Villa Scalabrini Special Care

During a review of review facility's Policy and Procedures (P&P,) titled Care Plan Policy Comprehensive, last reviewed 1/21/2026, the P&P indicated, Our facility's Care Planning/interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

Each resident's comprehensive care plan is designed to: reflect treatment goals, timetables and objectives in measurable outcomes.

Care plans are reviewed by the Care Planning Team at least quarterly.

555862 02/26/2026

Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352

During a review of Resident 23`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/22/2025, the MDS indicated Resident 23 usually understood others and usually made herself understood and had moderately impaired (limited vision; not able to see newspaper headlines, but can identify objects) vision and was unable to recall (remember) three words when asked to recall them.

The MDS indicated Resident 23 was dependent (helper does all the effort) on facility staff for toileting, bathing, hygiene and putting on/taking off shoes.

During a review of Resident 23's Impaired Cognitive (knowledge and understanding) Function/Impaired Thought Process related to Dementia Care Plan (CP), the CP indicated Resident 23 had episodes of confusion and disorientation and has short term memory loss.

The CP did not include interventions to addressing the need for supervision.

During an observation on 2/23/2026 at 1:04 p.m. in the dining/activity room, the door was closed and Resident 23 was observed seated in the wheelchair at the far end of the large dining room, facing the wall, eating lunch alone and without supervision. At 1:08 p.m.

The Infection Preventionist (IP) opened the door to the dining room and walked over and stood near Resident 23. At 1:10 p.m.

Certified Nursing Assistant (CNA 1) walked in from another back door into the dining room.

During an interview on 2/23/2026 at 1:10 p.m. in the dining room with CNA 1, CNA 1 stated Resident 23 should never be left alone, and that he (CNA 1) had only left for a few minutes to get something to eat. CNA 1 stated Resident 23 takes a very long time to eat and is usually the last resident in the dining room; however, the resident should not have been left alone due to confusion.

During an interview on 2/23/2026 at 1:16 p.m. in the dining room with the IP, the IP stated Resident 23 has dementia, and should not be left alone in the dining room.

The IP further stated that the CNA should not have left Resident 23 unattended, especially because the resident is facing the wall and his face was not visible in the event he was choking.

During a concurrent interview and record review of Resident 23's Dementia CP with the Director of Nursing (DON), the DON reviewed the dementia CP.

The DON stated the CP was not individualized to include an intervention addressing supervision.

The DON stated Resident 23 gets confused and should not be left alone in the dining room while eating.

During a review of the facility's Policy and Procedure (P&P) titled Care of Resident's with Dementia, last reviewed 1/21/2026, the P&P indicated the facility emphasizes individualized care for residents with dementia and that care must be individualized based on comprehensive assessment and documented in the CP.

The P&P indicated the facility shall maintain fall reduction program, safe environment for cognitively impaired residents and supervision levels appropriate to risk.

During a concurrent interview, LVN 1 stated that all CSs, including medication eKITs containing CSs should be reconciled at every shift. LVN 1 stated the eKIT labeled REF466, 351 and 501, containing CSs in Medication Room were not reconciled at every shift in February 2026, and it was important to account for all CSs to ensure accountability and prevent CS diversion.

The DON acknowledged the eKITs labeled REF466, 351 and 501 did not have accountability logs and were not reconciled at every shift in February 2026.

The DON stated that the facility will immediately implement an accountability log for reconciliation of eKits containing CSs.

During an interview on 2/25/2026 at 2 p.m., with the DON, the DON stated that LVN 2 failed to follow facility policy of documenting the preparation of CM immediately on the Antibiotic or Controlled Drug Record accountability log for Resident 21, 39 and 45.

The DON stated not documenting the Antibiotic or Controlled Drug Record timely can lead to accountability failures, CM diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents.

During a review of Resident 21's admission Record (a document containing demographic and diagnostic information,) dated 2/24/2026, the admission Record indicated Resident 21 was originally admitted to the facility on [DATE] with diagnoses including anxiety.

During a review of Resident 21's Medication Administration Record ([MAR - record of medications administered to a resident) for February 2026, the MAR indicated Resident 21 was prescribed clonazepam one (1) mg orally once a day related to anxiety, to be given at 9 a.m.

During a review of Resident 39's admission Record dated 2/24/2026, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] with diagnoses including osteoarthritis (joint disease resulting in bones rubbing together causing pain, stiffness, swelling, and reduced function in jointsˆlike knees, hips, hands.) During a review of Resident 39's MAR for February 2026, the MAR indicated Resident 39 was prescribed tramadol 50 mg orally two (2) times a day for moderate pain (pain rating of 4-6 on a 0-10 pain scale), to be given at 9 a.m. and 9 p.m.

During a review of Resident 45's admission Record dated 2/24/2026, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] with diagnoses including anxiety.

During a review of Resident 45's MAR for February 2026, the MAR indicated Resident 45 was prescribed clonazepam 0.5 mg orally twice a day for anxiety, to be given at 9 a.m. and 9 p.m.

During a review of the Policy and Procedures (P&P) titled Controlled Medications, last reviewed 1/21/2026, the P&P indicated: C.

When a CM is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: 1) date and time of administration 2) amount administered. 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply.

During a review of the P&P, titled Controlled Medication Storage, last reviewed 1/21/2026, the P&P indicated: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state and other applicable laws and regulations. a.

The DON and the consultant pharmacist maintain facility's compliance with federal and state laws and regulations in the handling of controlled medications. d. At each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record.

555862 02/26/2026

Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352

During a review of Resident 7's admission Record (a document containing demographic and diagnostic information,) dated 2/24/2026 the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] with diagnosis including arthritis (a disease that causes inflammation, pain, stiffness, and swelling in joints) and osteoarthritis.

During a review of Resident 7's Order Summary Report (a report listing the physician order for the resident,) dated 2/24/2026, the report indicated Resident 7 was prescribed: -Folic acid 1 mg, to give orally once a day for vitamin supplement, starting 12/31/2025.

During a review of Resident 7's ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for February 2026, the MAR indicated Resident 7 was prescribed: -Folic acid 1 mg tablet orally once a day for vitamin supplement, to be given at 9 a.m.

During a review of Resident 39's admission Record, dated 2/24/2026, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] with diagnosis including osteoporosis and bone density disorder.

During a review of Resident 39's Order Summary Report dated 2/24/2026, the report indicated Resident 39 was prescribed: 1.Multivitamin with minerals one (1) tablet orally once a day for supplement, starting 3/18/2025 2.

Loratadine 10 mg tablet orally once a day for itchiness, starting 4/23/2025 During a review of Resident 39's MAR for February 2026, the MAR indicated Resident 39 was prescribed: 1.Multivitamin with minerals one (1) tablet orally once a day for supplement, to be given at 9 a.m. 2.

Loratadine 10 mg one (1) tablet orally once a day for itchiness, to be given at 9 a.m.

During a review of Resident 47's admission Record dated 2/24/2026 the admission Record indicated Resident 47 was originally admitted to the facility on [DATE] with diagnosis including osteoarthritis, macular degeneration (eye disease,) polyneuropathy (nerve damage.) During a review of Resident 47's Order Summary Report dated 2/24/2026, the report indicated Resident 47 was prescribed: 1.Multivitamin with minerals one (1) tablet orally once a day for supplement, starting 2/17/2026 2.

Cyanocobalamin 1000 microgram ([mcg] a unit of measure of mass) tablet orally once a day for supplement, starting 1/29/2026. 3.

Systane 0.5 inch in the left eye twice a day for ectropion (a condition caused by aging that causes dry eyes,) starting 2/23/2024.

During a review of Resident 47's MAR for February 2026, the MAR indicated Resident 47 was prescribed: 1.Multivitamin with minerals one (1) tablet orally once a day for supplement, to be given at 9 a.m. 2.

Cyanocobalamin 1000 mcg one (1) tablet orally once a day for supplement, to be given at 9 a.m. 3.

Systane 0.5 inch in the left eye twice a day for ectropion, to be given at 9 a.m. and 6 p.m.

During a review of the facility's Policy and Procedures (P&P) titled Medication Administration-General Guidelines, last reviewed 1/21/2026, the P&P indicated that Medications are administered as prescribed .

Procedures 2.Medications are administered in accordance with written orders of the attending physician. 10.Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after).

During a review of the facility's P&P titled Incident Reporting, last reviewed 1/21/2026, the P&P indicated: Medication/Treatment Variances: The following incidents/concerns may be recorded on an appropriate Incident Report form: missed medication or treatment orders.

During a review of the facility's P&P, titled Medication Pass Tope, last reviewed 1/21/2026, the P&P indicated: Acceptable medication pass time is one hour before to one hour after the scheduled time for most medications (due at 9 a.m. give between 8 a.m. and 10 a.m.

Remember ten rights of medication pass right time.

555862 02/26/2026

Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352

During an observation on 2/25/2026 at 12:21 p.m., observed a tray labeled

was pushed on an open cart from the dining room through the hallway to Resident 30's room and placed on a table at her bedside.

During an interview on 2/26/2026 at 10:44 a.m. with the Director of Dietary Services (DODS), the DODS stated food should be covered if it is in the hallway.

The DODS stated if it is not covered it risks cross contamination or insects getting into the food.

During an interview on 2/26/2026 at 11:50 a.m. with the Infection Preventionist (IP), the IP stated food should be covered while transporting it to residents.

The IP stated if it is not covered it can be exposed to anything that is in the hallway and there is a risk of infection to the residents.

During a review of the facility's P&P, titled Safe Transport of Food from Kitchen to Dining Rooms, last reviewed 1/21/2026, the P&P indicated to protect food during movement all trays and pans should be covered.

555862 02/26/2026

Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352

During aˆconcurrentˆobservation an interviewˆon 2/23/2026ˆatˆ1:10ˆp.m. withˆCNA 1 in the dining room,ˆCNA 1ˆwasˆobservedˆnot wearing a mask and chewing food as he entered the dining room.

Observed CNA 1 was assisting residents during the lunch service and transporting residents from the dining room to their rooms. CNA 1 stated he was aware that he was supposed to wear a mask and stated he forgot to put it back on.

During a concurrent observation and interview onˆ2/23/2026 at 1:12 p.m. in the dining room with the Infection Preventionist (IP), the IPˆwalked in and stated to CNA 1, put on a mask, you have to wear a mask around the residents.

The IP statedˆthat all staff need to wear a mask all of the time, especially around residents.

The IPˆstatedˆstaff must wear masks anywhereˆresidents live or receive careˆsuch asˆthe dining room to keep residents safe from respiratory illnessesˆ(germs that can cause illnessesˆwhichˆaffectˆtheˆlungs and airways).ˆˆ During a review of the facility's policy and procedure (P&P) titled, COVID-19 Surveillance Plan,ˆlast reviewed 1/21/2026,ˆtheˆP&Pˆindicated: All staff to wear surgical mask during working hours.ˆ b.

During aˆconcurrentˆobservation and interviewˆonˆ2/25/2026ˆatˆ11:53ˆa.m. withˆthe DODS in the dining room,ˆthe DODSˆwasˆobservedˆnot wearing a mask.ˆResidents were seated waiting for their lunch traysˆwhile the DODS was present.

The DODSˆstatedˆheˆhad been vaccinatedˆ(treated withˆmedicationsˆthatˆproduce immunity to a particular infectious disease)ˆso he did not need to wear a mask.ˆˆ During an interview onˆ2/25/2026 at 2:54 p.m. with the Infection Preventionist (IP), the IPˆstatedˆthat all staff members need to mask 100% of the time regardless of their vaccine status.ˆThe IPˆstatedˆthe areasˆinˆthe facilityˆstaff need to mask include anywhereˆresidents live or receive careˆsuch asˆthe dining room.

The IP stated staff needed to wear masks to keep residents safe from respiratory virusesˆ(germs that can cause illnessesˆwhichˆaffectˆtheˆlungs and airways).ˆˆ During a review of the facility's policy and procedure (P&P) titled, COVID-19 Surveillance Plan,ˆlast reviewed 1/21/2026,ˆtheˆP&P indicated: All staff to wear surgical mask during working hours.ˆ

555862 02/26/2026

Villa Scalabrini Special Care 10631 Vinedale Street Sun Valley, CA 91352