Villa del Rio Gardens

In the surveyor’s words

From the most serious findings on record at Villa del Rio Gardens, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 10, 2022

  Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 76 and 179) received care to prevent pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) development, by failing to: 1. Implement Resident 179's care plan which indicated staff were to check the resident's skin for presence of sores, breakdown, impairment, and skin trauma, and use pressure reducing devices. 2. […]

• No harm, potential for more than minimal, widespreadF812Feb 10, 2022

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in the kitchen when: 1. The foods were not labeled with opened dates, there was no received dates, foods were stored in bins, refrigerator, and freezer without removing from original packaging. 2. The ice machine was not maintained in a clean and sanitary condition to ensure the ice was safe to consume. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) for 80 of 81 medically compromised residents who received food and ice from the kitchen. Findings. a. […]

• No harm, potential for more than minimal, patternF641Feb 10, 2022

  Based on observation, interview, and record review, the facility failed to accurately assess two of eight sampled residents' skin integrity (Residents 76 and 179). Cross Referenced F686. This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) on the sacrococcygeal (base of the spine, tailbone) area and Resident 76 developing a deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) on the left heel. Findings: a. […]

• No harm, potential for more than minimal, patternF758Feb 10, 2022

  Based on interview and record review, the facility failed to perform [CONDITION(S)] assessments and provide non-pharmacological interventions to Residents 6, 33, 43, and 49 prior to start of [CONDITION(S)] medications (medication that affects brain activities associated with mental processes and behavior) to ensure the use of psychotropics were necessary to treat a specific condition; and perform a gradual dose reduction ([GDR] an attempt to decrease or discontinue [CONDITION(S)] medication after no more than three months after starting on the [CONDITION(S)] medication) for Resident 49. These deficient practices had the potential to result in Residents 6, 33, 43, and 49 receiving unnecessary medications. […]

• No harm, potential for more than minimal, patternF880Feb 10, 2022

  Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of the coronavirus disease ([COVID-19 a disease caused by virus called [CONDITION(S)]-CoV-2}) an illness caused by a virus that can easily spread from person to person) by failing to: 1. Ensure housekeeping that was assigned to clean the hallway at the green zone (a room or group of rooms designated for residents who do not have nor were exposed to Covid-19) was wearing an N-95 (a type of mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols [a suspension of fine solid particles or liquid droplets in air] and prevent infections). 2. […]