.

Inspectors wroteBased on interview and record review, the facility failed to create person-centered care plans (a document that outlines the care and support a patient will receive) regarding non-pharmacological interventions (a healthcare treatment that doesn't involve medication) for three of 35 sampled residents (Residents 240, 290 and 440). This failure had the potential to decrease the types of supportive interventions these residents received while at the facility.

Inspectors wroteBased on observations, interview and record review, the facility failed to flush a gastronomy tube (GT- artificial external opening in the stomach for nutritional support) between each medication administered with water for one resident of four sampled residents reviewed for GT (Resident 1). This failure had the potential for Resident 1's GT to malfunction.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure behavior monitoring was in placed for a psychotropic (drugs that affect a person's mental state) medication in one of five reviewed for unnecessary medications (Resident 279). This failure had the potential for Resident 279 to continuously received the medication without proper monitoring and possibly affect Resident 279's health condition and or decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not left unattended in one of six residents observed for medication storage (Resident 18). This failure had the potential to affect residents' safety and may lead to drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clinical record was complete for one of 35 residents reviewed for medical record accuracy (Resident 153) when a physician's order for rolled washcloth was not monitored. This failure had the potential for Resident 153 to not have the adequate care and to not communicate Resident 153's care needs amongst healthcare providers.

Inspectors wroteBased on interview and record review, the facility failed to ensure one medication was administered without error for one resident (1). As a result, Resident 1 was administered amlodipine (antihypertensive; medication used to treat high blood pressure; medication helps to lower the blood pressure) outside of the parameter (guideline/instruction) ordered by the physician. This failure had the potential to further lower Resident 1's blood pressure.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the food served to residents were palatable and acceptable according to resident comments and facility policy. This failure had the potential to cause decreased food intake and negatively impact the resident's nutritional status. The facility census was 271.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice when: 1. A rubber tray with twenty five cups of milk and other drink beverages had a use-by date of 12/2/23, and a large plastic bin filled with individual plastic cups of canned sliced pears with a use-by date of 12/3/23, were found in the walk-in refrigerator on 12/4/23; 2. Three serving scoops with brown crusted substances and residue were stored with clean serving utensils, and 3. The ice machine was not cleaned and maintained according to manufacturer's instructions and standards of practice. These failures had the potential to expose residents to contaminants that could cause foodborne illness. The facility census was 271.

Inspectors wroteBased on observation, interviews, and documentation, the facility failed to ensure essential kitchen equipment was maintained in working operational condition when three of four ovens were not working or maintained according to standards of practice or facility policy. This failure affected the ability of the Food and Nutrition Services Department to prepare resident meals safely and efficiently, which had the potential for residents to receive undercooked food, and to develop food borne illness. The facility census was 271.

Inspectors wroteBased on observation, interview, record review, and document reviews, the facility failed to ensure that low air loss mattresses (LAL - an air flow mattress used to prevent skin breakdown by distributing weight over the mattress to reduce pressure to the skin) were set according to the physician's order for five of five residents (Resident 197, Resident 203, Resident 7, Resident 69, Resident 216) reviewed for pressure ulcer. These failures increased the risk for skin breakdown for all residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - assessment tool) related to the use of an anticoagulant (medicine that prevent or reduce blood clots) for two of 35 residents (Resident 69 and Resident 106) reviewed for MDS accuracy. Resident 69 and Resident 106's MDS assessments, dated 11/19/23, incorrectly coded that both residents received an anticoagulant medication during the 7-day look back period of 11/13/23-11/19/23. These failures had the potential for staff to provide both residents with inappropriate care due to the wrong data inputted in the residents' MDS assessment.

Inspectors wroteBased on interview and record review the facility failed to ensure the PASSAR Level 2 (PSL2) (Preadmission Screening and Resident Review- a form to determine if a resident has or is suspected of having a mental illness) was completed after PASSAR Level 1 (PSL1) was positive for one of 35 residents (Resident 183) reviewed for PASSAR. This failure had the potential to not ensure the appropriate mental health services for Resident 183.

Inspectors wroteBased on interview and record review, the facility failed to develop a patient-centered plan of care for one of 35 residents (Resident 152) related to language. This failure had the potential for Resident 152's care needs to not be addressed due to miscommunication.

Inspectors wroteBased on interview and record review, the facility failed to update the plan of care for one of 35 residents (Resident 101) related to activities of daily living (activities such as eating, toileting, dressing, etc.). This failure had the potential for Resident 101's ADL needs to not be addressed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to monitor and fully assess a sampled resident, Resident 221, with a severe weight loss of 17.3% in six months, according to the facility's policy. This failure led to further decline in Resident 221's nutritional and health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Medication Regimen Review (MRR - evaluation of a resident's medications with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications) was completed and implemented by the attending physician for one of 35 residents (Resident 66). This failure had the potential for Resident 66 to experience side effects from the medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was prepared in a form to meet the nutritional needs for a sampled resident, Resident 132. This failure had the potential to cause poor food intake because the resident did not receive meals that met the correct form according to the Resident 132's physician-ordered diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate one of 35 sampled residents' food preferences (Resident 140). This failure had the potential to result in decreased caloric and nutrient intake.

Inspectors wroteThe facility failed to implement proper infection control practices when: 1. An employee did not wear a gown while touching dirty linens 2. A tube feeding was not disposed of in a timely manner for 1 out of 35 sampled residents (Resident 196). These failures had the potential to spread infection amongst the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food and nutrition services staff maintained current competency in dietetic task operations to safely carry out the kitchen functions in a sanitary manner according to facility policies and standard of practice when: 1. A [NAME] could not correctly demonstrate how to calibrate the food thermometer; 2. A Dietary Aide did not correctly cool down the tuna salad before serving it; 3. A Dishwasher after emptying the garbage bins at the outside dumpster did not wash his hands after entering the kitchen. These failures had the potential to expose residents to unsafe and unsanitary food service practices that could result in widespread food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dietary staff correctly followed the recipes and menus as printed and according to the facility policy when: 1. Soup was not included on the menu. 2. White roll was served instead of wheat roll. These failures resulted in a vulnerable resident population receiving inadequate and/or incorrect nutrition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. Expired and undated foods were found inside the walk-in refrigerator and dry storage room; 2. Several pieces of red meat patties were found on long metal sheet pans uncovered and exposed on an open drying rack in the walk-in refrigerator; 3. Two ice machines were dirty with brown spots inside the ice bin containing ice and was not cleaned according to manufacturer's guidance; 4. Improper cooling procedures were conducted after tuna salad preparation; 5. Three Nursing unit refrigerators had expired foods and the correct temperature was not regularly maintained. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 17 of 61 residents reviewed were provided with safe, clean, comfortable and homelike environment when residents' rooms (109, 116, 117, 118, 120, 126, 127, 123, 129, 105, 111, 114, 131, 119, 115, 125, 127) had broken corner walls, broken brown baseboard, stained toilet seats, air vents with white and gray debris. These failures did not promote a homelike environment to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to set a pressure relieving mattress per the resident's weight for 7 of 45 sampled residents (39, 57, 74, 75, 128, 242, 520). As a result, there was the risk of skin breakdown and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 12 of 56 residents reviewed were free of accidents and hazards when: 1. A removable glass shelf of a mirror bathroom cabinet was found leaning against the wall next to Resident 107's bed. 2. Resident's room (109, 116, 117, 118, 120, 126, 127, 129, 105, 111, 114 131) had cracked and broken corner walls and baseboard that were pointed and had rough and rugged edges. 3. Two double doors going to the Dining area had pointed metal astragal (a piece of hardware that is used on a pair of doors to seal the gap between the doors when they are closed). Three corner wall guards' bottom area of the hallway in front of nursing station were broken and had pointed and rough edges. These failures had the potential to cause injury and harm to residents, staff and visitors.

Inspectors wroteBased on observation, staff interview and review of menus, the facility failed to ensure that substitutes and meal alternatives of equal nutritive value, including vegetarian food options, were offered and made available to residents as per facility policy. This finding had the potential to cause reduced food intake which could lead to weight loss and impaired nutritional status because of insufficient calories and protein.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one residents (Resident 57) reviewed for restraint, was free from unnecessary restraint, when the facility staff applied a restraint without a physician's order. As a result, Resident 57's freedom of movement was restricted.

Inspectors wroteBased on observation, interviews, and record reviews, the facility did not develop new fall preventative intervention for one of 45 sampled residents (Resident 175) after an incident of a fall. This failure had the potential for Resident 175 to have future falls.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide an interpreter service for one of three residents (Resident 25) reviewed for communication. This had the potential for the healthcare provider to misinterpret Resident 25's needs and health situation.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the physician's orders for one of 45 sampled residents (Resident 57) when: 1. The licensed nurses (LNs) did not apply compression stockings to Resident 57. 2. The LNs did not apply Scopolamine patch (medicated patch to prevent excessive secretions) to Resident 57. As a result, Resident 57 had the potential for developing deep venous thrombosis (DVT, a blood clot in a deep vein, usually in the legs). Also, Resident 57 had the potential to develop a secretion build up in the airways.

Inspectors wroteBased on interview and record review, the facility failed to address weight loss for one sampled resident (14). As a result, Resident 14 was at an increased risk of decline in health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the food was prepared by methods that conserved nutritive value and appearance when residents stated facility food was served cold without flavor and not at the appropriate texture. This deficient practice had the potential to decrease the food intake of residents and would negatively impact their nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 45 sampled residents' (Resident 235) food was prepared in a form designed to meet her nutritional needs. As a result, there was a potential for Resident 235's nutritional intake to be compromised.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of sampled 45 residents' (Resident 57) medical record was accurate related to the application of the resident's compression stockings. As a result, Resident 57's medical record incorrectly indicated that the resident's compressions stockings have been applied, when they were not.