The Villas at Poway

In the surveyor’s words

From the most serious findings on record at The Villas at Poway, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 21, 2024

  Based on observation, interview, and record review, the facility failed to ensure Resident 7 was not abused. As a result, Resident 7 experienced abuse from two staff members. In addition, other residents who were cognitively impaired (problem with the ability to think, learn, remember, use judgement, and make decisions) had the potential to suffer abuse from the two staff members. Findings: On 9/4/24 at 9:50 A.M., an unannounced visit was made to the facility in response to a reported abuse incident. An observation was conducted on 9/4/24 at 12:49 P.M. Resident 7 was sitting in a wheelchair in the hallway with other residents. […]

• No harm, potential for more than minimal, widespreadF803Mar 23, 2023

  Based on observations, interviews, and document reviews, the facility failed to ensure the menu was designed to meet the nutritional needs of the residents on pureed diets. This failure led to twelve (12) residents on pureed diets to receive fewer calories and nutrients which had the potential to further impair their nutrition and health status. Cross reference F804 Findings: During a review of the facility's undated therapeutic menu spreadsheet titled Week 2, Tuesday, 3/21/23, the Regular Diet lunch meal was 3 ounces (oz.) oven fried chicken breast, 1/2 cup mashed potatoes, 1/2 cup sauteed green beans and cherry tomatoes, 8 ounces (oz.) 1% milk, 6 oz. creamy lentil soup, 2 saltine crackers, and 1 iced brownie. The Dysphagia Pureed Diet lunch meal included a 3 oz. turkey puree with 1 oz. […]

• No harm, potential for more than minimal, widespreadF812Mar 23, 2023

  43518 Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation protocols were maintained in the kitchen according to standards of practice and facility policy when: 1. Loading dock area, dumpster cart, and area in front of the dumpster were not free of kitchen waste. 2. Ten (10) kitchen floor sink drains were dirty and filled with food waste. 3. An Ice Machine was not properly maintained and cleaned per manufacturer guidelines. 4. An expired supplement was found in a nourishment room refrigerator in the facility nursing station. These failures exposed residents to unsanitary practices in the kitchen, which had the potential to contaminate the food and place residents at risk of developing a foodborne illness. […]

• No harm, potential for more than minimal, widespreadF814Mar 23, 2023

  Based on observation, interview and record review, the facility failed to ensure: 1. Loading dock, dumpster cart, and area in front of the dumpster were free of kitchen waste. 2. Food and Nutrition department floor sink drains were free from food waste. These failures provided an unsanitary environment in the kitchen that harbored pests and had the potential to contaminate resident food. The nursing home census was 109 residents. Cross reference F812, F925 Findings: 1. During a kitchen observation of the garbage disposal and concurrent interview on 03/20/23 at 2:34 P.M., Food Service Worker 1 (FSW1) demonstrated the trash removal process from the kitchen. FSW1 brought trash bags in garbage can to dock. FSW1 went down service lift to get dumpster cart. […]

• No harm, potential for more than minimal, widespreadF908Mar 23, 2023

  43518 Based on observations, interviews, and document reviews the facility failed to ensure: 1. One ice machine in the main kitchen was maintained in a safe operating condition. 2. One ice machine in the skilled nursing facility (SNF) was maintained and cleaned according to manufacturer's guidelines and standards of practice. This failure created the potential for residents to receive and consume ice from machines that were contaminated with substances resembling mold and other hazardous chemicals, that could lead to foodborne illness and impair health status. The facility census was 109. Cross reference F812 Findings: 1. On 3/20/23 at 8:40 A.M., during the initial kitchen tour, a concurrent observation and interview was conducted with the Patient Service Supervisor (PSS). […]