Mar Vista Country Villa Healthcare & Wellness
MAR VISTA COUNTRY VILLA HEALTHCARE & WELLNESS in LOS ANGELES, CA — inspection on January 29, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 1's admission Record (AR), AR indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including hypokalemia (low potassium [important mineral that the body needs, to work properly] level in the blood, hypertension (HTN - elevated blood pressure), and chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand).
During a concurrent interview and record review on 1/29/2025 at 1:39 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) was supposed to report to the physician and document Resident 1's COC via SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members.
Also, being used as documentation for any changes of condition). LVN1 also stated that he (LVN1) was not sure why it was not completed.
During a review of the facility's policy and procedures (P&P) titled, Change of Condition Notification, reviewed on 6/19/2024, P&P indicated, that Facility to ensure residents, family, legal representatives and physicians are informed of changes in the resident's condition in a timely manner . COC related to attending physician notification is defined as when the attending physician must be notified when any sudden and marked adverse change in the resident's condition in which is manifested by signs and symptoms different than usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the attending physician and a change in the treatment plan.
555726 01/29/2025
Mar Vista Country Villa Healthcare & Wellness 3966 Marcasel Ave Los Angeles, CA 90066
During an interview on 1/29/2025 at 1:31 p.m., with the Social Service Director (SSD), SSD stated that she (SSD) was not informed of Resident 1's issue of possible abuse. SSD stated that the facility needs to do a proper investigation regardless of resident's condition and facility staff are mandated to report for resident's safety.
During a review of the facility's policy and procedures (P&P) titled, Reporting Abuse, reviewed on 6/19/2024, P&P indicated that facility to ensure compliance with federal, and state laws and regulations regarding reporting of incidents and suspected incidents of abuse, neglect and mistreatment of residents. P&P also stated that facility staff are mandatory reporters.
During a review of the facility's P&P, titled, Abuse and Neglect, reviewed on 6/19/2024, P&P indicated that the facility will report all allegations of abuse and criminal activity, as required by law and regulations, to the appropriate agencies. P&P also indicated that, allegations of abuse .are to be reported to the administrator or designated representative immediately.
555726 01/29/2025
Mar Vista Country Villa Healthcare & Wellness 3966 Marcasel Ave Los Angeles, CA 90066
that she (SSD) was not informed of Resident 1's issue of possible abuse. SSD stated that the facility
that the facility will protect the health , safety and welfare of facility residents by ensuring that all reports of residents abuse, mistreatment, neglect, exploitation, injuries of unknown source and suspicion of crimes are promptly reported and thoroughly investigated.
555726 01/29/2025
Mar Vista Country Villa Healthcare & Wellness 3966 Marcasel Ave Los Angeles, CA 90066
During a review of the facility's P&P titled, Change of Condition Notification, reviewed on 6/19/2024, P&P indicated, under documentation that, A licensed nurse will document and update the care to reflect the resident's current status.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand).
During a review of Resident 1's Care Plan (CP), as of 1/29/2025, CP indicated no documentation when Resident 1 stated to Licensed Vocational Nurse (LVN) 1, that Resident 1 was raped and touched by a CNA.
During a concurrent interview and record review on 1/29/2025 at 1:39 p.m., with LVN1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) was supposed to ensure an individualized care plan was completed for Resident 1. LVN1 also stated that he (LVN1) was not sure why it was not completed.
555726
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555726 B.
Wing 01/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Mar Vista Country Villa Healthcare & Wellness 3966 Marcasel Ave Los Angeles, CA 90066
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/7/2024, MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired and required moderate to maximal assistance from staff for activities of daily livings (ADLs- toileting hygiene, shower/bathing self, upper and lower body dressing, repositioning from sit to lying and sit to stand).
During a concurrent interview and record review on 1/29/2025 at 1:24 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress Notes (PN), dated 10/2/2024 was reviewed. Resident 1's PN indicated LVN1 documented that, Resident 1 confabulated stories that the CNA (Certified Nursing Assistant) raped her and touched her (Resident 1). LVN1 validated the documentation and stated that he (LVN1) did not remember reporting the issue to the Director of Nursing (DON), neither to the Facility Administrator (FA). LVN1 stated that he (LVN1) was supposed to report any possible abuse to the DON and FA and start an investigation.
During an interview on 1/29/2025 at 1:26 p.m., with the Registered Nursing Supervisor (RNS)1, RNS1 stated that she (RNS1) was not aware of Resident 1's issue of possible abuse. RNS1 stated that if LVN1 reported it to her (RNS1), RNS1 could have done an investigation and notify the DON and/or FA; and report it to the local police, ombudsman and the Department of Public of Health (DPH).
555726
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555726 B.
Wing 01/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Mar Vista Country Villa Healthcare & Wellness 3966 Marcasel Ave Los Angeles, CA 90066
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.