The Villa Rehab

Inspectors wroteBased on interview and record review, the facility failed to protect 1 of 4 residents (Resident #1) from verbal abuse by a Licensed Nursing Assistant (LNA).

Inspectors wroteBased on interview and record review, the facility failed to submit their five-day investigative report to the Division of Licensing and Protection within the allotted time.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents sampled was provided with adequate supervision and assistance devices to prevent accidents (Resident #1), by failing to systematically evaluate the effectiveness of interventions or revise care plan interventions after falls occurred. As a result, Resident #1 suffered a fall and sustained significant fractures in both ankles. This is a repeat deficiency with the violation cited during a previous complaint survey dated 7/30/25.

Inspectors wroteBased on interview and record review the facility failed to ensure care plans were updated with interventions after recurrent falls for 2 of 3 sampled residents (Resident #1 and Resident #2).

Inspectors wroteBased on interview and record review, the facility failed to have a system to ensure transfer notices and ombudsman notices were provided for 2 of 2 sampled residents transferred to the hospital. This has the potential to impact all residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that staff were competent in medication administration for 4 of 5 licensed nurses and failed to ensure that 10 of 10 direct care staff were competent in infection control measures.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that food was prepared in a safe sanitary manner and environment. This has the potential to impact all residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that the facility assessment provided adequate information related to competencies and training and failed to address needed positions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a risk assessment was completed to identify areas at risk for Legionella (a bacteria found in water that can cause a serious type of pneumonia, Legionnaires' disease) could grow and spread in the facility's water system, and failed to ensure proper infection control practices were followed.

Inspectors wroteBased on interview and record review the facility failed to ensure that a infection preventionist was employed at least part time.

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff have infection prevention and control training that covers facility policy and procedures for 10 of 10 sampled direct care staff.

Inspectors wroteBased on interviews and record review the facility failed to provide the required 12 hours of in-service training for 2 of 2 applicable licensed nursing assistants (LNAs).

Inspectors wroteBased on interview and record review the facility failed to ensure a medication error rate of less than %5. 2 of 26 medication administrations were observed to be in error making the error rate 7.7%.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of three residents (Resident #16) was free from physical restraints. During staff use of physical restraint Resident #16 became more agitated, aggressive, and resistive to redirection causing combative behavior, and threatening to hurt staff. As a result of the aggressive behaviors the facility refused to allow the Resident to return to the facility causing an extended stay in the hospital.

Inspectors wroteBased on interview and record review the facility failed to ensure that an allegation of staff to resident abuse was reported to the licensing agency for one of three residents in the applicable sample (Resident #16).

Inspectors wroteBased on interview and record review, the facility refused to allow a resident to return to the facility after being transferred to the hospital and inappropriately discharged the resident, for one of three residents in the applicable sample (Resident #16).

Inspectors wroteBased on interview and record review the facility failed to provide adequate assessment and supervision for 1 of 3 residents in the sample (Resident #16), to prevent a resident who was exit seeking to exit the facility. This resulted in staff using physical restraint in attempt to return the Resident to the facility, causing the Resident to exhibit increased agitation, resistiveness, and combativeness toward staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. The facility failed to document the temperatures of 1 of 3 freezers and the temperatures of 2 of 3 refrigerators, served food items to residents outside of the facility's standard for food temperatures, and failed to discard expired food items.

Inspectors wroteBased on interview and record review, the facility failed to address in their facility assessment what the staff competencies that are necessary to provide the level and types of care needed for the resident population identified in the assessment. This deficient practice has the potential to affect all 20 residents residing in the facility.

Inspectors wroteBased upon interview and record review, the facility failed to provide care and services according to accepted standards of clinical practice regarding Physician Orders and notification for 2 residents [Res.#6 and #17] of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program related to behavioral health or trauma informed care and services, as determined by resident needs and the facility assessment for 7 of 8 sampled staff. Review of the 2024 Facility Assessment indicates that the facility has had 27 residents with the diagnosis of anxiety disorder, 37 residents with depression, 2 residents with manic depression, 2 residents with psychiatric disorder, and 1 resident with Post Traumatic Stress Disorder. Review of employee training and competency files revealed that 4 Licensed Nursing Assistants and 3 Registered Nurses had no documented evidence that they received behavioral health and trauma informed care training on hire or annually for 2024. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to support the resident's right to file grievances anonymously. This has the potential to affect all residents in the facility. Findings Include: Per observation, the facility's entryway on the first floor has a bulletin board with the grievance process posted on it. The process includes who the grievance officer is and the contact information, but it does not give details on anonymously filing a grievance. There is no evidence of grievance forms or information on submitting a grievance anonymously. A review of the facility policy, titled Resident and Family Grievances, revised on 2/2/24, #9. A grievance may be filed anonymously, but it does not address a process to do it. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five applicable residents of the sampled 16 residents (Resident #14) was free from any significant medication errors.