Villa Health Care East

Based on observation, interview, and record review, the facility failed to prepare and provide food according to physician orders for 1 of 3 residents (R3) reviewed for diet consistency in the sample of 9. Findings Include:R3's admission Record document, print date of 1/22/26, documented R3 has diagnoses including Alzheimer's disease, atrial fibrillation, gastro-esophageal reflux disease, hypertension, spinal stenosis, aphasia following cerebral infarction, and glaucoma.R3's MDS (Minimum Data Set), dated 12/4/25, documented R3 is moderately cognitively impaired and requires setup assistance with meals. R3's Physician Order Summary Report, print date of 1/22/26, documented R3's physician order for a pureed texture diet with moderately thick (honey) consistency liquids. On 1/22/26 at 12:39 PM R3 was observed during the lunch meal. R3 was served pureed meat, peas, and carrots in a 3-compartment divided plate. R3 was also served pears with whipped topping in a small plastic bowl. The pears appeared to be diced rather than pureed. On 1/22/26 at 1:00 PM V9 CNA (Certified Nurse Assistant)…

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 interview and record review, facility failed to have sufficient nursing staff to assure resident safety and care for 4 of 7 (R3, R5, R6 and R7) residents reviewed for staffing. This failure has the potential to affect all 96 residents residing in the facility. Findings include:1.R3's Progress note, dated 10/4/2025, documented, 0025 CNA notified this nurse that she observed resident on the floor in her bathroom after hearing a loud crash. This nurse went to assess resident and noted resident to be on the floor flat in the bathroom. This nurse asked resident what happened in which resident stated to this nurse that she was in the bathroom using the bathroom when she went to stand up and got dizzy and fell on her bottom. This nurse asked resident if she was in pain and resident stated to this nurse her back was hurting her. Upon assessment no bruising, bleeding, skin tear/ open areas noted. Resident v/s at the time of incident 149/85, 77hr, 18resp, 99oxygen. This nurse attempted to notify (Power of…

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 interviews, observations, and record reviews the facility failed to implement and revise resident care plans after resident falls for 4 out of 7 residents (R2, R3, R4 and R7); reviewed for Resident Care Plans in a sample of 7. Findings include:1. R2's Face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, urinary tract infection, cerebral infarction, hemiplegia and hemiparesis on right dominant side, repeated falls, laceration of scalp, dementia, and lack of coordination. R2's Minimum Data Set (MDS) dated [DATE] documented she was moderately cognitively impaired and required substantial/maximal assistance from staff for toileting hygiene and going from a sitting position to a standing position (which means the helper does more than half the effort, lifts or holds trunk or limbs). R2's MDS continued to document she required partial/moderate assistance with toilet transfers. R2's Care Plan last revised on 4/10/25 documented she was at risk falls related to…

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 interview, observation, and record review, the facility failed to provide privacy while performing incontinence care and failed to provide dignity during dining assistance for 5 of 24 residents (R7, R9, R40, R60, R64) reviewed for resident privacy and dignity in the sample of 48. Findings include: 1. R9's admission Record, dated 8/20/25, documents R9 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM), Malnutrition, Congestive Heart Failure (CHF), Atherosclerotic heart Disease (ASHD), Osteoarthritis, Spinal Stenosis, Falls, Hypertension (HTN). R9's Minimum Data Set, dated [DATE], documents R9 is cognitively intact. On 8/20/25 at 11:20 AM, V22, CNA, provided incontinence care to R9. V22 failed to close the door to the room, pull the curtain around the bed, or close the blinds to the window. R9's bed was close to the window with a courtyard outside her window. There was a person walking around watering flowers while incontinent care was going on with R9 being exposed to…

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, interview and record review, the facility failed to ensure medications were securely stored, failed to ensure opened medications were labeled with open dates, and the facility was using expired blood glucose control liquids for 16 of 24 residents (R2, R11, R13, R14, R15, R21, R22, R23, R33, R41, R43, R51, R54, R57, R66, R179) reviewed for medication storage in the sample of 55. Findings include: On 8/6/2024 at 11:35 AM, a medication cart was observed with V7, Licensed Practical Nurse (LPN). At this time: 1. There was an open bottle of Timolol eye drops with R13's name on it. At this time V7 stated she couldn't tell the surveyor the date the bottle was opened, because she did not open it, but V7 knows everything is supposed to be dated when it is opened. R13's Physician's Orders dated 10/21/2020 documents, Timolol Maleate Solution 0.25 %- Instill 1 drop in both eyes in the morning for Glaucoma. 2. There was an open bottle of Durezol with R14's name on the label. There was no date to indicate when the bottle was opened. This information was also confirmed by V7.…

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, record review and interview the facility failed to implement infection control practices, failed to wear Personal Protective Equipment (PPE), failed to disinfect multi-use equipment, failed to test residents with COVID-19 symptoms, and failed to ensure residents and staff were tested on COVID-19 days to prevent the spread of COVID-19 infection for 8 of 24 residents (R6, R13, R24, R30, R38, R43, R45, R178) reviewed for infection control in the sample of 55. Findings include: 1. On 8/5/2024 at 11:28AM V23, Licensed Practical Nurse (LPN) donned a gown, placed a surgical mask over a N95 mask, donned gloves, but did not sanitize their hands prior to donning gloves. V23 removed a blood glucose glucometer from a drawer of medication cart and entered R43's room and obtained an accu check. R43 then exited the room with the blood glucose machine and laid it on top of a dispatch wipe on the medication cart. At 11:46AM V23, LPN stated they need to give report to a nurse relieving her. V23 takes 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 record review and interviews the facility failed to administer medications to one of three (R4) residents reviewed for medication errors in a sample of 55 residents. R4's face sheet dated 8/13/2024 documents diagnosis of enterocolitis due to clostridium difficile dated 7/11/2024. R4's physicians order sheets documents R4 on Contact/droplet isolation precautions RT C-difficile infection with a start date of 07/11/2024. R4's physicians order sheets documents R4 on vancomycin oral suspension 5ml four times a day until 8/8/2024 with a start date of 7/27/2024. R4's Medication Administration Record (MAR) dated 8/6/2024 documents on dates of 8/4/2025 at 8am,12pm,5pm, 8pm and on 8/5/2024 at 8am and 12pm that vancomycin oral suspension was not administered. On 08/13/24 at 7:45 AM, V27 LPN (Licensed Practical Nurse) stated that she did not administer the vancomycin doses on 8/4/2024 for the 8am and the 12pm dose and 8/5/2024 for the 8am and 12pm dose because the vancomycin did not come in from pharmacy and the convenience box did not have any vancomycin in it. On 8/12/2024 at 3:30…

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 interview and record review, the facility failed to provide education or documentation of refusal for the COVID-19 vaccine for 3 of 5 residents (R44, R51, R231) reviewed for immunizations in the sample of 55. Findings include: On 8/5/24 at 2:30 PM, V2, Infection Preventionist Licensed Practical Nurse stated that the facility does not have education material or declination refusals for the COVID-19 immunization. V2 stated that R44, R51, and R231 are the only residents in the building that have not been vaccinated for COVID-19 . The COVID 19 Vaccination Policy for Residents, dated 2/1/22, documents, Procedure: 1. Education is provided for all residents and / or responsible party on the COVID-19 vaccination. This policy fails to document how acceptance or refusal of the vaccine will be documented. 1. R51's admission Record, print date of 8/12/24, documents that R51 was admitted on [DATE]. R51's Electronic Medical Record (EMR) fails to document that R51 was educated and offered the COVID-19 vaccine. 2.…

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 interview, observation and record review, the facility failed to discard expired and discontinued medications and label and date medications. This error has the potential to affect all 86 residents living in the facility. Findings include: On [DATE] at 9:45 AM, the zone 2 medication cart was observed with V4, Licensed Practical Nurse (LPN). 1. R16's Lantus (Glargine) insulin pen has an opened-on date of [DATE]. R16's Physician Orders, dated [DATE], documents, Insulin Glargine Solution Pen Injector 100 unit/ ML (millimeter). Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus without complications. 2. R5's Albuterol inhaler had an expiration date of 10/22. R5's Physician Orders, dated [DATE], fails to document an order for an Albuterol inhaler. On [DATE] at 10:00 AM, V4, LPN, stated, (R5) never uses that inhaler. (R16) doesn't use the Lantus that much. (R5) doesn't even have on order for that inhaler. I think she got that a while ago when she had pneumonia. On [DATE] at 3:45 PM,…

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 2. On 05/23/2023 at 10:23 AM, R25 stated that at night a big pan of snacks are brought out and put behind the nurses station but it is not brought to their rooms or offered that way. The snacks are usually cookies, cakes or graham crackers. R25's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact. 3. On 05/23/2023 at 10:23 AM, R36 stated that pan of snacks are brought out at night and put behind the nurses station but it is not brought to their rooms or offered that way. The snacks are usually cookies, cakes or graham crackers. R36's MDS, dated [DATE], documented that his cognition was intact. 4. R34 stated that she is not offered a snack at night and that sometimes her blood sugars the next morning are affected like they are low. R34's MDS, dated [DATE], documented that her cognition was intact. 5. R42 stated that it is around 16 hours between supper and the next day's breakfast. She continued to state that breakfast lunch and supper are all too close together. R42's MDS, dated…

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 interview, observation and record review, the facility failed to store and serve food to prevent food borne illness, maintain kitchen storage in a sanitary fashion and assist a resident with dining with gloves on. This failure has the potential to affect all 86 residents living in the facility. Findings include: 1. On 05/22/23 at 8:30 AM, the kitchen was entered. The refrigerator in the kitchen had 1 container of cheese that had a use by date of 5/14/23, 1 container of macaroni salad that had a use by date of 5/18/23 and 1 container of three bean salad that had an use by date of 5/21/23. The walk-in refrigerator had a single premade salad on a shelf that was not covered. A large stainless steel rectangle storage container with multiple pounds of cooked ground beef that was dated cooked 5/22/23 was on a shelf that had items on the rack above. The lid to the container was open so 50% of the ground beef was not covered. The dry storage room had a large cardboard box of Styrofoam storage containers sitting on the floor. 2. On 05/23/23 at 12:10 PM, the noon meal was served from…

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 interview, observation and record review, the facility failed to wash hands when needed, change gloves when soiled and wear the proper personal protective equipment to prevent cross contamination for 4 of 18 residents (R3, R72, R47, R69) reviewed for infection control in the sample of 32. Findings include: 1. On 5/23/23 at 10:00 AM, V5, Certified Nurse Aide (CNA), and V7, CNA, entered R3's room to perform incontinent care. R3's incontinent brief was soiled with urine and feces. V7 failed to change her gloves when they became soiled during the care. When care was completed, V7 assisted R3 with rolling over touching R3's bare skin with the same gloves used for incontinent care, applied a new incontinent brief and covered R3 up. On 5/24/23 at 2:21 PM, V6, Infection Preventionist, stated that staff should change gloves when soiled and one pair of gloves should not be used for the process of incontinent care and then putting a new brief or clothing on. 2. On 05/24/2023 at 09:15 AM, V15, CNA, took R45 into the bathroom, donned gloves without benefit of hand hygiene, placed gait…

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, interview, and record review, the facility failed to ensure food was stored in a manner which prevents potential contamination. This has the potential to affect all 84 residents living in the facility. Findings include: On 8/9/2022 at 8:55 AM in the first standing refrigerator there was a tray of assorted beverages covered with foil. There was a sticker with handwritten dates on the tray, but there was no way to distinguish the contents of each individual beverage. On 8/9/2022 at 9:05 AM in the walk in refrigerator there was a cart covered with plastic that contained ten trays of food. The covering did not reach the bottom of the cart, and the bottom four trays were completely exposed to air. These four trays included approximately 8 individual cups of cottage cheese, 40 individual cups of melon, and 20 slices of chocolate cake on individual dishes. On 8/9/22 at 9:07 AM, V5, Dietary Manager, stated, I would expect all items to be covered, labeled, and dated. Yes, of course. On 8/9/2022 at 9:10 AM in the walk in freezer there was a clear plastic bag of steak…

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.