Ventura Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ventura Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 4, 2023

  Based on interview, observation, and record review, the facility failed to provide appropriate supervision to prevent an elopement for 1 of 1 sampled resident who eloped, Resident #1; and failed to provide appropriate supervision to prevent a fall with injury for 2 of 2 sampled residents reviewed for falls with injury, Resident #1, and Resident #3. The deficient practice allowed Resident #1 to exit the facility undetected on 11/24/22 at approximately 6:00 PM, walk approximately 100 feet outside, and fall. Resident #1 was transported by Emergency Services to the local trauma hospital. […]

• Actual harm, isolatedF692Aug 25, 2022

  Based on observation, interview, and record review, the facility failed to provide treatment and services necessary to maintain or improve dining-eating and to prevent significant weight loss for 2 of 8 sampled residents reviewed for nutrition (Resident #43 and #128); and failed to provide the necessary services to maintain good nutrition and prevent weight loss for 1 of 2 sampled residents (Resident #15) who required total assistance with eating. The findings included: 1. During the observation of Resident #43 on 08/22/22 at 11:00 AM, it was noted the resident to be lying in bed, appeared malnourished and underweight, and had cognition deficit. […]

• Actual harm, isolatedF697Aug 25, 2022

  Based on observation, interview, record review and policy review, the facility failed to provide pain medication associated with wound care for 1 of 2 sampled residents (Resident #223). The findings included: The facility's policy, titled, Negative Pressure Wound Therapy, implemented 11/2020, revealed, in part, Monitoring throughout the use of NPWT (negative pressure wound therapy) shall include, but is not limited to, the following: a. Pain associated with the therapy. On 08/16/22, Resident #223 was admitted to the facility from an acute care facility. On 08/22/22 at 10:30 AM, the resident was observed in her bed with her eyes closed. This surveyor attempted to have a conversation with the resident, but she was confused and unable to speak. […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2022

  Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standard for food service safety that included: maintenance of refrigeration units, maintenance of air-conditioning systems, ensure only dietary staff in food preparation and serving area, proper covering of garbage and trash, and proper equipment to be used for food storage and clean dishware. The findings included: 1. During the initial observation tour of the main kitchen on 08/22/22 at 8:45 AM, accompanied with the facility's Food Service Manager (FSM), the following was noted: (a) Observation of the dish machine area noted that there was a ceiling mounted air-conditioning vent located directly over the machine. […]

• No harm, potential for more than minimal, widespreadF727Jul 9, 2021

  Based on observation, interview and record review, the facility failed to have the services of a registered nurse (RN) for 8 consecutive hours a day, 7 days a week as required. The findings included: During the entrance conference conducted on 07/06/21 in the morning, the census was provided as 63 residents. On 07/06/21 at 3:15 PM, a copy was made of the facility staffing sheet located in the main hallway near the lobby. This staffing sheet displayed the breakdown of nursing staff for each shift for 07/06/21. The sheet showed the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) for each of the three shifts, 7 AM to 3 PM, 3 PM to 11 PM, and 11 PM to 7 AM. […]