Villa Mesa Care Center

In the surveyor’s words

From the most serious findings on record at Villa Mesa Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure care and monitoring were maintained for two of two sampled residents (Resident 23 and 4) reviewed for pressure ulcers (injury to skin and underlying tissues that develop because of prolonged pressure, shear (skin tissues slide in opposite directions when sticks to a surface), or friction) when: 1. For Resident 23, there was no documented evidence of wound treatments for Left Iliac Crest (thick, curved bony ridge at the very top of the hip bone), PI (Pressure Injury), change in condition, physician orders for January 7, 2026 through January 16, 2026, IDT meeting (Interdisciplinary Team meeting - a meeting where different professionals come together to discuss a patient's care) and care plan, to address… […]

• No harm, potential for more than minimal, patternF645Oct 3, 2024

  Based on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PAASRR) screening was completed prior to admission to the facility for 3 (Residents #22, #42, and #86) of 5 sampled residents reviewed for PASARR screening. Findings included: A facility policy titled, Pre-Admission Screening Resident Review Level I, revised10/2018, specified, Policy: The State of California has adopted a process to submit Pre-Admission Screening Resident Review electronically. All facilities must complete the [PASARR] by midnight of the date of admission. The policy revealed IX. The BOM [Business Office Manager] will review the status of [PASARR] daily before Stand-Up Meeting to review if new admissions' [PASARR] have been completed. […]

• No harm, potential for more than minimal, patternF921Mar 28, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents, staff and the public were provided a safe, functional, sanitary, and comfortable environment when the ceiling towards the back hallway from west station, was observed to be patched with plywood due to rain. This failure had the potential to result in jeopardizing the health and safety of the public, staff, and clinically compromised residents. Finding: An unannounced visit was made to the facility on [DATE], at 4:50 PM, to investigate a complaint about leakages in the facility. During an inspection of the facility on March 23, 2023, at 5:00 PM, the ceiling towards the back hallway from west station was observed to be patched with plywood. […]

• No harm, potential for more than minimal, patternF755Nov 19, 2021

  Based on observation, interview, and record review, the facility failed to implement their medication administration policy and procedure when the facility: 1. Failed to ensure Resident 39's insulin medication (medication to treat high blood glucose) was readily available for use. This failure had the potential to cause delay of treatment, which can cause negative effects to the overall health of Resident 39. 2. Failed to implement their policy and procedure involving special handling and storage for protecting and securing resident's-controlled medications (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) for one of two sampled residents reviewed for pain (Resident 38) when a licensed nurse did not immediately document when… […]

• No harm, potential for more than minimal, patternF880Nov 19, 2021

  Based on observation, interview and record review, the facility failed to implement infection control and prevention measures when: 1. Resident 56's soiled Nasal Canula (NC- a tubing to deliver oxygen in small amount through nostrils) was not properly disinfected or cleaned before applying back to the resident. 2. Resident 437's peripheral intravenous catheter (PIV, a small hollow tube inserted into a vein for administration of medication, fluids, or blood products) and dressing were not replaced. 3. […]