Asistencia Villa Healthcare Center

Inspectors wroteBased on observations, interviews and record review, the facility failed to establish and maintain effective infection prevention and control practices for nine of ten sampled residents (Residents 2, 11, 33, 36,59, 79, 81, 97, and 103) when: 1. For Resident (81), the oxygen tubing (a flexible plastic tube to deliver oxygen from the oxygen concentrator to the resident) was resting on top of the oxygen concentrator (a medical device that pulls in room air and concentrates oxygen to supplemental oxygen to the resident), open to air and not stored inside a respiratory equipment bag, on December 15, 2025.2. Two urinary catheter bags (a medical bag used for collecting urine) were touching the floor for Residents 2 and 59 on December 15, 2025.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light system (a communication device linking patients/residents to staff, allowing them to request assistance via a button or pull cord, alerting a central station for timely help) and shower equipment were maintained in safe and working condition for resident use when:1. One wall mounted call light located in one of two facility showers, did not have a pull cord accessible for resident use. This failure resulted in the inability for residents or staff to have a call light readily available in the shower to summon staff assistance in case of an emergency.2. One of two shower beds (used by residents for bathing and for transport to and from their room) had two non-functioning side rails due to missing locking pins. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure medication storage was secured and IV (intravenous, a small tube that gives fluids into a vein) fluid was properly labeled when: 1. An IV fluid bag for Resident (63) was observed without a documented date, time, medication name, rate, or staff initials on the label.2. One of two treatment carts (Cart in 400 hall - a mobile cabinet on wheels, used all the bandages, syringes, meds, etc. needed to treat patients right at their bedside) was found unlocked and unattended by staff.3. One of 15 medication carts (Station 1's medication cart - a cart used by licensed nurses to transport medication to resident rooms) was found unlocked and unattended by a licensed nurse. These failures had the potential to be accessed and dispensed by an unauthorized person, and placing the health of 93 residents at risk for harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a screening assessment to ensure individuals who are identified to have a significant mental illness (SMI), intellectual or developmental disability (I/DD)) are not inappropriately placed in nursing homes for long term care) were completed accurately for two of two sampled residents (Resident 7 and 36) when: 1. PASRR screening assessment for Resident 7 did not include his diagnosis of cerebral palsy (disorders affecting movement, posture, and muscle coordination, caused by damage to the developing brain). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty-seven (27) sampled residents (Resident 10) received medications as ordered by the physician, and the facility did not inform the physician of the missed medication doses when:a. Resident 10's anticoagulant Heparin (a blood thinner medication used to prevent the formation and growth of blood clots) was not administered on November 28, 2025, for 9:00 AM and 9:00 PM dose. Additionally, on November 29, 2025, she was not given her 9:00 AM dose (total of three missed doses). There was no documented evidence indicating the physician was notified of the missed doses.b. Resident 10's antibiotic Keflex (a medication used to treat a bacterial infection) was not administered on November 29, 2025, for 6:00 AM dose and 12:00 PM dose (total of two missed doses). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 10) investigated for urinary catheter (a medical device that drains urine from the bladder) received services for the care and maintenance of her catheter when Resident 10's urinary bag (a bag attached to the catheter that collects urine) was found in Resident 10's wheelchair and was not placed lower than her bladder to allow proper flow of urine from the bladder. This failure had the potential for Resident 10 to experience a backflow of urine from the urine drainage bag into the bladder, or for the urine flow to be obstructed which can lead to pooling of urine and urinary infections. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure careplan (a structured and individualized approach that helps clinicians provide effective care for patients) was initiated to address weight loss for one of six Residents (Resident 63) reviewed for nutrition / hydration. This failure had the potential to placed Resident 63 at risk for malnutrition and dehydration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications for two of 26 residents (Resident 19 and 103) observed for medication pass were administered according to the facility's policy & procedure, and maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) when:1. Resident 19 had an order to received Levothyroxine (medication to treat hypothyroidism - low levels of thyroid hormone) and was not available for administration. This failure had the potential to increase Resident 19's symptoms of hypothyroidism and can cause long - term health complications. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was less than five percent. There were two medication errors observed out of 26 opportunities for errors, affecting two of 13 observed residents (Residents 19 and 103), resulting in an overall medication error rate of 7.69 percent when:1. Resident 19 had an order to received Levothyroxine (medication to treat hypothyroidism - low levels of thyroid hormone) and was not available for administration. This failure had the potential to increase Resident 19's symptoms of hypothyroidism and can cause long - term health complications. 2. Resident 103 did not receive Sevelamer Carbonate (a medication used to control high phosphorus levels in patients with kidney disease) 800 mg (milligram - unit of measure) oral tablet with meals as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure utensils used for eating were kept in a clean and sanitary condition during lunch on December 15, 2025, when Resident 62 received a built up spoon (a type of adaptive utensil with an enlarged handle, designed to help individuals with a weak or limited grip) which had water pooled in its handle. When Resident 62 picked up the spoon and attempted to eat her food, the water spilled out of the handle and onto her food. This failure had the potential to cause food-borne illness as a result of contamination of food served to Resident 62 by water from an unknown source which had pooled in the handle of the spoon. During a concurrent observation and interview on December 15, 2025, at 12:38 PM, in the facility's dining room, Resident 62 was eating a sandwich for lunch. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision for one (1) of four (4) sampled residents (Resident 1), when Resident 1 left the facility without staff knowledge. Resident 1 was found five hours later in an adjacent building. This failure had the potential to result in serious injuries/accidents or death of Resident 1 due to lack of supervision. A review of Resident 1's Face Sheet (contains resident demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with diagnoses that included spinal stenosis cervical region (the bony tunnel (spinal canal) in the neck gets too narrow squeezing the spinal cord), abnormalities of gait and mobility (your usual way of walking is off). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure blood pressure medication was not administered in duplicated dose for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to receive an excessive dosage of the medication which could jeopardize her health and safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary care and services to ensure residents received care and services with activities of daily living (ADL) when two out of three residents (Resident 1 and Resident 2) waited a long time to be cleaned and changed. This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) ' s health and safety at risk, when the residents ' activities of daily living were not met in timely manner.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to follow its policy and procedure regarding medication error and adverse drug reaction reporting, for one of four sampled residents (Resident 1) when Resident 1 did not receive Pirfenidone (a medication to treat pulmonary fibrosis - a disease that damages the lung tissue, making it difficult to breathe) on December 21, 2024. This failure resulted in Resident 1 not receiving one dose of Pirfenidone and had the potential to adversely affect the health and safety of Resident 1 by causing a decline in lung function (when lung tissues cannot expand enough).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain a sanitary kitchen when: 1. There was a cabinet that stored a juice dispenser, the door to the cabinet had a sticky residue. Inside the cabinet there was a red juice spill. The cabinet under the steam table had food crumbs and trash. There was food residue around the floor sink under the steam table. This had the potential to attract pests and for microorganisms' growth. 2. The industrial mixer was stored with white food residue on the mixer. This had the potential to contaminate food being mixed in the mixer. 3. The ice machine had some brown build-up in the area where ice is formed. This had the potential to contaminate the ice. The facility failures had the potential to attract pests and cause foodborne illness to a population of 59 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of COVID-19 (Corona Virus Disease, a highly infectious disease caused by the SARS-CoV-2 virus) when the facility did not have any tracking and documentation of staff COVID-19 vaccination status. This failure had the potential to cause harm to the 95 residents residing within the facility by causing cross contamination of the environment and increasing the risk of exposure and spread of the COVID-19 virus.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure their equipment was maintained in safe operating condition when: The countertop water dispenser was found leaking and collecting standing water in the drain. This facility's failure to ensure a safe, operating equipment has the potential to increase risk of resident harm and attract pests due to the standing water which can affect the population of 59 residents who receive food from the kitchen.

Inspectors wroteBased on the observation, interview and record review, the facility failed to ensure a Significant Change of Status Assessments (SCSA) of the Minimum Data Set (MDS-a computerized assessment instrument) was completed within 14 days for one resident (Resident 36) when Resident 36 had a significant change in the nutrition route from enteral (nutrition delivered directly to the stomach or intestines) to oral (nutrition taken by mouth) after gastric tube (g-tube is a small tube that is placed through the skin into the stomach, used to give food, water, or medicine to people who can't eat by mouth) removal and a changed in the level of eating assistance. This failure resulted in Resident 36's care plan not being updated and revised to reflect his current status, which had the potential to delay the implementation of care and support needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services for one of two sampled residents (Resident 68) reviewed for restraints (tools used to keep a patient safe by limiting their movement. They can be things like special belts, mittens, or straps that prevent a person from hurting themselves or others, or from pulling out important medical equipment). This failure had the potential to cause inaccuracy in identifying Resident 68's care and support needs.

Inspectors wroteBased on the observation, interview and record review, the facility failed to store all drugs and biological in accordance with currently accepted professional principles and the facility's policies and procedures when one of four medication carts (200's hall medication cart ) reviewed for medication storage found to be unsanitary on October 16, 2024. This failure had the potential increase the risk of infection to a resident's receiving medications with unwanted chemical reactions and decreased efficacy.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement its policy and procedure on antibiotic stewardship (a set of practices aimed at ensuring the safe and effective use of antibiotics [medications used to treat infections]) for one of fourteen sampled residents (Resident 47) reviewed for antibiotic used, when the Infection Control Preventionist (ICP) nurse did not accurately assess and collect data to indicate the rationale and common clinical conditions necessary to ensure the appropriate use of antibiotic therapy for Resident 47. This failure had the potential to placed Resident 47 at risk for adverse events, including the development of anti-biotic resistant organisms, from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure to ensure the removal of medication from the medication cart immediately upon receipt of a physician order to discontinue an order to prevent error in administration of medication for one of four sampled residents (Resident 1). This failure had the potential to place a clinically compromised Resident 1's health and safety at risk when Resident 1 was administered a medication that had already been discontinued.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) health and safety at risk when residents call lights were not answered promptly to assist with their activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents when one of four residents (Resident 4) was unsupervised and fell on the floor. This failure contributed to Resident 4 falling and hitting his head and sustaining a subdural hematoma (a collection of blood between the covering of the brain after an injury to head).

Inspectors wroteBased on interview and record review the facility failed to ensure one of three clinically compromised residents (Resident 2) was provided transportation for her medical appointment. This failure had the potential to result in a delay of treatment that could adversely affect and further compromise Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for one of three residents (Resident 1), when Resident 1 ' s overhead light located on the wall, at the head of the bed, had the light shining directly at him. The light setting couldn ' t be adjusted or turned off since the beaded cord was stuck. This failure has the potential to negatively impact Resident 1 ' s sense of well-being and comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all mobility equipment was safe to be used on residents during transfers from bed to chair, when an electric lift (a mobility tool used to allow a person to be lifted and transferred with minimum physical effort. A weighing scale can be attached to the lift to weigh residents when lifted) used by two Certified Nursing Assistants (CNA 1 and 2) to transfer a resident (Resident 8) had a base that did not securely lock into place, causing the lift to tilt and the digital scale to hit Resident 8 on the forehead. This failure resulted in harm for one of eight sampled residents (Resident 8), when Resident 8 sustained two abrasions (the surface layers of the skin has been broken) on the right side of the forehead.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when the [NAME] (Cook 2) was not wearing a facial hair restraint while serving food during lunch on August 8, 2023. This failure had the potential to expose 90 medically compromised residents who receive food from the kitchen to foodborne illness due to food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the approved menus when: 1. Residents on CCHO (Consistent Carbohydrate diet, diet for diabetic residents, residents who have elevated blood sugar levels) received a larger portion of red roasted potatoes than was indicated on the menu for lunch on August 8, 2023. (1/2 cup was served and the menu indicated ¼ cup of potato) 2. There was no planned vegan (food containing no animal product) menu for one resident (Resident 353) on a vegan diet. 3. Resident 10 on a fortified (extra calories) full liquid diet (fluids and foods that are normally liquid and foods that turn into liquid when they are at room temperature) did not receive the correct lunch on August 8, 2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in operating condition when three pieces of equipment (steamer, convection oven, and industrial mixer) were not functioning. These failures led to equipment accumulating dust and grime and providing a source for bacterial growth that could be inadvertently transferred to food and can affect 90 medically compromised residents receiving food from the kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure call lights (a device that triggers a visual and/or auditory cue when a resident needs assistance) were accessible for use to provide assistance to meet the needs of three Residents 66, 79, and 10 of 33 sampled residents' when: 1. Resident 66 could not reach their call light while lying in bed. 2. Resident 79's call light was found on the floor while Resident 79 was in bed. 3. Resident 10 was provided a call light that is not working properly for her to use. These failures had the potential to affect the health and safety of Residents' 66, 79, and 10 in case of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled resident (Resident 505), Physician Orders for Life-Sustaining Treatment (POLST - a mobile medical order form that communicates choice of life sustaining treatment in an emergency situation) was filled out in its entirety in accordance with the facility's policy and procedure. This failure has the potential to imply full treatment without taking Resident 505's wishes or current medical condition into consideration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for a resident with an identified medical condition related to peripheral neuropathy (a medical condition that involves the damaged nerves causing pain, numbness, and weakness mostly felt in the hands and feet). This failure had the potential to limit the services and provision of individualized care necessary for one of eight sampled residents (Resident 304).

Inspectors wroteBased on interview, and record review, the facility failed to follow their policy and procedure when the SBAR (Situation, Background, Assessment and Recommendation- a standardized tool used by a facility to make detailed observations and gather relevant information to improve clinical communication about a resident) was not completed for a change of condition for one of eight sampled residents (Resident 8) who sustained an injury following an accident. This failure had the potential to cause negative physical, mental or psychosocial outcome for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide essential services to increase range of motion (measurement of how far you can move a body part) or to prevent further decrease in range of motion for one of three sampled residents (Resident 465). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition status for one resident (Resident 6), when Resident 6 lost 10 pounds (lbs.) and the Registered Dietitian (RD) was not notified and did not assess (evaluate) Resident 6. This failure had the potential to result in Resident 6 to decline medically and nutrionally.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication administration to meet the needs of one of seven residents, (Resident 41), when Resident 41 was provided a stool softener (medication for easier passage and less strain) without being assessed for loose stools, as directed by the physician order. This failure had the potential for placing Resident 41 at risk for fluid volume deficit (when fluid output exceeds fluid intake from diarrhea and causing dehydration).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. One Certified Nursing Assistant 4 (CNA 4) entered a transmission-based precaution room (a separate room that keep residents with certain medical conditions or infections separate from other people while they receive medical care) with contact precautions (require anyone entering the room to wear a gown and gloves) without wearing a gown or gloves for Resident 2. 2. Two Certified Nursing Assistants (CNA 7 and 8) entered a transmission-based precaution room with contact precautions without wearing a gown or gloves for Resident 462. 3. [...]