Villa Health Care East

Inspectors wroteBased on interview and record review, the facility failed to thoroughly conduct an abuse investigation for 1 (R7) of 5 residents reviewed for abuse in a sample of 7. Findings Include:R7's Undated Face Sheet documents R7 was admitted to the facility on [DATE]. R7's Minimum Data Set, dated [DATE] documents R7 is severely cognitively impaired. The Facility's Final Investigation Dated 1/27/26 documents incident occurred on 1/23/26 at 4:30 PM. Summary: (R7) made allegations of sexual inappropriate behavior. Resident reported to son and hospice social worker. Son reports that he was told about this on Tuesday, 01.21.26 but didn't mention to anyone because he didn't believe there to be any truth to this, Son, administrator, and Director of Nursing (DON) interviewed resident. Resident answered yes/no questions and denied inappropriate care or being fearful. Conclusion: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure R3 was adequately supervised and respond in a timely manner to alarms to prevent elopement for 1 of 1 (R3) resident reviewed for supervision. This failure resulted in R3 who is confused, has a history of exit seeking and wandering at the facility eloped into unknown and unsafe conditions that include exiting the facility, falling onto the concrete, log rolling to a handicap parking sign then sitting up and scooting on her buttocks through the facility parking lot alone until two bystanders observed R3 laying in the facility parking lot and stopped to assist her. This failure resulted in Immediate Jeopardy on [DATE] when R3 eloped from the facility exit door at 7:12 PM and was found by two bystanders at 7:18 PM and was assessed at the local hospital and returned to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and provide food according to physician orders for 1 of 3 residents (R3) reviewed for diet consistency in the sample of 9. Findings Include:R3's admission Record document, print date of 1/22/26, documented R3 has diagnoses including Alzheimer's disease, atrial fibrillation, gastro-esophageal reflux disease, hypertension, spinal stenosis, aphasia following cerebral infarction, and glaucoma. R3's MDS (Minimum Data Set), dated 12/4/25, documented R3 is moderately cognitively impaired and requires setup assistance with meals. R3's Physician Order Summary Report, print date of 1/22/26, documented R3's physician order for a pureed texture diet with moderately thick (honey) consistency liquids. On 1/22/26 at 12:39 PM R3 was observed during the lunch meal. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise 2 of 4 (R2 and R3) residents, reviewed for accidents in a sample of 7. This failure resulted in R3 sustaining a left hip fracture. R2 sustaining a right frontal laceration to her head. Both incidents resulted in hospitalization.

Inspectors wroteBased on interview and record review, facility failed to have sufficient nursing staff to assure resident safety and care for 4 of 7 (R3, R5, R6 and R7) residents reviewed for staffing. This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to implement and revise resident care plans after resident falls for 4 out of 7 residents (R2, R3, R4 and R7); reviewed for Resident Care Plans in a sample of 7.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide privacy while performing incontinence care and failed to provide dignity during dining assistance for 5 of 24 residents (R7, R9, R40, R60, R64) reviewed for resident privacy and dignity in the sample of 48.

Inspectors wroteBased on record review and interview the facility failed to ensure adequate supervision, and precautions in place for falls for 1 of 3 residents (R2) reviewed for accidents in the sample of 8. This failure resulted in R2 falling off bed fracturing her femur and requiring surgical repair.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for 1 of 4 (R2) residents, reviewed for falls in a sample of 4. This failure resulted in R2 sustaining a left hip fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were securely stored, failed to ensure opened medications were labeled with open dates, and the facility was using expired blood glucose control liquids for 16 of 24 residents (R2, R11, R13, R14, R15, R21, R22, R23, R33, R41, R43, R51, R54, R57, R66, R179) reviewed for medication storage in the sample of 55.

Inspectors wroteBased on observation, record review and interview the facility failed to implement infection control practices, failed to wear Personal Protective Equipment (PPE), failed to disinfect multi-use equipment, failed to test residents with COVID-19 symptoms, and failed to ensure residents and staff were tested on COVID-19 days to prevent the spread of COVID-19 infection for 8 of 24 residents (R6, R13, R24, R30, R38, R43, R45, R178) reviewed for infection control in the sample of 55.

Inspectors wroteBased on record review and interviews the facility failed to administer medications to one of three (R4) residents reviewed for medication errors in a sample of 55 residents. R4's face sheet dated 8/13/2024 documents diagnosis of enterocolitis due to clostridium difficile dated 7/11/2024. R4's physicians order sheets documents R4 on Contact/droplet isolation precautions RT C-difficile infection with a start date of 07/11/2024. R4's physicians order sheets documents R4 on vancomycin oral suspension 5ml four times a day until 8/8/2024 with a start date of 7/27/2024. R4's Medication Administration Record (MAR) dated 8/6/2024 documents on dates of 8/4/2025 at 8am,12pm,5pm, 8pm and on 8/5/2024 at 8am and 12pm that vancomycin oral suspension was not administered. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education or documentation of refusal for the COVID-19 vaccine for 3 of 5 residents (R44, R51, R231) reviewed for immunizations in the sample of 55.

Inspectors wroteBased on interview, observation and record review, the facility failed to discard expired and discontinued medications and label and date medications. This error has the potential to affect all 86 residents living in the facility.

Inspectors wrote2. On 05/23/2023 at 10:23 AM, R25 stated that at night a big pan of snacks are brought out and put behind the nurses station but it is not brought to their rooms or offered that way. The snacks are usually cookies, cakes or graham crackers. R25's Minimum Data Set (MDS), dated [DATE], documented that her cognition was intact. 3. On 05/23/2023 at 10:23 AM, R36 stated that pan of snacks are brought out at night and put behind the nurses station but it is not brought to their rooms or offered that way. The snacks are usually cookies, cakes or graham crackers. R36's MDS, dated [DATE], documented that his cognition was intact. 4. R34 stated that she is not offered a snack at night and that sometimes her blood sugars the next morning are affected like they are low. R34's MDS, dated [DATE], documented that her cognition was intact. 5. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to store and serve food to prevent food borne illness, maintain kitchen storage in a sanitary fashion and assist a resident with dining with gloves on. This failure has the potential to affect all 86 residents living in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to wash hands when needed, change gloves when soiled and wear the proper personal protective equipment to prevent cross contamination for 4 of 18 residents (R3, R72, R47, R69) reviewed for infection control in the sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, monitor and provide treatments as ordered to prevent the worsening or formation of pressure ulcers for 3 of 4 residents (R41, R6 and R22) reviewed for pressure ulcers in the sample of 37. This failure resulted in R41's Stage III pressure ulcer worsening to an unstageable pressure ulcer.

Inspectors wroteBased on interview and record review, the facility failed to identify, monitor and implement interventions to address weight loss for 1 of 3 residents (R34) reviewed for weight loss in the sample of 37. This failure resulted in R34 having a significant weight loss of 47.3 pounds indicating a 28.3% weight loss in 6 months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a manner which prevents potential contamination. This has the potential to affect all 84 residents living in the facility.