La Villa Grande Care Center

Inspectors wroteBased on record review and interviews, the facility failed to prevent a significant medication error for warfarin (a blood thinner medication) for one (#8) of three residents reviewed for medication errors out of 10 sample residents. Specifically, the facility failed to prevent a significant medication error when Resident #8 received warfarin, a blood-thinning medication, twice a day (once in the morning and once in the evening), instead of once a day at bedtime. Resident #8 was admitted on [DATE] and discharged to home on 9/22/25. Resident #8's diagnoses included hypertension, kidney disease, diabetes, stroke, and left-sided paralysis. Resident #8 was admitted to the facility from the hospital with stroke treatment and prevention orders for warfarin and laboratory monitoring of the blood level international normalized ratio (INR), which is used to monitor the ability for blood to clot. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#28) of three residents out of 37 sample residents. Resident #28, who was at risk for falls, was admitted on [DATE] with diagnoses of dementia, history of falling, abnormalities of gait and mobility, weakness and insomnia. On 5/1/25 the physician recommended the resident transition to a walker without wheels for safety and have a physical therapy (PT) evaluation. However, Resident #28 continued to use her four-wheel walker and a PT evaluation was not conducted until 5/13/25. Resident #28 fell three times in less than a week (on 5/6/25, 5/9/25 and 5/10/25). She was identified to have high blood pressure after the falls and was discovered to have a urinary tract infection (UTI) after the last fall on 5/10/25, increasing her risk for falls. [...]

Inspectors wroteVI. Resident #387 A. Resident status Resident #387, age over 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included stage three chronic kidney disease and bipolar disorder. The 7/4/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required partial to moderate assistance with toileting, personal hygiene, bathing and lower body dressing. B. Record review A review of Resident #387's May 2025 CPO revealed the following physician's orders: Olanzapine (Zyprexa, an antipsychotic medication) oral tablet 5 mg, give 2.5 mg (half tablet) by mouth as needed (PRN) for agitation daily at night, ordered 5/17/25 with an end date of 5/31/25. Lorazepam (an antianxiety medication) oral tablet 0.5 mg, give one tablet by mouth daily PRN for anxiety, ordered 5//25 with an end date of 5/31/25. [...]

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in temperature and taste.

Inspectors wroteII. Failure to use consistent hand hygiene practices when providing meal assistance A. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Handwashing Facts dated 4/17/24, retrieved on 6/1/25 from https://www.cdc.gov/clean-hands/data-research/facts-stats/index.html, Hand washing with soap removes germs from hands. This helps prevent infections because people frequently touch their eyes, nose and mouth without even realizing it. Germs get into the body through the eyes, nose and mouth and make us sick. Germs from unwashed hands can get into food and drinks while people prepare or consume it. Germs can multiply and some types of foods or drinks, under certain conditions and make people sick. Germs from unwashed hands could be transferred to other objects and then transferred to another person's hands. B. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#15) of one resident out of 37 sample residents. Specifically, the facility failed to ensure an assessment was conducted to determine whether the self-administration of medications was clinically appropriate for Resident #15.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to ensure the State Survey Agency (SSA) contact information, including the phone number, address and email address were posted and in a manner accessible and understandable to all residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#68 and #71) of seven residents out of 37 sample residents were kept free from abuse. Specifically, the facility failed to: -Prevent an altercation between Resident #68 and Resident #71; -Protect Resident #68 from physical abuse by Resident #65; and, -Protect Resident #71 from physical abuse by Resident #68.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#80) of two residents with limited range of motion out of 37 sample residents received appropriate treatment and services. Specifically, the facility failed to ensure Resident #80 was consistently provided services through the walk-to-dine program in order to maintain the resident's ambulation status.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility's medication error rate was 7.69%, which was two errors out of 26 opportunities for error.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Ensure safe and appropriate storage of food items in the refrigerators and pantry; and, -Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross contamination.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure services provided met professional standards of practice for two (#3 and #9) of seven residents out of 5 sample residents. Specifically, the facility failed to: -Ensure Resident #9's fluid intake was monitored and managed effectively, which resulted in the resident being sent to the hospital for fluid overload; -Provide Resident #3, who chose not to consistently follow her recommended diabetic diet, with education related to the specific risks associated with not following her dietary recommendations; and, -Ensure Resident #3's diabetic care plan was updated to include documentation of the resident's refusals to comply with her recommended diabetic diet.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure one resident (#83) of five sample residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable, and to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the facility failed to ensure timely interventions were put in place to prevent the development of pressure injuries to Resident #83's heels which resulted in two unstageable pressure injuries. Resident #83 was admitted to the facility after a fall resulting in her impaired mobility. The resident was at risk for pressure injuries and had a current pressure injury to her sacrum on admission. [...]

Inspectors wroteBased on observations and interviews the facility failed to employ sufficient dietary and food and nutrition staff to carry out the functions of the food and nutrition services. Specifically, the facility failed to provide sufficient numbers of adequately trained food and nutrition staff which contributed to prolonged wait times for meals and overall decreased the residents ' satisfaction with their dining experience.

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure cold food items were held at the proper temperature to reduce the potential risk of foodborne illness; -Ensure the garbage disposal was not held up by cement blocks which were not cleanable; -Ensure the kitchen had a cleaning schedule; -Ensure the nourishment refrigerators were monitored; -Ensure the temperature of the refrigerators were taken; and -Ensure the health shakes were stored properly

Inspectors wroteBased on resident and staff interviews and record review the facility failed to address and/or act promptly upon the grievances and recommendations of resident council and individual resident concerns on issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to: -Ensure timely interventions were implemented and sustained in response to resident grievances related to consistent palatable temperatures when food was delivered to the residents; and, -Ensure a grievance for Resident #56 was followed up on and resolved in a timely manner.

Inspectors wroteBased on observations, record review, and interviews the facility failed to accurately reflect the resident's status on the minimum data set (MDS) assessments accurately for four (#62, #3, #56, and #51) of 18 residents reviewed out of 48 sample residents. Specifically, the facility failed to: -Ensure Resident #62 was accurately documented as a one-person transfer; -Resident #3 and Resident #51 had pneumococcal vaccination status was accurate; and -The use of antidepressants was coded accurately for Resident #56

Inspectors wroteBased on interviews and record review the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner. Specifically, the facility failed to answer call lights in a timely manner for residents requesting help.

Inspectors wroteBased on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for three out of three units at the facility. Specifically, the facility failed to: -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure staff performed hand hygiene in between tasks; -Ensure proper use of a clean field/surface during wound care for Resident #83; -Ensure proper hand hygiene was in place during wound care, specifically when donning and doffing gloves; and, -Ensure appropriate personal protective equipment was used as ordered during wound care, specifically a gown.

Inspectors wroteBased on record review and staff interviews the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#3, #16 #62, #51 and #59) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to: -Offer Resident #62 a pneumococcal vaccination upon admission; -Offer additional doses of the pneumococcal vaccine to Residents #3, #16 and #51; and, -Administer annual flu vaccinations to Residents #51, #3, #59.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#11) of four residents reviewed out of 48 sample residents. Specifically, the facility failed to ensure Resident #11 ' s proxy selected or refused life-saving treatments within the power of a proxy.

Inspectors wroteBased on record review and staff interviews, the facility failed to inform resident of the facility's bed hold policy for one (#56) of three residents reviewed for discharge/transfer out of 48 sample residents. Specifically, the facility failed to ensure Resident #56 or the responsible party were informed in writing of the facility's bed hold policy prior to being discharged or transferred from the facility.

Inspectors wroteBased on record review and interviews the facility failed to permit a resident to return to the facility after a leave of absence for one (#86) of three residents reviewed for discharge during hospitalization out of 48 sample residents. Specifically, the facility failed to assess Resident #86's status at the time the resident sought to return to the facility and denied him to return based on his status which led to him going to the hospital.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide appropriate treatment and services to maintain or improve the resident' s ability to perform activities of daily living (ADLs) for one (#52) of two residents reviewed for eating out of 48 sample residents. Specifically, the facility failed to provide Resident #52 with adaptive equipment to maintain his ability to feed himself.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#71) of one resident reviewed for hearing problems out of 48 sample residents. Specifically, the facility failed to ensure Resident #71 was assisted to see an audiologist.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a therapeutic diet for one (#52) of two out of 48 sample residents. Specifically, the facility failed to adequately thicken Resident #52 ' s liquids per his physician's order.

Inspectors wroteBased on record review and interviews the facility failed to ensure the facility ' s binding arbitration agreement was thoroughly and accurately explained to the residents before signing the agreement for two residents (#189 and #190) of five out of 48 sample residents. Specifically, the facility failed to: -Thoroughly explain the arbitration agreement in a form and in a manner to ensure Resident #189 and Resident #190 understood the agreement before signing the agreement; -Accurately inform Resident #189 and Resident #190 when the agreement could be rescinded before the residents signed the agreement; and, -Ensure staff reviewing the agreement with Resident #189 and Resident #190 understood the components of the agreement.

Inspectors wroteBased on resident interview, observations and staff interviews, the facility failed to ensure one resident (#83) of three residents' call light system was functioning in its entirety out of 48 sample residents Specifically, the facility failed to: -Ensure Resident #83's restroom call light was functioning properly; and, -Ensure a timely response to repair Resident #83's call light after staff became aware the call light was not working.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure effective and timely fall prevention practices to prevent falls for two (#19 and #49) of 12 residents out of 30 sample residents. Specifically, the facility failed to: -Conduct timely post fall investigations or at all; -Review residents' falls with the interdisciplinary team (IDT); -Update residents' care plans to reflect interventions to prevent falls; -Educate new staff on fall preventions for residents; and, -Follow care planned interventions to prevent falls. These failures led Resident #19 to experience six falls since admission from 2/2/22 through 7/18/22, the date of last fall, which resulted in the resident being treated at the emergency room for excessive bleeding of a head wound sustained during the fall requiring the resident to receive six staples to his head to close the wound. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Ensure cold food items were stored and served at proper temperature to prevent potential food-borne illnesses; -Prevent potential cross contamination during meal preparation and meal delivery; and, -Demonstrate appropriate use of gloves when handling ready-to-eat foods.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper use of infection control practices for COVID-19 testing for two of four resident hallways. Specifically, the facility failed to ensure contracted COVID-19 testing staff performed appropriate hand hygiene and use of personal protective equipment (PPE) while performing COVID-19 tests on multiple residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper activities of daily living care for one (#231) of six residents of 30 sample residents. Specifically, the facility failed to address Resident #231 calling out for assistance from her room.