Aria at Villa Pines

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 33 residents who reside in the facility. Surveyor observed the stove hood to have dust directly above the food preparation area and attached to the light fixtures, the sprinklers, the 5-foot shelving, and a metal box. Surveyor observed the facility's stand mixer to be stored with a plastic covering. When staff removed the plastic covering, Surveyor observed food particles on the undercarriage. Surveyor observed one dented can in circulation. Evidenced by:Example 1Facility policy, titled Cleaning Instructions: Hoods and Filters, includes: . To clean the interior and exterior of the hood, use a cloth soaked in soapy detergent water. Rinse thoroughly and air dry. [...]

Inspectors wroteNumber of residents sampled:Number of residents cited:Based on observation, interview and record review, the facility did no establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infection. This has potential to affect the census of 33 residents. The facility did not add the residents with COVID infection during an outbreak to the January infection Control Rates. CNA F (Certified Nursing Assistant) had a breach in infection control when performing pericare (cleansing of the genital area) and catheter care (cleansing of the catheter tubing). Evidenced by: Facility policy Management of Covid-19, Influenza, and other ARI Outbreak, revised 11/11/25 states in part: .7. [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 15 Residents (R16) reviewed for notification of change in condition. R16 had weight gains or losses greater than three pounds in one day and a physician was not notified as ordered. This is evidenced by: The facility's policy, titled Change of Condition Process, effective 3/1/21, states in part: Policy Statement: The purpose of this policy is to promptly implement a system for a resident having a change in condition. A change in condition is defined as an improvement or decline in their physical, mental, or psychosocial status. Procedure: Change of Condition: 1. When a change of condition or change from baseline is observed and reported, the licensed nurse is responsible for evaluating the Resident's condition. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 incidents reviewed, affecting 1 of 2 residents (R34). R34 had a potential allegation of abuse and the facility did not submit a report to the State Agency (SA). Evidenced by:The facility's Abuse Prevention Program, undated, states, in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a thorough investigation in response to allegations of abuse for 1 of 3 incidents reviewed affecting 1 of 2 residents (R34). On 3/12/26, the facility became aware of an alleged violation of abuse for R34. The facility did not interview other residents and staff about the allegation. Evidenced by:The facility's Abuse Prevention Program, undated, states, in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and secure environment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate interventions were in place for safety to prevent accidents from occurring for 1 of 1 resident (R25) reviewed for elopement. The facility did not ensure that R25 was wearing a WanderGuard each shift from 12/23/25 to present. Evidenced by: The facility policy entitled Elopement Prevention and Missing Resident Policy, revised on 10/10/25. Policy states in part: .Residents who are at risk for elopement shall be provided with at least one of the following safety precautions. 1. A WanderGuard device that will notify facility staff when the resident has left the building without supervision. All WanderGuard safety devices and door alarms should be placed appropriately and maintained and tested per the manufacturer's instructions as part of the facilities Prevention Maintenance Program. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 of 1 Residents (R7) reviewed for oxygen. R7 did not have oxygen tubing changed on a weekly basis. Evidenced by:The facility's Oxygen Tubing Change Procedure policy, undated, states, in part: Purpose: To ensure safe, sanitary, and effective delivery of oxygen therapy while minimizing the risk of infection and equipment malfunction. Policy Statement: Oxygen delivery devices (including cannulas, masks, and tubing) will be changed routinely and as needed based on resident condition, infection control standards, and manufacturer recommendations. Procedure 1. Routine Tubing Change Frequency- Oxygen tubing and delivery devices shall be changed: . *Every 14 days if humidification is in use. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This affected 1 of 1 sampled residents (R8) reviewed for medication errors. R8 was given morphine sulfate oral solution (an opioid prescribed to relieve pain) after the printed expiration date on the medication card. This is evidenced by:The facility's policy, titled Medication Storage in the Facility, revised 1/18, states in part: Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Procedures:. H. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 25 opportunities with an error rate of 8%. R 21 received isosorbide mononitrate ER (extended release) 30 mg tab crushed. R15 received 24-hour metoprolol succinate 25 mg ER tablet crushed. Evidenced by:Facility policy titled Medication Administration-General Guidelines dated Dec. 2019 states in part: .Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example: 1. Long-acting or enteric-coated dosage forms should not be crushed. An alternative should be sought. Example 1 R21's physician order states Isosorbide Mononitrate ER Oral Tablet Extended Release 24-hour 30 mg. (Isosorbide Mononitrate). Give 60 mg by mouth one time a day for essential HTN. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 3 residents reviewed for grievances (R2). R2 voiced a grievance to the facility, and the facility did not complete appropriate interviews or provide follow up with the complainant after the conclusion of the investigation. Evidenced by: The facility's policy titled Grievance Policy dated 4/1/25 states in part .4. The Grievance Officer will route the grievance to the appropriate department head related to the grievance filed, and an investigation of the grievance will be conducted. Based on the nature of the grievance, the Grievance Officer will initiate any additional interventions that are indicated at that time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure for 2 of 7 residents (R2 and R5), each resident received food with at a palatable temperature. An anonymous complainant voiced concerns regarding food temperatures. R2 and R5 voiced concern related to cold food. Test tray found food was not served at appropriate temperatures. In addition, the cauliflower/broccoli was mushy. Evidenced byFacility policy, Food Temperatures, undated, states, as follows: Procedure: All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F (Fahrenheit). All cold food items must be stored and served at a temperature of 41 degrees F or below. Food preparation and service areas will follow these methods: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 26 residents. Surveyor observed [NAME] J use single use alcohol pads multiple times. [NAME] J did not allow thermometer to air dry before using it in different dishes. Surveyor observed 3 utensils to have pieces missing from them and in circulation. Surveyor observed food to be removed from original container, undated, and not closed properly in freezer. Surveyor observed food in refrigerator past the use by date. Evidenced by: Example 1 Manufacturer's recommendations for use of Medline Large Alcohol Prep Pad, 70% isopropyl alcohol, dated ., includes: Sterile pads are packaged in single-use packs for convenience . This product is intended for use on the body only. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 6 residents reviewed for accidents (R12 and R14). Surveyor observed R14 to be seated next to a charging electric power wheelchair in a common tv room. R12 is at risk for aspiration pneumonia and Surveyor observed CNA L (Certified Nursing Assistant) assisting R12 with his meal in a reclining position in bed and not upright. Surveyor observed CNA L to be organizing R12's room instead of supervising him and assisting him with his meal. CNA L did not use the care planned adaptive equipment, a plastic spoon. CNA L did not assist R12 in putting ½ teaspoon sized bites on his spoon. R12 had seven (7) coughing episodes during observation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R23 and R12) of 5 opportunities and 1 (R10) of 1 supplemental for hand hygiene for sampled residents. Surveyor had an observation of multiple breaks in appropriate infection control practice for handwashing and catheter care for R23. Surveyor had an observation of a break in appropriate infection practice by not wearing gloves when administering R10's eye drops. Surveyor observed CNA L (Certified Nursing Assistant) wearing gloves assisting R12 with his meal and touching dirty linens and other things around R12's room without removing gloves and without handwashing. This is evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that nursing staffing information was accurate and current. This has the potential to affect all 26 residents in the facility. The facility's nursing staff information postings were not updated daily. This is evidenced by: Division of Quality Assurance (DQA) memo 12-020 titled, Clarification Concerning Posting Requirements for Nurse Staffing documents: Required Staffing Information .Nursing homes must post information about the number of staff directly responsible for resident care on each shift. This information must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift . The information that is posted must include the following . 1. Facility name. 2. The current date. 3. [...]