Villa las Palmas Healthcare Center

In the surveyor’s words

From the most serious findings on record at Villa las Palmas Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600May 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was free from verbal and mental abuse when: Certified Nursing Assistant (CNA) 2 yelled at Resident 1 and made disparaging comments to the resident about their ability to perform bed mobility while also making humiliating comments to the resident regarding their weight and size. Cross reference F607. As a result: Resident 1 cried, experienced depressed mood, psychosocial (the influence of social factors on an individual's mind or behavior) distress, and felt unsafe in the facility and worthless. Findings: A review of Residents 1 ' s Admission Record dated 5/1/25, indicated the resident was readmitted to the facility on [DATE]. […]

• Actual harm, isolatedF692Mar 4, 2024

  Based on interview and record review, the facility failed to address the nutrition and hydration need of one of three residents (Resident 1) when: Resident 1's nutrition and hydration need, as recommended by the registered dietician (RD), was not implemented. The interdisciplinary team (IDT - team of individual with different specialties) did not address Resident 1's weight loss. As a result, Resident 1 was found lethargic (lack of mental and physical energy) and hard to arouse (wake up). […]

• No harm, potential for more than minimal, widespreadF812May 8, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure food items stored in the residents' refrigerator were labeled and dated and discarded within two days per the facility policy. This deficient practice had the potential to affect who stored items in the residents' refrigerator. Findings included: An undated facility policy titled, Bringing In Food For Our Residents, revealed, Food or beverages should be labeled and dated to monitor for food safety. The policy revealed, Food or beverage items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away two days after the date marked. […]

• No harm, potential for more than minimal, patternF850Apr 17, 2025

  Based on interview and record review, the facility failed to employ a qualified Social Services Director (SSD) on a full- time basis that met the qualifications specified in the regulation. This deficient practice placed all 151 residents at risk of not receiving medically-related social services necessary to attain their highest practicable well-being. Findings: An anonymous complaint regarding the SSD not meeting job qualifications was received by the California Department of Public Health. On 4/17/25, an unannounced site visit was conducted. An interview was conducted with the Director of Nursing (DON) on 4/17/25 at 2:10 P.M. The DON stated there had been some staff turnover in the SW department. […]

• No harm, potential for more than minimal, patternF880Oct 18, 2023

  Based on observation, interview and record review, the facility failed to implement infection control standards of practice when: 1. A dedicated blood pressure cuff, stethoscope and thermometer were not available for eight residents who were on contact isolation precautions for a multi-drug resistant organism (MDRO-bacteria that developed resistance to one or more classes of antibiotics). 2. Face shields or eye protection were not available for staff to use upon entering a resident room with a diagnosis of Coronavirus (COVID-19 an infectious respiratory infection). These failures had the potential to expose other residents, staff, and visitors to infection. Findings: 1. An interview was conducted with the Infection Preventionist (IP) on 9/29/23, at 10:07 A.M. […]