Villa Healthcare & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL), specifically nail care, received necessary services to maintain good grooming and personal hygiene for one (Resident #59) of a total survey sample of 32 residents.The findings include: On 09/15/25 at 2:00 PM, an observation was made of Resident #59's fingernails, which had grown approximately 1/2 to ¾ inch beyond the tip of the nailbed on both her right and left hands. The resident reported that she did not like her fingernails as long as they were, and that she was afraid she might scratch herself with such long nails. She could not recall whether or not staff had offered to trim her fingernails. (Photographic evidence obtained) On 09/16/25 at 11:41 PM, a second observation was made of Resident #59's fingernails, which had grown approximately 1/2 to ¾ inch beyond the tip of the nailbed on both her right and left hands. They appeared the same as they had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to appropriately store resident's medication by leaving medication at bedside for one (Resident #4) of three residents sampled for unsecured medication. Resident #4 who had not been assessed for self-administration of medication was observed taking medications that had been left on his overbed table. These medications were also accessible to other residents who should not have access to them. The findings include: During an interview with Resident #4 on 04/23/2025 at 10:22 AM, the resident picked up a medicine cup from his overbed table containing multiple pills in it. When asked if the pills were his morning medications he stated, yes and then took them. A medical record review for Resident #4 indicated he was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 13/15, indicating intact cognition. A review of medication to be given to Resident #4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that services provided met professional standards of quality for one (Resident #74) of 28 residents in the total sample. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The findings include: During medication reconciliation completed for Resident #74, an order was reviewed, which read: Start date 5/23/23: Midodrine 5 milligrams (mg): Give 5 mg by mouth one time a day for low blood pressure; hold if systolic blood pressure is greater than 120. Further review of the medical record included the Electronic Medication Administration Record (eMAR), which revealed this medication was signed off as having been administered 44 times when the SBP was recorded above 120 mmhg (millimeters of mercury), out of 128 doses signed off as administered from the resident's date of admission through the date of medication reconciliation. The record review revealed a SBP greater than 120 on the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, staff interview, and a review of the facility's policies and procedures, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #26) of 12 residents receiving pressure ulcer treatment, from a total sample of 28 residents. The findings include: On 9/27/23 at 11:50 a.m., Registered Nurse (RN) A was observed preparing wound care supplies from the treatment cart for Resident #26. He dispensed Zinc Oxide 20% into a small medication cup. He was asked to explain the treatment order. He stated, It's Zinc Oxide ointment to his sacral area daily. RN A rubbed the Zinc Oxide ointment 20% on Resident #26's sacral area. The area was reddened and dusky in color. When RN A returned to the treatment cart, he was asked to look at the tube of Zinc Oxide ointment. He took it from the cart. He was asked what percent of Zinc Oxide the order was for. He stated, I'm not 100% sure; I know it's for Zinc. He was asked how he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed ensure that residents who needed respiratory care, received oxygen therapy as ordered for two (Residents #11 and #43) of 18 residents receiving oxygen therapy from a total sample of 28 residents. The findings include: 1. On 9/25/23 at 12:05 p.m., Resident #11 was observed lying in bed with the TV on, her eyes closed, and receiving oxygen via nasal cannula at 2.5 Liters per minute (L/min). (Photographic evidence obtained) A review of her medical record's active orders revealed a 2/9/23 physician's order for Oxygen at 2 L/min via nasal cannula every shift. Further review of the physician's orders revealed the following: A 2/9/23 order: Change oxygen tubing weekly and PRN (as needed) every night shift, every Sunday. A 2/9/23 order: Albuterol Sulfate Nebulization Solution (2.5 mg/3ml) 0.083%, 1 application inhale orally via nebulizer every 6 hours as needed for shortness of breath (SOB). A 2/9/23 order: Budesonide Inhalation Suspension 0.5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure that it's medication error rate was not 5% or greater. There were two errors with 28 opportunities for error resulting in an error rate of 7.14% and affecting one (Resident #74) of eight residents observed during medication administration. The findings include: On 9/26/23 at 9:30 a.m., Licensed Practical Nurse (LPN) B was observed preparing medications for Resident #74. LPN B administered the oral medications first, then set up a nebulizer inhalation treatment: Budesonide Inhalation: 0.5 milligrams (mg)/2 milliliters (ml) suspension. LPN B placed the inhalation mask over the resident's mouth and nose. She then told the resident she would return in 10 minutes to remove the mask. After 10 minutes had passed, LPN B returned and removed the mask. She was asked if she had completed medication administration for Resident #74. She stated yes. LPN B did not offer Resident #74 water or instruct her to rinse her mouth and spit after completing the inhalation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure its residents remained free of significant medication errors. This impacted one (Resident #74) of eight residents observed during medication administration, out of 28 residents in the total sample. Resident #74 received medication for low blood pressure outside of the ordered parameters for 44 of 128 doses administered. The findings include: During medication reconciliation completed for Resident #74, an order was reviewed, which read: Start date 5/23/23: Midodrine 5 milligrams (mg): Give 5 mg by mouth one time a day for low blood pressure; hold if systolic blood pressure is greater than 120. Further review of the medical record included the Electronic Medication Administration Record (eMAR), which revealed this medication was signed off as having been administered 44 times when the SBP was recorded above 120 mmhg (millimeters of mercury), out of 128 doses signed off as administered from the resident's date of admission through the date of medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff interviews, and a review of the facility's policy and procedure for Standards and Guidelines for Wound Care, the facility failed to ensure that resident medical records were complete and accurately documented, in accordance with accepted professional standards and practices, for two (Residents #65 and #26) of 12 residents receiving pressure ulcer treatment, from a total sample of 28 residents. The findings include: 1. An observation of Resident #65 was made on 9/25/23 at 3:00 p.m. She was observed lying in bed with an air mattress, positioned with pillows. The resident's medical record was reviewed and revealed that she was admitted to the facility on [DATE]. Her diagnoses included the following: mild protein calorie malnutrition, unspecified contact dermatitis, and osteomyelitis of sacral and sacracoccygeal region. Her care plan was reviewed and noted that she had a pressure ulcer of the sacral area which reopened in December 2022. A 9/27/23 physician's treatment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a review of the facility's policies and procedures for Infection Control and Guidelines for Wound Care, the facility failed to prevent the potential development and transmission of infection by not following infection prevention techniques during a wound dressing change for one (Resident #65) of three residents observed during wound care, from a total sample of 28 residents. The findings include: An observation of Resident #65 was made on 9/25/23 at 3:00 p.m. She was observed lying in bed with an air mattress, positioned with pillows. The resident's medical record was reviewed and revealed that she was admitted to the facility on [DATE]. Her diagnoses included the following: mild protein calorie malnutrition, unspecified contact dermatitis, and osteomyelitis of sacral and sacrococcygeal region. Her care plan was reviewed, and it noted that she had a pressure ulcer of the sacral area which reopened in December 2022. A 9/27/23 physician's treatment order was reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and employee interviews, the facility failed to distribute and serve food in accordance with professional standards for food service safety, by failing to practice appropriate hand hygiene and glove use during food preparation activities to prevent cross-contamination. This failure potentially affected all residents receiving food from the facility's kitchen. The findings include: A food service observation was conducted in the kitchen at 11:55 AM on 12/2/2021. At 12:00 PM, the Chef was observed setting up the food items for lunch service. The Chef was observed with a pair of gloves on during the set up. He was observed pouring the sauce for the meal from a pot into a stainless steel pan, then taking the pot to the dishwashing area and rinsing it out with the hand-held nozzle. He then returned to the food service area and began to stir the sauce in the the stainless steel pan without doffing the gloves, washing or sanitizing his hands, and donning a new pair of clean gloves. At 12:07 PM on 12/2/2021, the Chef was interviewed about hand hygiene while in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and policy review, the facility failed to develop and implement a comprehensive person-centered care plan that addressed hearing and vision deficits for one (Resident #32) of 41 residents in the sample. The findings include: On November 29, 2021 at 12:10 p.m., Resident # 32 was observed sitting on the edge of her bed, clipping her nails. She was unaware of the knocking on her door and calling her name for permission to enter. When her name was called out somewhat louder, she looked up and stated, I didn't hear you. I'm almost deaf. She was asked if she had hearing aides or a communication board. She stated, No. I've been here three months. I need to see a specialist; I keep telling them that but nothing happens. I used to have hearing aides, but I lost one and the other broke. The girl from therapy gave me this thing (amplifier with headphones), but it doesn't work, even with new batteries. My daughter bought this thing (hearing aide-looking device for one ear from a box marked amplifier), but it doesn't work either, even with new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff and resident/resident representative interviews, and a review of resident and facility records, the facility failed to ensure residents who were dependent for grooming and hygiene, received the appropriate nail care to prevent soiled, jagged or excessively long nails for three (Residents #9, #35 and #78) of five residents reviewed for activities of daily living (ADLs), from a total of 41 residents in the sample. The findings include: 1. A record review for Resident #9 found an Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/27/21. It noted Resident #9 was not able to make himself understood. He had memory problems to include no recall of staff names, the current season, his room location or that he was in a nursing facility. Resident #9 had moderately impaired cognitive skills for daily decision making. There was no rejection of care over the assessment look-back period. Resident #9 required extensive assistance with hygiene. His diagnoses included non-Alzheimer's dementia (a disease that progressively destroys…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interview, the facility failed to ensure oxygen therapy was administered as ordered by the physician for one (Resident #65) of nine sampled residents reviewed for oxygen therapy from a total sample of 41. The findings include: A review of Resident #65's medical record revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: cerebral infarction, aphasia, chronic obstructive pulmonary disease, and atrial fibrillation. She required total assistance with all activities of daily living (ADLs) except eating. She was ordered continuous oxygen at 1 liter per minute via nasal cannula. An observation of Resident #65's oxygen concentrator on 11/29/21 at 10:55 AM, found the oxygen rate was set at 2 liters per minute. An observation of the oxygen concentrator on 11/30/21 at 12:20 PM, found the flow rate set at 2.5 liters per minute. On 12/2/21 at 2:15 PM, the oxygen flow rate was set at 2.5 liters per minute. An interview was conducted with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.