Villa Siena

Based on observation, interview, and record review, the facility failed to ensure an expired emergency kit (a kit/box containing medications for immediate use during a medical emergency) and a medication were replaced timely to ensure unexpired medications were available for resident use.During a visit to the medication room on 7/21/25, at 10:21 a.m., with Licensed Vocational Nurse (LVN) B, an emergency kit containing three refrigerated medications was observed in the medication refrigerator. A review of the contents list on the outside of the kit indicated the expiration date for two lorazepam vials (injectable medication to treat seizures and agitation) was 3/2025. Further inspection of the contents inside with LVN B revealed one lorazepam vial had the expiration date of 3/2025 (4 months ago), and another vial expired in 4/2025. LVN B acknowledged this finding and stated it should be replaced.On 7/21/25, at 10:37 a.m., random inspection of medications in the medication room with LVN B revealed a tube of Capzasin Quick Relief Gel (topical medication for arthritis pain) for Resident…

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 follow their policies for influenza vaccine (known as flu shot, immunization against infection by influenza viruses) and pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) when the facility did not offer pneumococcal vaccinations and influenza vaccinations in accordance with the current Centers for Disease Control and Prevention (CDC) recommendations to 22 of 29 residents (Residents 2, 3, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 16, 18, 20, 21, 23, 24, 25, 26, 27, and 181). This failure had the potential to put the residents at risk of acquiring pneumococcal and influenza infections. Findings: 1. Review of Resident 2's face sheet indicated that the resident was admitted on [DATE]. Review of Resident 6's face sheet indicated that the resident was admitted on [DATE]. Review of Resident 7's face sheet indicated that the resident was admitted on [DATE]. Review of Resident 9's face sheet indicated that the resident was…

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 obtain informed consents for the use of restraints (a specific intervention or device that prevents the patient from moving freely or restricts normal access to the patient's own body) for 13 of 13 sampled residents (2, 3, 5, 7, 8, 9, 15, 17, 18, 20, 24, 26, and 29) who were using a personal safety alarm (a small, noise-making device meant to surprise a potential attacker or draw attention to an individual in distress), floor mat alarm (a mat that is placed on the floor which sounds when it senses that a person is walking over it), and wander/elopement alarm (the person at risk of eloping is provided with a bracelet or anklet that triggers an alarm if they attempt to exit those doors which then alerts staff so they can assist the individual), when 1. There was no documentation indicating that Resident 2 or her responsible parties (RP) signed the informed consent to use the floor mat alarm; 2. There was no documentation indicating that…

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 accurately assess and complete the Minimum Data Set (MDS, an assessment tool) for 20 of 29 residents (Residents 2, 3, 5, 6, 7, 9, 10, 11, 13, 14, 15, 16, 18, 20, 21, 23, 24, 25, 26, and 29). This failure had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions. Findings: 1. Review of Resident 29's clinical record indicated that she was admitted on [DATE]. Resident 29's MDS dated [DATE] was reviewed. The MDS section M0210 asked, Does this resident have one or more unhealed pressure ulcers/injuries? and was coded 0. No. Resident 29's MDS dated [DATE] was reviewed. The MDS section M0210 was coded 1. Yes. The MDS section M0300 asked to enter Current number of unhealed pressure ulcers/injuries at each stage, and number 1 was entered for B. stage 2: 1. Number of stage 2 pressure ulcers; number 1 was entered for B. stage 2: 2. Number of these stage 2 pressure ulcers that were present upon…

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 a registered nurse (RN) was on duty for 8 consecutive hours for 8 days during the months of October, November, and December of 2023. This failure had the potential to affect resident's care, health, and wellbeing. Findings: A review of the facility's Staff Schedule Sheet - Licensed Nurses dated October 2023, indicated, no RN was scheduled or was on duty on 10/7/23, 10/21/23, or 10/28/23. A review of the facility's Staff Schedule Sheet - Licensed Nurses dated November 2023, indicated, no RN was scheduled or was on duty on 11/4/23, 11/11/23, or 11/24/23. A review of the facility's Staff Schedule Sheet - Licensed Nurses dated December 2023, indicated, no RN was scheduled or was on duty on 12/2/23, or 12/9/23. During an Interview with the director of nursing (DON) on 4/18/24 at 11:08 a.m., she stated the facility was unable to provide evidence that an RN was on duty at the facility for the above dates in October, November, and December of 2023. The DON confirmed there was no RN on duty on 10/7/23, 10/21/23,…

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 service operations were carried out according to standards of practice when: 1. The ice machine drain pipe and the floor drainage sink did not have air gaps (an unobstructed vertical space between the water outlet and the flood level of a fixture), 2. A Dietary Aide did not wear a hair net while serving food in the the Skilled Nursing Facility (SNF) kitchen, 3. The temperature of the resident's refrigerator in the activity room was not recorded two times each day. These failures could potentially expose 29 residents to harmful contaminants that could cause foodborne illness. Findings: 1. During a concurrent observation and interview on 4/15/2024 at 11:25 a.m. with the Food Service Director (FSD) in the SNF Kitchen, the ice machine drain pipe touched the bottom of the floor drainage sink. The FSD confirmed the above observation and stated that there should be a two-inch air gap between the ice machine drain pipe and the bottom of the floor drainage sink. During a review of 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, the facility failed to develop and implement care plans for one of 13 sampled residents (Resident 8) when a care plan for a fall was not developed. This failure had the potential to not meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Findings: Review of Resident 8's clinical record indicated she was admitted on [DATE] and had diagnoses including dementia (a decline in mental capacity affecting daily function), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and personal history of traumatic fracture (broken bone from force being applied to a bone). Review of Resident 8's minimum data set (MDS, an assessment tool) dated 4/03/24 indicated she had a brief interview of mental status (BIMS, a tool used to assess cognition) score of 03, meaning she had severe cognitive impairment [a score of 0 to 7 indicates severe cognitive impairment, 8-12…

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 respiratory care in accordance with professional standards of practice for one of one sampled resident (Resident 27) when: 1. Resident 27's nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source) and humidifier were outdated; 2. The licensed nurses failed to document when oxygen was administered to Resident 27; 3. Resident 27's physician order for oxygen did not have an indication for use. These failures had the potential to compromise Resident 27's health and safety. Findings: 1. Review of Resident 27's clinical record indicated he had diagnoses including heart failure (heart cannot pump enough blood and oxygen to support other organs in the body), hypertensive heart disease with heart failure (type of high blood pressure that affects the blood vessels of the heart), and cardiomyopathy (chronic disease of the heart muscle). During an observation on 4//15/24 at 9:35 a.m., Resident 27 was lying in bed receiving oxygen at 2 liters per minute (LPM, rate of oxygen…

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 obtain physician admission orders for two of 29 residents (Resident 1 and 17). These deficient practices had the potential for unauthenticated and inaccurate treatment orders. Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (an irregular, often rapid heart rate that causes poor blood flow) and heart failure (condition in which the heart does not pump blood as well as it should). A further review of Resident 1's physician order summary indicated no order for admission to the facility. A review of Resident 17's face sheet indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including unspecified atrial fibrillation and sequelae (consequence) of cerebral infarction (also called ischemic stroke, disrupted blood flow to the brain due to problems with the blood vessels that supply it). A further review of…

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 ensure a physician's order for a PRN (as needed) psychotropic medication (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days for one of five sampled residents (Resident 27). This failure had the potential to result in the resident receiving the medication for an excessive length of time and experiencing adverse medication side effects. Findings: Review of Resident 27's physician order dated 3/14/24 indicated Lorazepam 0.5 milligrams (mg, unit of dose measurement). Give one tablet by mouth every 6 hours PRN as needed for anxiety/restlessness as manifested by inability to relax. Review of Resident 27's medication administration record (MAR) indicated Resident 27 received PRN Lorazepam 0.5 mg on 4/3/24, 4/4/24, and 4/5/24. During an interview and concurrent record review with director of nursing (DON) on 4/18/24 at 9:07 a.m., she stated PRN psychotropic medications should be limited to 14 days unless the physician provides a rationale to extend the PRN use beyond the 14 days. The DON…

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 proper medication storage for three out of 29 residents (Residents 6, 13, 27) when expired or discarded medications were stored, not put away. This failure had the potential for residents to receive medications with unsafe and reduced potency from being used past their expiration date, which could lead to unsafe medication for the residents. Findings: 1. During an inspection of the medication cart with LVN C on [DATE] at 3:18 p.m., a Latanoprost solution (eye drop for glaucoma [eye disease]) for Resident 6 was stored in the cart. The medication container box indicated it was opened on [DATE], and the expiration date was [DATE]. LVN C confirmed the Latanoprost solution had expired and should have been removed from the cart. A review of Lexi-comp, a nationally recognized drug information resource, indicated the following for Latanoprost solution storage: Once opened, the container may be stored at room temperature for 6 weeks. 2.…

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 properly store and label the food brought from outside the facility by the family for one of one sampled residents (Resident 24). This failure had the potential for unsafe storage and might result in foodborne illness. Findings: During an observation with the Director of Staff Development (DSD) on 4/17/2024 at 2:25 p.m., seven small plastic containers in an open big container for Resident 24 were not labeled with a date in the residents' refrigerator. During an observation on 4/18/2024 at 2:28 p.m., it was observed that seven small plastic containers in an open big container for Resident 24 were not labeled with a date in the residents' refrigerator. During a concurrent observation and interview with the Food Service Director (FSD) on 4/19/2024 at 9:20 a.m., seven small containers in an open big plastic container for Resident 24 were not labeled with dates in the residents' refrigerator. The FSD confirmed the above obervation and stated that all the food in the refrigerator should be labled with residents'…

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 document review, the facility failed to ensure infection prevention practices were followed when: 1. For Residents 2, 12, and 22, staff did not clean the glucometer machine according to the manufacturer guidelines; and 2. For Resident 29, staff did not perform hand hygiene during a wound treatment procedure. These failures had the potential to spread infection in the facility. Findings: 1. During a medication administration observation on 4/16/24 at 11:45 a.m., Licensed Vocational Nurse A (LVN A) used a glucometer machine to take Resident 2's blood sugar. LVN A cleaned the glucometer machine with a Sani-Cloth wipe (a disinfectant wipe, a product used to kill microorganisms) and put the glucometer in the medication cart without any air drying time. During an observation on 4/16/24 at 11:58 a.m., LVN A used a glucometer machine to take Resident 22's blood sugar. LVN A cleaned the glucometer machine with a Sani-Cloth wipe and put the glucometer in the medication cart without any air drying time. During an observation on 4/16/24 at 12:03 p.m., LVN A…

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 interviews, and record review the facility failed to ensure to follow their policy and procedure for nurse assistant certification for one of three certified nursing assistants (CNA A) during his employment. This failure had the potential for not meeting resident's safety, and attain or maintain the highest practicable physical, mental, and psychosocial well-being of 27 residents currently residing in the facility. Findings: During record review of employee file for current nurse assistant certification for CNA A indicated, CNA A's nurse assistant certification expired on [DATE]. During the search for CNA A's nurse assistant certification verification status at the California Department of Public Health (CDPH)'s License and Verification (L &V) web site (a collection of files accessed through a web address, covering a particular subject and managed by a particular person or organization) on [DATE] indicated there was no active nurse assistant certification for CNA A. Review of facility's Daily staffing…

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 facility document review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. An ice machine was not kept in a sanitary condition; and 2. The certified nursing assistant G (CNA G) assisted two residents (Resident 8 and 5) in then dining room without performing hand hygiene. These failures had the potential to cause cross-contamination of food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the 29 residents eating at the facility. Findings: 1. During an observation on 12/05/22 at 10:02 a.m. in the main kitchen, the ice machine had blackish substances on the interior top part. There was no signage indicating the ice machine was out of order or not in use. The top part was wiped with white paper towel, and the white paper towel had blackish substances. There was the monthly ice machine cleaning log on the top of the ice machine. 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.

Based on observation, interview, and facility record review, the facility failed to implement infection control practices when the licensed vocational nurse D (LVN D) did not perform hand hygiene prior to donning (putting on) gloves during medication administration for three of five randomly selected residents (Residents 1, 25, and 3). This failure put residents and staff at risk of possible spread of infection. Findings: 1a. During a medication administration observation on 12/6/2022 at 8:42 a.m., the LVN D entered Resident 1's room, donned a new pair of gloves and administered Resident 1's oral (by mouth) medications and nasal spray. The LVN D did not perform hand hygiene prior to donning gloves. 1b. During a medication administration observation on 12/6/2022 at 9:10 a.m., the LVN D entered Resident 25's room, donned a new pair of gloves and administered Resident 25's nasal spray. The LVN D did not perform hand hygiene prior to donning a new pair of gloves. 1c. During another medication administration observation on 12/6/2022 at 9:41 a.m., the LVN D donned another pair of gloves…

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 services were provided to meet the professional standard of practice for 5 of 12 sampled residents (Residents 4, 19, 3, 13 and 1) when: 1) Licensed vocational nurse D (LVN D) did not check Resident 4, 19 and 3's blood pressure (BP) and pulse rate (PR) or heart rate (HR) prior to administration of antihypertensive (a type of medication used to lower blood pressure) medication. 2) documentation of pacemaker (implanted device for a heart condition, a battery-powered device implanted inside the heart to restore a normal heartbeat.) information in residents' medical records were lacking for Residents 1, 4 and 13. 3) No pacemaker care was included in Resident 4's care plan. These failures had the potential to jeopardize the residents' health. Findings: 1a. During a medication pass observation on 12/6/2022 at 8:58 a.m., the licensed vocational nurse D (LVN D) administered Resident 4's medications: Lisinopril 20 milligram (mg- unit of measurement) 1 tablet (tab) and Metoprolol Succinate ER (extended release)…

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 provide treatment and care in accordance with professional standards of practice for two of 12 sampled residents (Residents 26 and 27) when: 1. For Resident 26, nursing staff did not apply Posey boot (heel protector) to left foot as ordered; and 2. For Resident 27, there was no proper supervision in the dining room and a nutrition care plan was not updated. These failures had the potential to affect the residents care and jeopardize their health and well-being. Findings: 1. Review of Resident 26's clinical record indicated she was admitted [DATE] and had the diagnoses of Alzheimer's disease (a condition characterized by memory loss), pressure ulcer (injury to skin and tissue resulting from prolonged pressure on the skin) of left heel, and hypertension (high blood pressure). Review of Resident 26's physician order dated 4/18/22, indicated Posey boot on left foot. During an observation on 12/07/22 at 3:30 p.m., while Resident 26 was lying…

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 residents were seen by their attending physicians for two of 12 sampled residents (Residents 11 and 9). These failures had the potential to affect residents' care, health, and wellbeing. Findings: 1. A review of Resident 11's clinical records indicated, Resident 11 was admitted on [DATE] with diagnoses including dementia (a condition characterizes by a decline in mental capacity affecting daily function), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and osteoarthritis (OA, joint disease characterized with pain). During a concurrent interview and record review with the director of staff development (DSD) on 12/7/2022 at 1:01 p.m., the DSD reviewed Resident 11's physician's progress notes. The DSD confirmed the physician's last visit to Resident 11 was on 8/31/2022. The DSD stated the physician should visit residents in their facility monthly until stable and…

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 a registered nurse (RN) for at least 8 hours a day to 29 residents. This failure had the potential to affect resident's care, health, and wellbeing. Findings: During multiple observations at the facility on 12/5/2022 from 8:30 a.m. to 4:00 p.m., 12/6/2022 from 8:00 to 4:00 p.m., 12/7/2022 from 8:30 a.m. to 4:00 p.m., 12/8/2022 from 8:30 a.m. to 2:00 p.m. and 12/9/2022 from 8:30 a.m. to 2:00 p.m., there were no RN available. During a concurrent interview and record review on 12/9/2022 at 10:28 a.m., the Director of Staff Development (DSD) reviewed the daily staffing sheet, dated 12/1/2022 to 12/9/2022. The DSD confirmed their director of nursing (DON) who was an RN, was on vacation. The DSD confirmed there was no RN coverage since 12/3/2022. The DSD stated, they only have one RN scheduled every Sunday, but the RN was off on 12/4/2022. During an observation on 12/9/2022 at 10:30 a.m., the DSD asked the executive director (ED) about the RN coverage. The ED stated, Yes, we don't have an RN right now. A…

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 daily staffing information posted was complete. This failure had the potential to result in nurse staffing misinformation about resident's care. Findings: During a concurrent observation and record review on 12/5/2022 at 10:22 a.m., a nurse staffing information was observed posted on a board within a sliding glass display case, beside the nurse station. The posting was titled, Villa [NAME], Report of Nursing Staff Directly Responsible for Resident Care, dated 12/5/2022, it indicated nothing about the total number and the actual hours of licensed and unlicensed staff directly responsible for resident care per shift and the resident census. During a concurrent interview and posting review on 12/9/2022 at 10:48 a.m., the director of staff development (DSD) reviewed the nurse staffing posting. The DSD confirmed there was no total number and actual hours of licensed and unlicensed staff directly responsible for resident care per…

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 an account of controlled drug was maintained and reconciled for one of three randomly selected residents (Resident 5). This failure had the potential for misuse or diversion of controlled medications. Findings: A review of Resident 5's Physician Orders for the month of December 2022, it indicated, TRAMADOL HCL [a class of drugs known as opioid analgesics - use to relieve moderate to severe pain] 50 MG TABLET [tab]- GIVE 2 HALF TABS = 50 MG THREE TIMES A DAY PRN [pro re nata - as needed only] (ONLY IF PAIN IS EQUAL TO OR GREATER THAN 7/10 [for severe pain]). During a concurrent observation and record review on 12/5/2022 at 3:39 p.m., a narcotic count was performed with the licensed vocational nurse F (LVN F). The actual count of Resident 5's Tramadol HCL 50 mg half tablets was 80 half tablets. The LVN F reviewed Resident 5's Controlled Drug Record of Tramadol 50 mg half tablets and stated there should be 81 half tablets of Tramadol HCL as indicated. During a follow up interview with the LVN F 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to properly label and store medications and biologicals when: 1. The medication cart drawer had some sticky, brown substance at the bottom and on the sides; 2. A box of Loperamide Hydrochloride (a medication for loose stools) 2 mg (milligram - a unit of measurement) tablets for Resident 26 was expired and stored in the medication cart; 3. A bottle of Fluticasone Propionate (a nasal spray for relief of nasal congestion, itchy and runny nose) for Resident 1 was not labeled. These failures had the potential for residents to receive unsafe and reduced potency of medications. Findings: 1. During an inspection of the facility's medication cart and interview with the licensed vocational nurse F (LVN F) on [DATE] at 3:31 p.m., the drawer below the narcotic box had some over the counter medications placed on a removable box. The bottom part of the removable box had some sticky and brownish build up substance. The bottom and side part of the medication…

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 electronically submit staffing information based on payroll data on a quarterly schedule to the Centers for Medicare & Medicaid Services (CMS) in 2022. The deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: A review of facility's Payroll-Based Journal (PBJ - nurse staffing and non-nurse staffing datasets) Data Report indicated, the facility did not submit the third fiscal year quarter of 2022 (April 1-June 30) staffing information based on payroll data. During an interview with the director of staff development (DSD) on 12/9/2022 at 10:25 a.m., the DSD stated the human resource (HR) staff was responsible for the submission of the staffing information to CMS. During an interview with the HR staff on 12/9/2022 at 11:18 a.m., the HR staff stated the submission of the staffing information to CMS should have been done on a quarterly basis. A review of CMS' Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual,…

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.