Villa Rancho Bernardo Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF886Feb 20, 2021

  Based on interview, review of Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH testing guidelines memo, and review of the facility's COVID-19 testing documentation for staff and residents, the facility failed to ensure residents were tested according to current COVID-19 testing standards for COVID-19 outbreak testing of all residents from 01/29/21 to present. On 02/01/21, the facility tested residents located on the Lexington Unit of the facility as a part of outbreak testing because Resident (6) tested positive for COVID-19 on 01/29/21. On 02/08/21, the facility tested residents located on the Fairmont unit because of R7 testing positive for COVID-19 on 02/08/21. […]

• Immediate jeopardy, patternF880Feb 20, 2021

  Based on observations, staff interviews, resident record review, and facility policy review, the facility: 1. Failed to ensure two of 46 secure unit residents (Resident (R) 1 and R2), who were placed in contact and droplet isolation and quarantined for 14 days due to potential exposure of COVID-19, were kept isolated from the other residents in the unit which placed the remaining 44 residents at risk for possible exposure to COVID-19. Additionally, the facility failed to ensure residents in the secure unit, including R1 and R2, maintained adequate social distancing and used source control measures to prevent the potential spread of COVID-19 during communal group activities and dining in the unit dining room. […]

• Actual harm, isolatedF580Feb 21, 2023

  Based on interview and record review, the facility failed to recognize a change in condition (CIC, a shift in health status), and arrange immediate transportation to a hospital for one of three sampled residents reviewed for CIC (Resident 1). In addition, the facility did not immediately notify the Medical Doctor (MD) of all aspects of the CIC. As a result, there was a prolonged delay in providing medical treatment which prevented Resident 1 from receiving vital clinical therapy for a potential stroke. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses to include fractured (broken) ribs, per the facility Admission Record. On 12/29/21 at 11:10 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she was assigned to Resident 1 on 12/6/21. […]

• No harm, potential for more than minimal, widespreadF804Dec 7, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure the food served to residents were palatable and acceptable according to resident comments and facility policy. This failure had the potential to cause decreased food intake and negatively impact the resident's nutritional status. The facility census was 271. Cross reference F805, F806 Findings: During the initial survey screening process on 12/4/2023 at 8:15 A.M., multiple observations and interviews were conducted with the residents about the facility's food and meals. […]

• No harm, potential for more than minimal, widespreadF812Dec 7, 2023

  Based on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice when: 1. A rubber tray with twenty five cups of milk and other drink beverages had a use-by date of [DATE], and a large plastic bin filled with individual plastic cups of canned sliced pears with a use-by date of [DATE], were found in the walk-in refrigerator on [DATE]; 2. Three serving scoops with brown crusted substances and residue were stored with clean serving utensils, and 3. […]