Rancho Mesa Care Center

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs when the regular diet (no modifications) meatloaf was not served to 26 residents who are on a medically prescribed mechanical soft diet (designed for people who have trouble chewing and swallowing) instead of meatloaf that is mashable and topped with gravy. This failure had the result to increase the risks of choking and aspiration (process when swallowing food enters the lungs) for 26 out of 52 highly vulnerable residents. Findings: During an observation in the kitchen on August 5, 2024, at 11:46 AM, the [NAME] (Cook) prepared a plate for a resident on a mechanical soft diet. She served the resident the regular diet meatloaf. During a review of the facility document titled, Cooks Spreadsheet - Summer Menus, [undated], indicated that mechanical soft diet meatloaf should be served mashable & moist with gravy. During an interview on August 5, 2024, at 3:37 PM with the Dietetic Services Supervisor (DSS), DSS stated the cook should follow the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, facility failed to ensure that a Minimum Data Set (MDS- a computerized assessment instrument) Discharge Assessment was completed and transmitted in accordance with federal guidelines for one of three residents (Resident 53) reviewed for residents assessment. This failure resulted in Resident 53's assessment not completed upon discharge on [DATE]. Findings: During a review of Resident 53's admission Record (a document that contains demographic and clinical data), the admission Record indicated, Resident 53 was admitted to the facility on [DATE], with diagnoses which included hyperlipidemia (an abnormally high concentration of fats or lipids in the blood) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent interview and record review, on August 9, 2024, at 9:15 AM, with the License Vocational Nurse/Minimum Data Set Nurse (LVN/MDS Nurse), the LVN/MDS Nurse reviewed Resident 53's clinical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status for one of 55 sampled residents (Resident 58) when tube feeding (process where food is delivered into the stomach by a machine) was not administered based on physician order. This failure had the potential to result in decline in function and unplanned weight change to Resident 58. Findings: A review of Resident 58's admission Record, (contains demographic and medical information), indicated Resident 58 was initially admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disruption of blood supply to the brain), aphasia (difficulty in talking), dysphagia (difficulty in swallowing), and debility (physical weakness). During an observation on August 6, 2024, at 9:45 AM, Resident 58 was laying in his bed. He was not able to answer questions and he appeared frail. His tube feeding was not connected and the machine was off. There was no tube feeding bag hanging…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have nursing staff with appropriate competencies and skills set to provide nursing services to Resident 58 when he only received 940 ml (milliliters - unit of measure) of tube feeding (supply of food delivered via tube to the stomach) but should have received 1200 ml (millimeters) of medically prescribed enteral tube feeding formula as ordered by his physician on August 6, 2024. This failure had the potential to result in altered nutrition status for one of 55 medically compromised residents. Findings: A review of Resident 58's admission Record, (contains demographic and medical information), indicated Resident 58 was initially admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disruption of blood supply to the brain), aphasia (difficulty in talking), and dysphagia (difficulty in swallowing). During a concurrent interview and record review on August 6, 2024, at 10:00AM with Licensed Vocational…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to ensure medication for one of seven sampled residents (Resident 42) observed for medication administration, was administered according to the physician's orders, when Resident 42 received Omeprazole [medication prescribe to minimize the acid reflex] after breakfast, on August 7, 2024. This failure has the potential to cause less effective management of Resident 42's condition, as the medication may not work as intended when taken after meal. Findings: During a record Review of Resident 42's admission Record (contains demographic and medical information) the admission record indicated, Resident 42 was admitted to the facility on [DATE], with the diagnosis which included hepatic encephalopathy (a condition that affects the brain and occurs when the liver isn't working properly), morbid (severe) obesity due to excess calories (the person has an extremely high amount of bodyfat), and phantom limb syndrome with pain (a condition where a person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store medications under proper temperature control, as specified by the manufacturer when two vaccine solutions were found inside the medication cart (used to transport medication between patients' rooms), instead of the refrigerator. This failure had the potential to increase the risk of residents receiving vaccine medications with decreased efficacy. Findings: During a concurrent observation and interview on August 6, 2024, at 12:10 PM, while inspecting the 30's hall medication cart with Licensed Vocational Nurse 1 (LVN 1) 1 unopened vial of Covid Spikevax 23-24 (an updated COVID-19 vaccine for the 2023-2024 year), was stored inside the medication cart, the vial was labeled Do not freeze. Keep Medicine in Refrigerator. In addition, 1 unopened syringe of medication Afluria Quad 2023-2024 (a flu vaccine for the 2023-2024 flu season), labeled Refrigerator, was stored inside the medication cart. LVN 1 stated the vaccines had been in the medication cart since the start of his shift at 7:00 AM. Furthermore, LVN 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a representative (ensures residents wishes are respected) was in place for two of three sampled residents (Resident 1 and Resident 2). Resident 1 and Resident 2 had impaired decision making abilities and did not have a representative in place to give consent for medical decisions. This failure resulted in two clinically compromised residents making medical decisions in which resident 1 and resident 2 were unable to understand or comprehend based on their History and Physical. Findings: An abbreviated survey was conducted on October 23, 2023, at 3:55 PM, to investigate a complaint related to Resident Rights. 1.A review of Resident 1's, face sheet (contains demographic information) indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included: schizoaffective disorder (affects your thoughts, mood, and behavior), bipolar disorder (feelings of extreme happiness and sadness), psychosis (not in touch with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a repeated resident to resident altercation, for one of three sampled residents (Resident 2) when Resident 2 had been placed on 1:1 (one-to-one) monitoring (one-to-one monitoring uses continuous staff observation to safeguard patients judged likely to harm themselves or others) and the monitor stepped away from Resident 2 leaving him unattended. This failure had the potential to cause Resident 2 to begin an altercation with another resident. Findings: An unannounced visit was made to the facility on September 19, 2023, at 10:28 AM, to investigate a facility reported incident regarding a resident-to-resident altercation. A review of Resident 2's face sheet (a document that gives a summary of resident information), undated, indicated an admission date of August 25, 2023, with diagnoses that included: psychosis (a mental disorder characterized by a disconnection from reality), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow their policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2's care being prolonged and put them at risk for physical and psychosocial harm. Findings: 1.During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE], with diagnoses which included: joint replacement surgery, left artificial hip, left artificial knee and morbid obesity. During a review of the clinical record for Resident 1, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated July 3, 2023, indicated, Resident 1's score was a 15, which indicated that there was no mental impairment. In an interview with Resident 1, on August 24, 2023, at 3:41 PM, Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Three oranges and seven onions with mold were found in the kitchen inside of a plastic box. 2. A box of 14 yellow squash was wet and leaking inside of the refrigerator, that was stored in the central supply room. 3. Thirty two ounces (unit of weight) of plain yogurt container found inside the refrigerator expired. 4. The ice machine was found dusty outside and inside with dark black stain seen on both sides of the ice maker tray. 5.A shelf storing clean water pitchers were stored in the Central Supply room, near the laundry room. These failures had the potential to contaminate resident's food and cause food -borne illness to a population 56 medically compromised residents who receive food from the kitchen. Findings: 1. During a concurrent observation and interview on June 26, 2023, in the kitchen at 8:06 AM, there were three oranges with mold inside a plastic box inside at the bottom of a stainless steel shelf. Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure their infection control practices were implemented in accordance with their policy and procedure when: 1. One of the kitchen sink air gaps (a form of backflow prevention device) had black, brown grime. 2. Two bar guns (a device used to serve types of carbonated drinks and non-cabonated drinks) were found to contain red residual fluid and were not clear. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to 56 medically compromised residents and staff in the facility. Findings: 1. During a concurrent observation and interview on June 27, 2023, at 12:55 PM, with the Dietary Aide (DA 3), the kitchen sink air gap had black, brown grime. The DA 3 verified the air gap and stated it was the Maintenance Supervisor responsibility to clean the air gap. During an interview with the Maintenance Supervisor (MS), on June 29, 2023, at 9:02 AM, the MS acknowledged the air gap and stated it is the responsibility of the kitchen staff to clean the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three (Residents 10, 54, and 64) of five sampled residents received care in accordance with the facility's policy and procedure. 1. For Resident 10 and 64, the facility failed to ensure their blood sugar levels were monitored and documented prior to administering insulin (medication used to lower blood sugar) according to physician's order. 2. For Resident 54, the facility failed to ensure weekly weights monitoring were carried out per physician's order. These failures had the potential to result in harm or death of the resident from medical complications caused by elevated or decreased blood sugar levels and resident harm from complications of nutritional deficiencies. Findings: 1. During a review of Resident 10's Face Sheet (a summary of medical and demographic data) dated June 27, 2023, the Face Sheet indicated, Resident 10's admitting diagnosis on April 17, 2023 included; Type 2 diabetes mellitus with diabetic neuropathy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to protect the privacy of personal information for five of five sampled residents (Resident's 40, 6, 42, 10, and 19) when Licensed Vocational Nurse 1 (LVN 1) left the electronic health record (EHR) exposed to public view during medication administration. This failure had the potential to violate Resident 40, 6, 42, 10, and 19's right to privacy and confidentiality of medical information. Findings: During a medication administration observation on June 28, 2023, at 1:18 PM, the computer screen displayed the EHR for Resident 40. LVN 1 walked away from the medication cart, leaving the EHR exposed to public view. During an interview with LVN 1, on June 28, 2023, at 1:25 PM, LVN 1 stated, it's ok to leave the computer screen exposed with the resident's health information as long as it's facing the door to the resident's room. During a second observation on June 28, 2023, at 1:30 PM, LVN 1 walked away from the medication cart and walked into Resident 6's room leaving the EHR exposed to public view. During a third…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) assessments were completed accurately to reflect the residents' current health status, care, and services for one of eight residents' (Resident 4) reviewed for antibiotic therapy. Findings: A review of Resident 4's face sheet (a document containing resident's basic information and diagnoses) indicated Resident 4 was admitted on [DATE], with diagnoses that included Type 2 diabetes mellitus, (a chronic condition that affects the way the body processes blood sugar), and benign prostatic hyperplasia with lower urinary tract symptoms. (age-associated prostate gland enlargement that can cause urination difficulty with any combination of urinary symptoms). During a review of Resident 4's Minimum Data Set, (MDS), dated [DATE], the MDS indicated Resident 4 was receiving antibiotic therapy for five (5) days. A review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- a screening done upon admission into a facility to determine if a resident with serious mental illness and/or intellectual/development disability require nursing facility services and/or specialized services) was completed accurately for one resident reviewed for PASSR (Resident 12). This failure had the potential to delay identification and treatment of Resident 12's mental disorder. Findings: During a concurrent observation and interview with Resident 12, on June 26, 2023, at 8:19 AM, in Resident 12's room, Resident 12 was sitting on the edge of her bed eating breakfast. Resident 12 stated she was a survivor of satanic cult. During a review of Resident 12's Face sheet (contains demographic and medical information), it indicated Resident 12 was admitted to the facility on [DATE], with the diagnoses of schizophrenia (mental disorder in which a person interpret reality…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure secure storage of medications when: 1. The central supply medication storage cabinet was found open and unattended on June 26, 2023, at 9:55 AM. 2. The medication storage room was found open and unattended on June 26, 2023, at 10:01 AM and June 27, 2023, at 12:42 PM. 3. The treatment cart #3 was left unlocked and unattended on June 26, 2023, at 11:30 AM. These failures had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 56 residents. Findings: 1. During a concurrent observation and interview, on June 26, 2023, at 9:55 AM, in the Central Supply Room, with the Central Supply Supervisor (CSS), the central supply medication storage cabinet was found open and unattended. The CSS verified the finding and stated it should be not be unlocked and unattended. The CSS further stated she would put a lock on it right away. 2. During a concurrent observation and interview, on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to designate a qualified Director of Food Services to provide oversight of the dietary department which includes, implementing menus, purchasing food, training of staff, and ensuring compliance with all state and federal regulations. This failure had the potential to result in a lack of effective oversight in the operations of the dietary department and supervision which could lead to poor quality of services in the dietary department. Findings: During an interview on June 28,2023, at 1:38 PM, the Dietary Services Supervisor (DSS) stated, she is waiting to take her exam to become a Certified Dietary Manager. During a review of facility's document titled FNS (Food and Nutrition Services) JOB DESCRIPTION dated, 2018, indicated, .for QUALIFICATIONS .3. Must meet the qualifications of FNS Director as stated under State & Federal Regulations. During an interview with the Administrator (Admin) on June 29, 2023, at 2:18 PM, the Admin acknowledged that the DSS did not meet one of the state qualifications for a dietary supervisor, she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store and serve food that conserved flavor and appearance when: 1. Five packages of flour tortillas were found dry and had expired 10 days ago. This failure had the potential to cause food-borne illness (stomach issues from expired and contaminated food) and less palatable. Findings: 1.During an observation on June 26, 2023, at 8:35 AM with the Dietary Services Supervisor (DSS) in the dry storage room area on the top shelf five packages of flour tortillas were found dry and had expired 10 days ago. During an interview with the DSS on June 26, 2023, at 8:35 AM, the DSS acknowledged that the flour tortillas were found expired and dry, and they should not be used. During a record review of facility's policy and procedure titled DRY GOODS STORAGE GUIDELINES dated, 2018, indicated Do check expiration dates on boxes of foods to be sure the length of time is correct.

Based on interview, and record review, the facility failed to ensure the antibiotic stewardship program (a program to measure and improve how antibiotics are prescribed by clinicians and used by patients) was implemented in accordance with facility policy when the monitoring of antibiotic usage and resistance data (monitoring the effectiveness of the antibiotics) were not documented for two consecutive months (May and June 2023). This failure had the potential to inaccurately monitor the use of antibiotics for 56 residents. Findings: During a review of the Antibiotic Stewardship binder, undated, was conducted on June 28, 2023, at 3:50 PM, the binder forms Nursing Center Infection Control Summary Report (a monthly report of the infections and the facility's plan to address) and Infection Prevention and Control Surveillance Log (log of infections, the signs/symptoms, organism on culture, treatment and comments) were not filled out for the months of May and June 2023. During a concurrent interview and record review with the Infection Prevention Nurse (IPN) and the Consultant Infection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure equipment was maintained in safe operating condition when: One of three refrigerators observed, had condensation (water) dripping from the top of the refrigerator to the bottom area. This failure had the potential for the refrigerator to not function properly to cool the food and/or contamination of the food stored inside the refrigerator which could cause foodborne illnesses to a population of 56 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview with the Dietary Services Supervisor (DSS), on June 26, 2023, at 9:05 AM, one of the three refrigerators located inside of the Central Supply room area, had condensation dripping from the top of the refrigerator area to the bottom. The refrigerator was storing boxes of vegetables. An open box of yellow squash under the refrigerator was wet from the dripping water. DSS stated that the refrigerator should be fixed and remove the contaminated vegetables. During an interview on June 29,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.