Del Rosa Villa

In the surveyor’s words

From the most serious findings on record at Del Rosa Villa, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 13, 2024

  Based on interview and record review, the facility failed to prevent elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) by one of eight residents (Resident 1) with a wander guard system (a wander guard system relies on three components: bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time. When a resident with a bracelet approaches a monitored door, the system alerts with an audible sound) when Resident 1, who was at risk for elopement, did not have close monitoring of his whereabouts and eloped from the facility through a parking lot gate which automatically opened to vehicles entering and exiting from the facility's parking lot. […]

• No harm, potential for more than minimal, patternF803Jan 24, 2025

  Based on observation, interview, and record review, the facility failed to follow the menu when: 1. six (6) of six (6) Residents on pureed diet (a diet of smooth, blended foods that require no chewing) was served 2/3 cup of pureed Jambalaya instead of one cup that the menu called for during lunch on January 21, 2025. 2. 33 of 33 Residents on regular carbohydrate controlled (CCHO-consistent, constant, or controlled carbohydrate [sugars, starches and fiber]) diet, were served one whole slice of garlic bread instead of half a slice the menu called for during lunch on January 21, 2025. This failure had the potential to compromise residents' nutritional status when menus were not followed for 39 of 39 Residents on a Pureed and CCHO diet. Findings: 1. […]

• No harm, potential for more than minimal, patternF759Dec 13, 2023

  Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure the facility medication error rate was e less than 5%. There were two medication errors out of 34 opportunities, which yielded a medication error rate of 5.88%, for 2 (Resident #10 and Resident #60) of 5 residents observed for medication administration. Findings included: A review of the facility policy titled Administering Medications, revised in April 2019, revealed, 10. […]

• No harm, potential for more than minimal, patternF622Jun 20, 2023

  Based on interview and record review, the facility failed to ensure two of three residents (Resident 1 and Resident 2) had documentation that indicated the reason the residents were transferred from one skilled nursing facility (SNF) to another SNF, 250 miles away which was not in accordance with their Policy and Procedure or Federal Regulations. This failure had the potential to negatively impact Resident 1 and Resident 2's psychosocial well-being as the result of an unnecessary transfer. Findings: On June 6, 2023, at 10:15 a.m., an unannounced onsite visit was conducted at the facility to investigate a complaint regarding Discharge and Transfer Rights. 1. […]

• No harm, potential for more than minimal, patternF684Jan 9, 2023

  Based on observation, interview and record review the facility failed to ensure call lights were answered in timely manner to provide care and services for three sampled residents (Resident 1,2 and 3). This failure had the potential to place a clinically compromised Residents (Resident 1,2 and 3) health and safety at risk. When residents were left soiled for a prolonged time. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses to include peritoneal abscess (intra-abdominal infection/pus) surgical aftercare, colostomy (surgical colon opening), type 2 diabetes (body doesn't produce enough insulin, or resist insulin), difficulty walking, hypertension (high blood… […]