Mar Vista Country Villa Healthcare & Wellness

In the surveyor’s words

From the most serious findings on record at Mar Vista Country Villa Healthcare & Wellness, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 1, 2025

  Based on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was closely supervised, monitored, and within staff reach to prevent a fall. The facility was aware that Resident 1 is confused (is the inability to think as clearly or quickly as you normally do), has a history of falls, and impulsive behavior (refers to actions that are taken without sufficient thought or consideration of the consequences) of getting up from the wheelchair (WC) without assistance.This deficient practice resulted in Resident 1 falling on 6/24/2025 at 8:30 PM. […]

• Actual harm, isolatedF689Jun 5, 2024

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) was monitored and supervised to prevent fall and injuries as evidenced by failing to: 1. Ensure Resident 4's bed was in low position based on Resident 4's fall care plan and physician order. 2. Ensure Resident 4 had floor mats based on Resident 4's fall care plan and physician order. 3. Ensure Resident 4 was not left unattended by Certified Nursing Assistant 4 (CNA 4) while the bed was in high position , and the bed rails (also called side rails; are adjustable metal or rigid plastic bars that attach to the bed. […]

• Actual harm, isolatedF689Feb 2, 2024

  Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents (Resident 1), who was assessed at risk for fall by failing to: 1. Ensure Certified Nurse Assistant 1 (CNA 1) provided two-person physical assistance (had help from another staff member) when turning Resident 1 in bed as indicated in Resident 1's Minimum Data Set (MDS- a required standardized assessment and care planning tool) dated 12/20/2023. 2. […]

• Actual harm, isolatedF690Nov 10, 2023

  Based on interview and record review, the facility failed to provide necessary care and treatment for urinary tract infection (UTI, an infection in the drainage system for removing urine) due to failure to promptly (with little or no delay) notify a physician and or a nurse practitioner (NP - a nurse with a graduate degree in advanced practice nursing) of a urinalysis (UA - urine test used to check for infection or kidney problems) test results positive for bacteria on [DATE] and failure to place an order for urine culture and sensitivity (C&S -a test to diagnose germs such as bacteria or fungus [yeast or mold] that can cause an infection and checks on the appropriate medicine, such as an antibiotic [medication to treat infection]) for one of three sampled residents (Resident 1) in… […]

• Actual harm, isolatedF689Jun 22, 2023

  Based on observation, interview, and record review, the facility failed to provide a safe environment to prevent accident for one of three sampled residents (Resident 1). The facility failed to ensure: 1. The specific lift machine (designed to lift and transfer patients from one place to another) was identified based on Resident 1's assessed needs for a safe transfer and as per the lift machines manufacturer's Operational Manual and the facility's policy and procedure (P&P) on Sit-to-Stand Lift and the P&P on Transfer of Residents. 2. The specific lift machine and the number of staff needed in the transfer procedure was documented and care planned in Resident 1's clinical record to prevent the staff from using the wrong lift machine. 3. […]