Sgmc Health Villa

Inspectors wrote2. Review of R2's EMR revealed diagnoses including, but not limited to, age-related nuclear cataract, primary open-angle glaucoma, and hemiplegia and hemiparesis of the right side. Review of R2 's Quarterly MDS, dated [DATE], revealed Section C (Cognitive Patterns) documented a BIMS score of 15 (indicating little to no cognitive impairment). Review of R2's clinical record revealed no assessment for self-administration of medications. Review of R2's Clinical Physician Orders revealed no orders for self-administration of medications. Observation on 6/2/2025 at 12:18 pm of R2 's room revealed a package of throat lozenges in a clear storage container on the floor, visible to anyone entering the room, one three-ounce container of Resinol medicated ointment, and one bottle of hydrogen peroxide on the resident's overbed table. [...]

Inspectors wroteBased on staff interviews, record review, and review of the Resident Assessment Instrument 3.0 (RAI) Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for eight of 31 sampled residents (R) (R27, R38, R25, R44, R14, R12, R4, and R23).

Inspectors wrote3. Review of R2 's EMR revealed diagnoses including, but not limited to, unspecified asthma and morbid (severe) obesity due to excess calories. Review of R2 's Quarterly MDS, dated [DATE], revealed Section N (Medications) documented R2 received an anticoagulant, and Section O (Special Treatments, Procedures, and Programs) documented that R2 received oxygen. Review of R2's Clinical Physician's Orders revealed an order dated 9/30/2022 for oxygen via a NC at two LPM as needed (PRN) and an order dated 9/29/2023 for Eliquis oral tablet 5 mg (a medication used to prevent and treat blood clots), one tablet by mouth two times a day. Review of R2's Care Plan Report revealed no care plan for oxygen use or anticoagulant medication use. Observations on 6/2/2025 at 12:18 pm and 6/3/2025 at 10:00 am revealed R2 receiving oxygen via a NC at two LPM. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Falls Assessments/ Falls Risk Policy, the facility failed to ensure post-fall assessments were conducted for one of 10 residents (R) (R39) with falls. This deficient practice had the potential to place R39 at risk of falls, medical complications, and a diminished quality of life.

Inspectors wroteBased on resident and staff interviews and review of the facility policy titled Individual Rights and Responsibilities, the facility failed to ensure mail delivery service was provided to residents on Saturdays. This deficient practice had the potential to affect all residents in the facility. The facility census was 55.

Inspectors wroteBased on resident and staff interviews, record reviews, and review of the facility's policy titled, Villa Abuse, Neglect, Exploitation, Mistreatment of Individuals, the facility failed to ensure that an allegation and suspicion of abuse was reported to the State Survey Agency (SSA) within the required time frame for one of 14 sampled residents (R) (R A).

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled, Villa Abuse, Neglect, Exploitation, Mistreatment of Individuals, the facility failed to implement thorough protective measures following an allegation of staff to resident abuse. Specifically, the facility failed to remove a staff member from the schedule and allowed the staff member to work in the area where the resident/victim resided during the investigation of abuse, for one of 14 sampled residents (R) (R A).

Inspectors wroteBased on observation, staff and resident interviews, record review, and review of facility policy, the facility failed to develop a care plan for five dependent residents (R) (#31, #40, #12, #48, #58) reviewed for Activities of Daily Living (ADLs); and failed to implement the care plan related to providing contracture management/braces/range of motion (ROM) services for one resident (R#41) of 30 sampled residents.

Inspectors wroteBased on observation, staff and resident interviews, record review and review of facility policy, the facility failed to ensure six residents (R) (R#31, R#40, R#12, R#48, R#54, and R#58) received showers and personal hygiene needs of 30 sampled residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, family interviews, and review of facility document titled, SGMC Lakeland Villa Facility Assessment 2022, the facility failed to ensure that the facility had adequate nursing staff. The deficient practice affected the care provided to the 58 residents that resided in the facility.

Inspectors wroteBased on observations, interviews, and review of facility documents titled Daily Patient Room Cleaning Steps, Housekeeping Orientation Skills Validation Form, and Tray Presentation Standards the facility failed to maintain sanitary and clean conditions related to cross contamination when mopping resident rooms and bathrooms. In addition, the facility failed to ensure food items on meal trays were covered when delivered. This deficient practice impacted two of four hallways.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician and responsible party timely of a newly developed pressure ulcer for one resident (R) (R A) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure weekly wound measurements were obtained for one of two residents (R) (R A) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that one of 30 sampled residents (R) (R#57) received routine dental services as needed.

Inspectors wroteBased on record review and staff interviews the facility failed to review and revise the Comprehensive Care Plan for four of 24 residents (R#210, #49, #2 and #28) whose care plans were reviewed. Failure to revise the Care Plan for each resident resulted in the nursing staff being unaware of the current status of each resident, which resulted in a fall with a major injury for R#210. Actual harm was identified to have occurred on 6/29/2021 when R#1 fell, while being transferred with a mechanical lift, and sustained an intertrochanteric fracture of the right hip that required surgery.

Inspectors wroteBased on observations, record reviews, and resident and staff interviews the facility failed to use a two-person transfer for one of four residents (R#210) transferred with a Hoyer lift. Actual harm was identified to have occurred on 6/29/2021 when R#1 fell, while being transferred with a mechanical lift, and sustained an intertrochanteric fracture of the right hip that required surgery.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide staff with the necessary education and skill set to perform resident transfers; the facility staff improperly transferred one of four residents (R#210). This resulted in actual harm that required surgery.

Inspectors wroteBased on interviews, record review, and review of policy titled, Villa Drug Regiment the facility failed to ensure the pharmacist provided documentation to the attending Physician, the facility's Medical Director and the Director of Nursing (DON) regarding any irregularity (including excessive dose, duplicate therapy, excessive duration, without adequate monitoring, without adequate indications for its use, the presence of adverse consequences or any combinations of the previous reasons) identified during the pharmacist's review of the drug regimen and medical chart for each resident for five of five residents reviewed (Resident (R) #2, R#28, R#43, R#48 and R#49).

Inspectors wroteBased on observation and interview, the facility failed to ensure that foods were used by the expiration date and failed to ensure kitchen equipment was clean and sanitary. This deficient practice affected 53 of 58 residents that received an oral diet.

Inspectors wroteBased on observation and staff interview the facility failed to ensure that the area around the garbage dump was clean and free of debris. This deficient practice had the potential to affect all 58 residents at the facility.

Inspectors wroteBased on record review, staff interviews, and review of the Hospice Services Agreement the facility failed to meet components of the written agreement with hospice for four of four residents receiving hospice services.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a significant change assessment for one of 24 residents (R#59) reviewed.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure the comprehensive assessment accurately reflected the status of each resident for two of 24 residents (R#28, R#43).

Inspectors wroteBased on record review, staff interview, and review of facility policy, the facility failed to develop and implement a comprehensive person-centered care plan for one of one residents (R#49) admitted to Hospice.

Inspectors wroteBased on record review and interview with facility staff, the facility failed to ensure one of one residents (R#15) reviewed for End Stage Renal Disease with Hemodialysis received services consistent with professional standards of practice by failing to have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that PRN [as needed] orders for psychotropic drugs were limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) #49) reviewed for medication management.