Villa Gardens Health Care Unit

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a Registered Nurse (RN, a healthcare professional who completed an Associate Degree in Nursing [AND] or Bachelor of Science in Nursing [BSN] from an approved program. Then, they pass a comprehensive national test [NCLEX-RN] and meet state licensure and certification requirements that develop care plans, give treatments and medications, perform diagnostic tests, work with physicians to coordinate care, and supervise Licensed Vocational Nurse [LVN] and Certified Nursing Assistant [CNA] ) for eight (8) consecutive hours, seven (7) days a week on 1/18/2025, 1/19/2025, 1/21/2025, and 1/22/2025 based on the facility assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of two (2) of three (3) sampled residents (Residents 5 and 40) in accordance with its Policy and Procedure (P&P) by failing to ensure:1.a. Resident 5's Famotidine (medication used to treat and prevent conditions caused by too much stomach acid such as heartburn [burning chest pain] and gastroesophageal reflux disease [GERD, stomach acid flows back up the esophagus (canal that connects the throat to stomach)], was not left unattended on top of the medication cart on 12/3/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was handled, prepared, and stored in accordance with the facility's policy by failing to ensure:1. Expired products were removed from the kitchen dry storage.2. Food items were dated, labeled, and kept clean after opening in the dry storage area and walk in refrigerator. These failures had the potential to result in harmful bacteria growth that could lead to food borne illnesses to 38 of 38 medically compromised residents who receive food in the kitchen. During a concurrent observation and interview on 12/2/2025 at 7:49 AM in the kitchen dry storage area and walk in refrigerator with [NAME] 1, the following were observed:1. Two (2) unopened containers of cooking wine were observed covered in dust and labeled with the dates 11/14/2022 and 11/13/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of three (3) dumpsters (large trash container designed to be emptied into a truck), containing garbage (mostly decomposable food waste or yard waste) and refuse (dry material such as glass, paper, cloth or wood that does not readily decompose) were covered or entirely covered as indicated on the facility's Solid Waste Disposal policy. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry disease such as rodents, parasitic worms , or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease threat to the residents and staff of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure by failing to: 1. Ensure an opened box of disposal gloves was left on top of Resident 31's dirty linen container. This failure had the potential to result in the spread and development of infection through cross contamination (when bacteria or other microorganisms are unintentionally transferred from one person or object to another). 2. Resident 36's used nasal cannula was left on the resident's wheelchair. This failure had the potential to expose Resident 36 to harmful bacteria when the resident reinserts the nasal cannula prongs. 3. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 38) received sufficient notice prior to the resident's last coverage date (LCD) for Medicare Part A (insurance which covers inpatient hospital care, skilled nursing facility [SNF], hospice [focuses on the care, comfort, and quality of life of a resident with serious illness, who is approaching the end of life], laboratory tests, surgery, home health care [wide range of health care services that can be given in the resident's home for an illness or injury]) services. This deficient practice had the potential for Resident 38 to not be aware of possible charges for services rendered that were not covered after the resident's last Medicare coverage day.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for one (1) of four sampled residents (Resident 5) for the environment care area in accordance with the facility's policy and procedure when facility failed to leave Resident 5's wheelchair. which was at the resident's bedside, overflowing with the resident's personal belongings. This deficient practice resulted in unsafe and unsanitary conditions placing Resident 5 at risk for infection, uncomfortable living, and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Three medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, to yield an overall medication error rate of 12 percent (%) for one (1) of three (3) sampled residents (Resident 5) observed during medication administration (med pass). This deficient practice resulted in Resident 5 not receiving medications as ordered which had the potential to result in harm due to unmet individual medication needs.

Inspectors wroteBased on interview and record review, the facility failed to implement its protocol for Antibiotic (medication used to kill bacteria and to treat infections) Stewardship Program by failing to ensure a culture ( growing microorganism like bacteria from a resident ) in a laboratory to diagnose infections, identify the specific germs, and tests which antibiotics effectively kill or stop it) was obtained before ordering antibiotic for one (1) of 1 sampled resident (Resident 36). This deficient practice had the potential for Resident 36 to be prescribed inappropriate antibiotics and increased the risk for developing antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics) and suffer adverse side effects from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to follow its Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) policy to inform and provide a written information regarding the right to formulate an advance directive for one (1) of two (2) sampled residents (Resident 26). This deficient practice had the potential to cause conflict in carrying out Resident 26's wishes regarding health care decisions during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to prevent falls (move downward, typically rapidly and freely without control, from a higher to a lower level) for one (1) of two (2) sampled residents (Resident 35) by failing to identify causative factors of the resident's fall, and revise the care plan with new resident- specific interventions (programs or activities that are designed to address the specific needs of the resident to ensure their well-being) to prevent further falls. On 7/14/2024 at 8:24 AM, Resident 35 was found sitting on the floor at 6:15 AM awake, very confused, and soaking wet with urine, there was no documented evidence of interventions provided to address resident's confusion and incontinence (involuntary loss of bowel and bladder control). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its oxygen therapy (a treatment that provides extra oxygen) policy for two (2) of three (3) sampled residents (Residents 8 and 37) by failing to: 1. Ensure Resident 8's humidifier bottle (plastic bottle of water that adds moisture to the flow of oxygen) was dated and not empty during oxygen therapy. This failure had the potential to result in adverse effects (an undesired harmful effect resulting from a medication or other intervention) of oxygen therapy for Resident 8 including nasal membrane (moist tissue that lines the nasal cavity and produces mucus) drying. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to to follow proper food handling practices in accordance with its policy and procedure by failing to:: 1. Properly label food items in the kitchen refrigerator. 2. Ensure there was no expired bread in the kitchen dry storage area. 3. Properly label food items in the resident refrigerator. These deficient practices have the potential to result in food borne illness (any sickness that is caused by the consumption of foods or beverages that are contaminated with certain infectious or noninfectious agents) in a population of 35 residents who consume food by mouth.

Inspectors wroteBased on observation and interview the facility failed to ensure two (2) of three (3) dumpsters were covered with a lid and were not overflowing with trash in accordance with the facility policy. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially enter the facility and spread diseases to the residents.

Inspectors wroteAmended: Based on observation, interview and record review, the facility failed to implement appropriate infection control practices for 4 of 5 sampled residents (Residents 19, 24, 37 and 199) as indicated on the facility's policy and procedure (P&P) by failing to ensure: 1. Resident 199's visitor was educated and used indicated personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) inside novel respiratory isolation (an isolation that requires the use of a disposable gown, eye protection [goggles or face shield], fit-tested respirator [N-95 or higher] and gloves) room. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to follow its manual catheter irrigation (a procedure that uses sterile fluid to flush a blocked or clogged indwelling catheter [a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage]) policy when Licensed Vocational Nurse 5 (LVN 5) failed to cap the drainage tube of the indwelling catheter with a sterile protective sheath during irrigation for one (1) of one sampled Resident (Resident 18) as indicated in the facility's policy and procedure (P&P). This deficient practice had the potential for Resident 18 to develop urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on interview and record review, for one (1) of 12 sampled resident (Resident 5), the facility staff failed to: 1. Accurately and completely document the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) dose administered on 10/2/2024, after administering insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). 2. Have documented evidence for the monitoring of signs and symptoms of hypoglycemia (a condition in which your blood sugar level is lower than the normal range) and hyperglycemia (a condition where too much sugar is circulating in the blood) as indicated in the resident's care plan and the pharmacist recommendations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within the resident's reach (arm's length) for one (1) of 1 sampled resident (Resident 24) as indicated on the facility's call system policy. This deficient practice had the potential for Residents 24 to not being able to call the facility staff for assistance especially during an emergency, which could lead to an injury or harm to Resident 24.

Inspectors wroteBased on interview and record review the facility failed to document and perform a wound care treatment for one of two sampled residents (Resident 1). This failure had the potential to result in Resident 1's wounds getting worse in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from accident hazards by failing to secure a keyboard that was placed on top of a music equipment cart on 12/31/23 at 3:30 PM while an entertainer (a person such as a singer, musician, [NAME], or comedian whose job is to entertain others) was setting up their equipment for a performance. This failure resulted in the keyboard slipping off the cart and falling onto Resident 1's feet and caused her to sustain blood blisters that needed surgical intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one of four sampled residents (Resident 23) by failing to flush in between each medication administered through the gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition directly to the stomach). This deficient practice had the potential for drug-to-drug interactions (a reaction between two or more drugs) and for the resident to be at risk for adverse reactions (an unwanted, uncomfortable, or dangerous effects the drugs/medications may have).

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean the dryer lint trap for three (3) of 3 dryers as indicated in the policy. This deficient practice had the potential to cause fire in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they were free of medication error rate of five (5) percent or greater, as evidenced by the identification of two medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) out of 25 opportunities (observations during medication administration) for error and yielded a cumulative error rate of eight (8) percent for two of four sampled residents (Resident 4). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to dispose expired medications found in the medication room as indicated on the facility policy. This deficient practice had the potential for adverse reaction in the event that these expired medications were administered to the residents. Findings, On 10/7/23 at 4:27 PM, during an inspection of the medication room with Licensed Vocational Nurse 1 (LVN 1), the following were observed: a. 16 individual packets of Simply Thick Easy Mix Instant Food Thickener 96 g (Gram - a unit of measure) with an expiration date of 8/3/23. b. Two bottles of Pepto-Bismol (medication used to treat diarrhea, heartburn nausea, and upset stomach) 525 mg (milligrams - unit of measure)/30 ml (milliliter - unit of measure) with an expiration date of 5/20/23. On 10/7/23 at 4:40 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store food under sanitary conditions in one (1) of 1 kitchen, by: a. Failed to ensure pasteurized eggs (gently heated in their shells, just enough to kill the bacteria but not enough to cook the egg) was not stored in the same shelve and/ or beside the regular eggs. b. Failed to ensure opened food items stored in dry goods area were labeled and dated. c. Failed to discard expired food and was not stored in the kitchen. The deficient practice of not separating pasteurized eggs with regular eggs has high risk of accidental usage of regular eggs that to be served to residents and had high potential for transmission of salmonella (a germ that may cause diarrhea, fever, and stomach cramps, leading to hospitalization and death). [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the facility's Infection Surveillance Log Form (ISL - a form used by the facility to indicate if the resident met the criteria for the use of antibiotic [medication used to treat infection]) which is part of the facility's Antibiotic Stewardship Program (protocols and a system in the facility to monitor antibiotic use) prior to the administration antibiotic medication for three of three sampled residents (Resident 22, 26, and 90). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized baseline care plan within 48 hours of admission to reflect the assessment and meet the immediate needs that included interventions to address hearing for one of 12 sampled residents (Resident 189). This deficient practice had the potential to negatively affect the well-being and the delivery of necessary care and services for Resident 189.

Inspectors wroteBased on record review and interview, the facility failed to ensure a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one of two sampled resident (Resident 24) in accordance with the facility's hospice agreement by failing to ensure: a. A physician's order for hospice care from December 2022 to October 2023 b. A current physician's certification for hospice benefit from 3/2023 to 10/2023 c. A hospice comprehensive assessment to include a documented evidence of hospice staff progress notes visit and hospice staff visit calendar d. Hospice care plan was developed This deficient practice had the potential for Resident 24 not to receive the hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control practices for one sampled resident (Resident 26) as indicated on the facility's policy and procedure by failing to ensure availability and use of EPA (Environmental Protection Agency) approved disinfectant solution in cleaning a contact isolation ( used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) room with Clostridioides difficile (C. diff, a germ that causes diarrhea). This failure placed all the residents, staff, and the visitors at higher risk for cross contamination, and increased spread of C. diff infection in the facility and the community.