Villa Scalabrini Special Care

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 26) drug (medication) regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) by failing to provide a detailed clinical rationale for continuing Temazepam (a psychotropic medication used as a hypnotic [relating to, producing, or inducing sleep] for insomnia [inability to sleep or stay asleep]) at the original prescribed dose on 8/29/2024 for Resident 26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) three (3) medication emergency kitS ([eKIT] - kit containing medications needed to be used during emergencies) containing ([CS] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM]) for February 2026, in one (1) of one (1) inspected Medication Rooms (Medication Room.) 2. Account for one (1) dose of CM for Resident 21, 39 and 45 in one (1) of two (2) inspected medication carts (Medication Cart Green.) As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Six (6) medication errors out of 31 total opportunities contributed to an overall medication error rate of 19.35% affecting three (3) of five (5) residents observed for medication administration (Resident 7, 39 and 47.) The medication errors were as follows: 1. Resident 7 did not receive folic acid (a supplement used for osteoarthritis [a joint disease where the cushions at the ends of bones breaks down causing pain, stiffness, and reduced function]) as ordered by Resident 7's physician. 2. Resident 39 did not receive multivitamins with minerals (a vitamin supplement,) and loratadine (a medication used for itching,) as ordered by Resident 47's physician. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and distribution when: 1. Pasta was stored in a container with a lid that was not tightly sealed. 2. One tomato and one onion were cut in half and stored in the refrigerator in plastic wrap with no date. These failures had the potential to result in harmful bacterial growth, cross contamination (transfer of harmful bacteria or allergens from one place to another), and foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 53 residents who received food from the kitchen out of 56 total residents. 3. For Residents 5 and 30, meal trays were transported down a hallway to residents eating in their rooms with some food items left uncovered. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to maintain infection control measures when: a. Certified Nursing Assistant (CNA 1) was not wearing a face mask (personal protective equipment that serves as a mechanical barrier to interfere with air flow from the nose and mouth) while in the dining room assisting residents. b. The Director of Dietary Services (DODS) was not wearing a mask (personal protective equipment that serves as a mechanical barrier to interfere with air flow from the nose and mouth) while in the dining room. This deficient practice increased the potential of spreading respiratory illnesses to the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) included objective measurable goals for monitoring insomnia (a condition characterized by inability to fall or stay asleep) for one (1) of five (5) sampled residents (Residents 12) reviewed for unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) medications. As a result, Resident 12 did not have an identified goal for minimum number of hours spent sleeping, to monitor the effectiveness of Resident 12's medication therapy related to insomnia. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who was diagnosed with dementia (a progressive state of decline in mental abilities) received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one of six residents (Resident 23) reviewed under the dementia care by failing to develop an individualized care plan with interventions addressing supervision to support Resident 23's dementia care needs. This failure had the potential to affect Resident 23's safety and well-being. [...]

Inspectors wrote3. During a review of Resident 45's admission Record, the admission Record indicated that the facility admitted the resident on 12/25/2024, with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), lack of coordination, and repeated falls. During a review of Resident 45's Minimum Data Set (MDS-a resident assessment tool) dated 12/31/2024, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 45 was dependent on the staff (helper does all of the effort) for showering and bathing. [...]

Inspectors wrotec. During a review of Resident 11's admission record, the admission Record indicated the facility admitted Resident 11 on 12/10/2020 and readmitted the resident on 11/25/2024 with diagnoses including multiple sclerosis (a chronic disease that damaged the central nervous system), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood well), and type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). [...]

Inspectors wrote2. During the Treatment Cart 1 inspection and observation, on 2/16/2025 at 3:24 p.m., and a concurrent interview with Licensed Vocational Nurse 3 (LVN 3), an expired vaginal cream was observed stored in the cart. LVN 3 confirmed that the observed vaginal cream did expire on 9/2024 and belonged to a resident who has already been discharged from the facility. The LVN 3 stated that licensed staff is required to immediately remove all expired medications from treatment carts. During a concurrent observation and interview on 2/16/2025 at 3:28 p.m. with LVN 3, four expired povidone-iodine swab sticks were observed inside Treatment Cart 1. LVN 3 stated these povidone-iodine swab sticks were expired on 10/2023, and should have been removed and disposed of. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when two of two sampled resident (Resident 25 and Resident 53) reviewed under the nutrition task were not assessed and evaluated by a Registered Dietitian (RD- a health professional who has special training in diet and nutrition) after having weight loss. This deficient practice had a potential to result in ineffective nutrition intervention and goals and an increased weight loss for Resident 25 and Resident 53.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food storage practices by failing to ensure food stored in the facility's dry storage and refrigerator were labeled with an expiration date and opened dated. This deficient practice had the potential to place three of 53 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 4 (LVN 4) washed their hands before administering eye drops to one of five sampled residents (Resident 4). 2. Ensure LVN 4 removed their isolation gown prior to leaving a resident's room for one of five sampled residents (Resident 4) who was on enhanced barrier precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). 3. Ensure a resident's urinal (a container used to collect urine) was labeled with the resident's name for one of two sample residents (Residents 48). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident`s dignity and respect in full recognition of their individuality when Certified Nursing Assistant 1 (CNA 1) was standing over a resident while assisting the resident during a meal for one of three sampled residents (Resident 25). This deficient practice had the potential to negatively affect the resident`s psychosocial wellbeing and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses to assist a patient when in need) was within a resident`s reach while in bed for one of one sampled resident (Resident 18) reviewed under the environment task. This deficient practice had the potential to result in Resident 18 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of one sampled residents (Resident 48), when Licensed Vocational Nurse 1 (LVN 1) left the resident's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated the residents' right to privacy and confidentiality of medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for a resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) setting for one of three sampled residents (Resident 1) reviewed under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential to place Resident 1 at risk for discomfort and development of pressure ulcers/injuries.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 45) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to Provide Restorative Nursing exercises as ordered by the physician. This deficient practice had the potential to place the resident in further decline of her range of motion and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment was free of accident hazards for two of eight residents (Resident 20 and 49) reviewed under the Accidents care area by failing to: 1. Ensure the television in the Resident 20's room is strapped or bolted to prevent it from falling. 2. Ensure licensed nurses did not leave Resident 20's medications at bedside and unattended. Resident 49 was not capable of self-administration of medications. These deficient practices placed the residents at risk for injury and harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 13) with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to: 1. Update/revise the care plan (a document outlining a detailed approach to care customized to an individual resident's need) for Resident 13`s indwelling catheter after 6/3/2024. 2. Implement the care plan intervention of monitoring for sign and symptoms of Urinary Tract Infection (UTI-an infection in the bladder/urinary tract) such as pain, burning, blood-tinged urine (red or pink urine), and foul smelling (bad-smelling) urine. These deficient practices had the potential to result in Resident 13 receiving inadequate care and supervision at the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 25) reviewed under the nutrition task, by failing to assess and monitor the resident after having weight loss. This deficient practice had the potential to place Resident 25 at risk for further weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure licensed nurses check for gastrostomy tube (G-tube, a tube inserted through the abdomen to deliver nutrition and medications directly to the stomach) placement (verifying that a G-tube, is positioned correctly in the stomach and not in another location by aspirating stomach contents through the tube using a syringe) before administration of medications as indicated in the resident's care plan for one of two sampled residents (Resident 4) reviewed under the Tube Feeding care area. This deficient practice had the potential to increase Resident 4's risk of aspiration (the accidental inhalation of foreign material, such as food, liquid into lungs).

Inspectors wrote2. A review of Resident 2's admission Record indicated the facility originally admitted the resident on 2/28/2011 and readmitted on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) and chronic kidney disease (a gradual loss of kidney function). A review of Resident 2's MDS dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired. The MDS further indicated that Resident 2 was totally dependent on staff for oral hygiene, toileting hygiene, shower, upper body dressing and lower body dressing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (device used by residents that when pressed informs facility staff that assistance is being requested) were within resident's reach while in bed for one of three sampled residents (Resident 27). This deficient practice had the potential to delay the provision of services and resident's needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) did not leave residents' electronic medical records (a digital version of a patient's medical history) open on the medication cart (a device used to store, transport, and organize medications and medical equipment) while the cart was left unattended in the hallway for two of two sampled residents (Resident 1 and 54) investigated for privacy and confidentiality. This deficient practice violated the resident's right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LAL - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per manufacturer's guidelines for one of one sampled resident (Resident 1) investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen as ordered by the physician for one of three sampled residents (Resident 46). This deficient practice had the potential to result in Resident 46 not receiving the needed oxygen that Resident 46 required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) administered a resident's metoprolol (medication that treats high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) with food, as prescribed by the physician for one of five sampled resident (Resident 54). This deficient practice had the potential to place the resident at increased risk of adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave medications unattended on top of the medication cart (a device used to store, transport, and organize medications and medical equipment) in the hallway when she walked away from it for one of five sampled residents (Resident 54) observed during the medication administration task. This deficient practice placed residents or unauthorized personnel at risk of accessing the medications. 2. Ensure an unopened insulin (hormone that lowers the level of glucose [sugar] in the blood) pen was refrigerated and not placed in the medication cart for one of five sampled residents (Resident 44) investigated under medication storage and labeling. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report for one of four sampled residents (Resident 1) the result of the investigation of an injury of unknown origin (the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious) within five (5) working days of the incident. This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by CDPH.

Inspectors wroteBased on interview and record review, the facility failed to provide timely radiology service for one of four sampled residents (Resident 1). On 11/4/2023, Resident 1 had pain and swelling on the left upper arm of unknown origin (the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious); the same day the physician ordered X-rays, but they were not taken until 4/6/2023. This deficient practice resulted in a two-day delay of care and services to treat Resident 1 fracture of the left upper arm.