Addolorata Villa

Inspectors wroteBased on interview and record review, the facility failed to effectively address R2's behaviors, put effective fall interventions in place, and provide appropriate hands-on ADL care to one resident (R2) who is high risk for falls. This failure resulted in R2 falling out of bed while being provided with care and sustaining multiple lacerations to his face requiring six sutures in total. Findings Include:R2 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: Alzheimer's disease, dysphagia, cognitive communication deficit, muscle weakness, and repeated falls. Facility Reported Incident dated 4/19/2026 states in part but not limited to the following: On 4/19/2026 at 5:20AM, V5 (Certified Nursing Assistant) provided care to R2. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement safety measures during transfer back to wheelchair from standing position resulting in R1's fall, hospitalization and sustaining a facial laceration, nasal fracture and neck fracture (type 2 odontoid fracture) and R1 passing in the facility. Findings Include:On 3/26/2026 at 12:13 PM V6 (Activity Aide/Assistant) stated she witnessed R1 pushing his wheelchair while walking. V6 demonstrated and said she took the wheelchair from R1, turned the wheelchair around by placing it behind R1 and verbally instructed R1 to sit down. In the process of R1 trying to sit back down, R1 fell forward hitting his head and face to the floor. V6 said she positioned herself behind the wheelchair. V6 said there was no gait belt used. V6 screamed and asked for assistance after learning R1 had injuries from the fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their menu and provide adequate portions to all residents residing on unit 2-East and all residents receiving a puree diet. This failure applied to all 18 residents currently on the 2East unit of the facility. Findings Include:Per facility census dated 1/12/2026, 18 residents are residing on the 2-East unit. On 1/13/2026 at 9:45AM, V14 (Cook) was observed to be pureeing chicken [NAME] for lunch. V14 said we need 14 servings of puree chicken for lunch today. V14 was observed adding 6 chicken thighs to the blender along with chicken broth. This surveyor asked V14 if he felt that was enough puree to serve 14 servings, in which he said yes. It is to be noted that per diet spread sheet, one full piece of chicken is served to residents on a regular diet. [...]

Inspectors wroteBased on observation, interviews and records review, the facility failed to implement care plan interventions for the treatment and management of pressure ulcers; and failed to ensure multiple sheets are not used on low air loss mattress per manufacturer's guidelines. These deficiencies affect one (R20) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with restorative services to aid in maintaining range of motion per resident's plan of care. This failure applied to one (R42) of three residents reviewed for restorative services.

Inspectors wroteBased on interview and record review, the facility failed to implement care plan interventions during ambulation and transfer which affected one resident (R1) that required hospital transfer. This failure resulted in staff's inability to prevent a fall and R1 sustaining a hip fracture.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for abuse prevention by not reporting an allegation of abuse for a resident with a history of making abuse allegations. This failure applies to one of four residents (R1) reviewed for abuse.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for abuse prevention by not investigating an allegation of abuse for a resident with a history of making abuse allegations. This failure applies to one of four residents (R1) reviewed for abuse.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to assess and prevent the development of a pressure ulcer for one ((R28) of two residents reviewed for pressure ulcers. This deficiency resulted in R28's intact skin developing a facility acquired Unstageable pressure ulcer.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to adequately monitor and supervise a cognitively impaired resident in preventing a fall for one (R120) of five residents reviewed for accidents and supervision. This deficiency resulted in R120 falling from a wheelchair in the common area in the facility and sustaining an acute subcapital femoral neck fracture. R120 underwent a surgical procedure called left hip hemiarthroplasty.

Inspectors wroteBased on interview and record reviews, the facility failed to provide bed hold notifications to residents and/or family members when residents were discharged to a local hospital. This failure affected 5 residents (R5, R19, R37, R64 and R120) reviewed for bed hold notification in a total sample of 38. This failure had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform proper hand hygiene, failed to follow proper food storage practices, and failed to ensure dishwasher maintained proper temperature during final rinsing cycles to prevent the spread of food-borne illness and contamination. These failures have the potential to affect all 87 residents receiving meals from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to implement a physician's order for an as soon as possible (STAT) X-ray after one resident (R1) sustained an unwitnessed fall and complained of pain in the right hip area; and the facility failed to document in the medical record after one resident (R1) sustained an unwitnessed fall. This failure affected one resident (R1) who was transferred to a local emergency room ten hours after the unwitnessed fall took place and was diagnosed with a right hip fracture.

Inspectors wroteBased on interview and record review, the facility failed to prevent an incident of resident to resident physical aggression. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 kicking R1 in the leg and R1 sustaining a 7 cm skin tear. Findings Include: Facility Reported Incident reviewed, and reads in part: On 9/2/24 at 2:20PM, R1 was in the common area when R1 began talking in a loud voice at a R3 who was trying to push a table over. R2 approached R1 while R1 was speaking to the R3 and kicked R1 in the left lower leg, resulting in a skin tear. R1 has a diagnosis of Dementia and Restlessness and Agitation. R1's most recent BIMs score conducted on 8/16/2024 was 03/15 indicating severe impairment. R1 has diagnosis of Dementia, R1 exhibits poor safety awareness and poor impulse control. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received her medications as ordered. This applies to 1 of 3 residents (R5) reviewed for medication administration in the sample of 11.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents' right to be free from physical, verbal, and mental abuse by an employee, and failed to follow its abuse policy related to prevention, identification of abuse. These failures affected one (R55) of six residents in the sample of 37 residents reviewed for abuse. These failures resulted in R55 feeling angry, uncomfortable, and humiliated by the employees physical and verbal actions towards R55. R55 is a [AGE] year-old female who has resided at the facility since 6/1/2022 with past medical history including, but not limited to [NAME] ataxia, age-related osteoporosis without current pathological fracture, vitamin D deficiency, thoracogenic scoliosis, thoracic region, overactive bladder, pain in right leg, pain in left hip. [...]

Inspectors wroteBased on observation, interview, and record review, the facility administration failed to take appropriate action to ensure the safety of 2 (R38, R55) of 3 residents reviewed for abuse in the sample of 69. The facility administration failed to protect residents from harmful actions inflicted by staff, failed to conduct a thorough investigation of allegations of abuse, and failed to honor the requests of the resident(s) to remain safe and free from harm. This failure has the potential to affect all 69 residents currently residing in the facility.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure stock medications were labeled with open and expiration date, failed to ensure opened vaccine vial, nasal sprays, inhalers, and insulins were labeled with open and discard dates, and failed to store an inhaler with a pharmacy label. These failures affected six (R6, R7, R12, R25, R42, R50) residents reviewed for medication storage and labeling and have the potential to affect residents receiving medications from the second-floor east side medication cart and first-floor rosewood medication cart. On [DATE] at 1:00pm, Surveyor and V40 RN (Registered Nurse) inspected the second-floor medication cart for rooms 201 through 228. The following observations were made: V40 stated, Floor Stock meds should be labeled with open date and manufacturers expiration date. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegation of rough handling/mistreatment made by one resident (R38) regarding an employee (CNA/V6); failed to prevent further instances of rough handling/mistreatment initially reported to V9/RN on 2/6/24 who failed to recognize the alleged abuse, failed to report the alleged abuse; and failed to immediately remove alleged abuser from further contact with the resident. This failure affected one resident (R38) of 6 residents reviewed for abuse in the sample of 69. This failure resulted in R38 to experience severe pain to her left shoulder as a result of V6's rough treatment and continues to express feelings of pain, fear, anguish, and intimidation when V6 returns to roughly handle the resident even after repeated requests to be gentle in providing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions to promote wound healing for one of three Residents (R18) reviewed for pressure ulcer and pressure ulcer interventions, in a total sample of 69 residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent prior to administering a psychotropic medication to one resident (R42) of three residents reviewed for unnecessary medications in a sample of sixty-nine.

Inspectors wroteBased on interview and record review, the facility failed to ensure assigned nursing staff were adequately communicating about a new admission to ensure proper coverage when staff were taking breaks in order to meet resident needs. This failure applied to one of one (R1) resident reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders to administer appropriate pain medications for a post- surgical resident experiencing extreme pain and failed to assess the severity of pain for 1(R4) of 4 residents reviewed for pain management in the sample. This failure resulted in R4 being unable to sleep due to extreme hip pain from post-surgical hospitalization for a hip fracture due to a fall sustained in the facility.