Villa Feliciana Chronic Disease

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status by failing to implement interventions for 2 (#11 and #65) of 4 residents reviewed for Tube Feeding/Nutrition. The facility failed to complete weekly weights for Resident #11 and #65. Review of the facility's policy titled Weights-Obtaining Accurate Weights, updated on 10/2022, revealed the following: Purpose: To insure that accurate body weights are obtained on all residents at admission, and at least monthly thereafter, unless ordered more frequently by the attending physician. Policy: B. The nursing staff.will be responsible for obtaining and documenting the weights on the Electronic Health Record (EHR). C. In addition to the above, all residents will be weighed once a month, unless ordered more frequently by the attending physician. Procedure: G. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure there were sufficient numbers of Certified Nursing Assistants on a 24-hour basis to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 3 (#14, #53 and #104) of 38 residents reviewed for staffing in the initial pool. Review of the facility's Resident Census dated 01/20/2026 revealed there were 162 residents who resided in the facility. Further review of the Census revealed there were 24 residents who resided on Unit 3 and 25 residents who resided on Unit 5. Review of the facility's daily Staffing Assignment Sheet for the 6:00 a.m. - 6:00 p.m. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were stored properly in accordance with currently accepted professional principles. The facility failed to ensure expired medications were not available for use for Resident #71 and Resident #131 in Medication Cart a, and for Resident #65 in Medication Cart b of 5 medication carts reviewed. On 01/20/2026 at 1:55 p.m., an observation was made of Medication Cart a with S6LPN. The following was observed:One bottle of Latanoprost Ophthalmic Solution 0.005% with an expiration of 12/2025 for Resident #71; andOne bottle of Latanoprost Ophthalmic Solution 0.005% with an expiration of 12/2025 for Resident #131. On 01/20/2026 at 2:03 p.m., an interview was conducted with S6LPN. She confirmed the Latanoprost Ophthalmic Solution 0.005% bottles for Resident #71 and Resident #131 were expired and available for use. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the residents who were served food from the facility's kitchen. Review of the facility's policy with a revision date of 02/2023, titled Food Storage: Cold Foods revealed in part, the following:Procedures5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. On 01/20/2026 at 8:52 a.m., an observation of the dry storage room in Kitchen b revealed the following:1 opened, 1/2 full, gallon container of soy sauce, with no open date, with a label which read Refrigerate after opening. On 01/20/2026 at 8:59 a.m., an observation of Kitchen b revealed the following: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the oxygen tubing was labeled with the date and time for 1(#54) of 5 residents reviewed for respiratory care. Review of the facility's undated policy titled Oxygen Administration revealed the following, in part, Procedure: O. Document date, time, oxygen flow rate, route and frequency and duration of treatment. S. Replace tubing, cannula or mask at least every week when oxygen is used intermittently or as needed. Resident #54 was admitted to the facility on [DATE] with diagnoses that included, in part, Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbations, Pleural Effusion, and Atrial Fibrillation. Review of Resident #54's Care Plan revealed the following, in part: Problem: The resident has oxygen therapy related to diagnosis of COPD, Pleural effusion Intervention: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect the residents' right to be free from physical abuse and psychosocial harm for 3 (#1, #3, and #R1) of 5 residents reviewed for abuse. The facility failed to protect:1. Resident #3 from physical abuse by Resident #R2;2. Resident #R1 from physical abuse by Resident #2;3. Resident #3 from physical abuse by Resident #2; and4. Resident #1 from physical abuse by Resident #2. This deficient practice resulted in physical and psychosocial harm on 10/28/2025 at 5:45 p.m. for Resident #3, a severely cognitively impaired resident with a history of a traumatic brain injury, when Resident #R2 drug Resident #3 from the bench onto the ground and hit him with balled fist at least 7 times in the face and head causing Resident #3 to bleed from the lip and mouth. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report allegations and incidents of physical abuse to Administration and/or the State Agency for 3 (#1, #3, and #R1) of 5 residents reviewed for abuse. The facility failed to ensure:The State Agency was notified when Resident #R1 was physically abused by Resident #2; The State Agency was notified when Resident #3 was physically abused Resident #2;Staff reported an allegation of physical abuse to Administration when Resident #1 notified staff he was physically abused Resident #2; and The State Agency was notified when Resident #3 physically abused Resident #R2.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide a functioning assistance device for supervision to prevent an accident from occurring for 1 (RR1) of 2 (#3 and RR1) residents who required assistant devices.

Inspectors wroteBased on record review and interviews, the facility failed to have sufficient nursing staff to provide nursing and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident based on the Facility Assessment. The deficiency had the potential to affect the facility's total census of 153 residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents who were capable of using the call system had call bells accessible for 5 (#2, #R4, #R5, #R6, and #R7) of 7 ((#1, #2, #3, #R4, #R5, #R6, and #R7) sampled residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a safe, clean, comfortable homelike environment for 1 (#2) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) sampled resident's rooms observed.

Inspectors wroteBased on record review, interviews, and observations, the facility failed to have sufficient certified nursing assistant staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (Unit 2B) of 2 (Unit 1A and Unit 2B) resident units reviewed for staffing. This had the potential to affect the 20 residents residing on Unit 2B.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents' Medication Administration Record (MAR) were accurately documented for 2 (#1 and #2) of 3 (#1, #2, and #3) residents reviewed for pharmaceutical services. This deficient practice had to the potential to affect any of the 153 residents residing in the facility.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to prevent misappropriation of resident property by S4RN for 2 (#1 and #2) of 3 (#1, #2, and #3) sampled residents. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. This deficient practice resulted in an Immediate Jeopardy situation on 02/01/2025 when S4RN withheld Resident #1 and Resident #2's 7:00 p.m. 01/31/2025 medications. Two staff members observed both Resident #1 and Resident #2's 7:00 p.m. 01/31/2025 dose of medications inside of S4RN's personal bag after S4RN verbalized the resident's refused the medications. These medications included cardiac, hypertension, seizure, diabetic, and psychiatric medications. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure allegations of neglect/misappropriation of property were reported in the required timeframe for 2 (#1 and #2) of 5 (#1, #2, #3, R1, and R2) sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff utilized appropriate PPE during care with residents who required EBP (Enhanced Barrier Precautions) for 3 (#35, #52, and #54) of 3 (#35, #52, and #54) of 3 (#35, #52, and #54) residents observed during chronic wound care and use of indwelling medical devices. This deficient practice had the potential to affect any of the 20 residents residing in the facility on Enhanced Barrier Precautions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an environment which promotes quality of life through dignity and respect for 1 (#94) of 5 (#10, #16, #94,#107, and #150) residents reviewed for resident rights. The facility failed to ensure residents were assisted with meals in a dignified manner as evidenced by staff standing over Residents #94 while assisting him to eat.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective system was in place to incorporate Level II PASARR determination recommendations in the resident's care planning for 1 (#106) of 3 (#33, #106, and #145) residents reviewed for PASARR. This deficient practice had the potential to affect any of the 58 residents residing in the facility with a PASARR Level II as determined by the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure services provided met professional standards of quality by failing to ensure nursing staff accurately documented Pressure Ulcer treatment as performed for 1 (#52) of 4 (#45, #52, #65, and #139) residents reviewed with Pressure Ulcers. This deficient practice had the potential to affect any of the 13 residents residing at the facility with Pressure Ulcers.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident with Pressure Ulcers received treatment and services consistent with professional standards by failing to implement the physician ordered treatment for 1 (#52) of 2 (#52 and #62) residents reviewed with wound vacuums. This deficient practice had the potential to affect any of the 13 residents with Pressure Ulcers as listed on the facility's CMS-802.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect residents' right to be free from physical abuse by another resident for 3 (#3, #7, and #9) of 12(#1, #2, #3, #4, #5, #6, #7, #8, 9, 10, 12, and 13) residents reviewed for abuse. The facility failed to ensure: 1. Resident #3 was free from physical abuse by Resident #4; 2. Resident #7 was free from physical abuse by Resident #8; and 3. Resident #9 was free from physical abuse by Resident #10.

Inspectors wroteBased on observations, interviews and record review, the provider failed to ensure physician's orders were implemented for 1 (#13) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by failing to ensure a resident did not receive a medication he was allergic to for 1 (#10) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 1 (#8) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13) residents reviewed for medications.

Inspectors wroteBased on interviews, and record review, the facility failed to notify the physician when a residents had a change in condition for 3 (#12, #13, and #14) of 16 residents reviewed for abuse.

Inspectors wroteBased on record review and interviews, the facility failed to ensure allegations of abuse were reported immediately, but not later than 2 hours after the allegation was made to the administrator and to the state survey agency for 2 (#7 and #16) of 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure PRN orders for psychotropic medications were limited to 14 days and indicated the duration for 4 (#4, #8, #13 and #14 ) of 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect each residents' right to be free from physical abuse for 3 (#3, #5, and #9) of 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 ,#13, #14, #15, and #16) residents reviewed for abuse. The facility failed to ensure: 1. Resident #3 and Resident #9 were free from physical abuse by Resident #4; and 2. Resident #5 was free from physical abuse by Resident #6.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents plan of care was revised by failing to update behavior interventions after a verbal altercation for 1 (#1) of 16 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) residents reviewed for care plans.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to protect each residents' right to be free from abuse for 3 (#8, #9, and #13) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12 and #13) residents reviewed for abuse. The facility failed to protect: 1. Resident #8 from mental abuse by S11CNA; 2. Resident #9 from physical abuse by Resident #10; and 3. Resident #13 from physical abuse by Resident #11. This deficient practice resulted in an actual psychosocial harm on 05/10/2024 around 6:00 p.m., when S11CNA made degrading comments about Resident #8's bowel condition loudly at the Nurses' Station with Resident #8 seated nearby. Resident #8 experienced crying, sadness, and felt degraded after S11CNA's comments about him.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident received necessary services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive care plan by failing to implement and document increased behavior monitoring for 1 (#9) of 5 (#3, #4, #5, #6, and #9) residents reviewed for increased monitoring for behaviors.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from physical abuse by another resident for 3 (#RF7, #F47, and #F125) of 11 (#F6, #F11, #F13, #F75, #F47, #F120, #F125, #F132, #F338, #RF7, and #RF8) residents reviewed for abuse. The facility failed to ensure: 1. Resident #RF7 was free from physical abuse by Resident #F132; 2. Resident #F47 and Resident #F125 were free from physical abuse by each other. This deficient practice resulted in an actual harm for Resident #RF7 on 01/05/2024 at 12:41 p.m. when he was punched in the face by Resident #F132 and sustained multiple facial fractures. Resident #RF7 took a canned beverage from Resident #F132's meal tray and Resident #F132 approached Resident #RF7 and punched him in the face. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received mail on Saturdays for 3 (#62, #120, and #132) of 7 (#47, #62, #99, #112, #117, #120, and #132) residents reviewed for mail during the resident council meeting. This deficient practice had the potential to affect 144 residents residing in the facility. Review of the facility's Policy titled, Mail revealed the following, in part: Purpose: To ensure residents receive their mail in a timely manner. Procedure: 1. Weekend and holiday mail will be picked up by the Nursing Department .Any packages received on weekends and holidays shall be distributed by the nursing department. During the resident council meeting on 11/13/2023 at 1:38 p.m., Resident #62, Resident #120, and Resident #132 all stated mail was not delivered on Saturdays and was held until the following Monday. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident equipment was maintained in a safe and orderly manner by failing to ensure geri-chairs were in good repair for 1 (#4) of 2 (#4 and #94) residents reviewed for environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegations of physical abuse to the state survey agency within 2 hours for 2 (#75 and #89 ) of 4 (#75, #89, #132, and #338) residents reviewed for abuse.

Inspectors wroteBased on interviews and record review, the facility failed to implement a person-centered plan of care by failing to ensure weekly restorative nursing assessments were completed for 1 (#99) of 2 (#9 and #99) residents reviewed for limited range of motion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure: 1. Oxygen tubing was labeled and the oxygen humidifier bottle was properly changed for 1 (#4) of 3 (#4, #81, and #84) residents; and 2. Oxygen orders were initiated for 1 (#81) of 3 (#4, #81, and #84) residents reviewed for oxygen therapy.

Inspectors wroteBased on interviews and record review, the facility failed to implement a person-centered plan of care by failing to ensure weekly restorative nursing assessments were completed for 1 (#99) of 2 (#9 and #99) residents reviewed for limited range of motion.