Villa Manor Care Center

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement policies and procedures related to immunizations for five (#4, #6, #12, #38 and #58) of five residents reviewed for immunizations out of 37 sample residents. Specifically, the facility failed to:-Ensure the residents medical records indicated the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and,-Ensure the residents medical records documented if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment for residents and to help prevent the development and transmission of communicable diseases and infections for two of three units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) while providing care to residents who were on enhanced barrier precautions (EBP).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one (#70) of five residents out of 37 sample residents reviewed for respect and dignity. Specifically, the facility failed to ensure Resident #70 was covered appropriately during transport through the facility hallway.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#85) of five residents reviewed for abuse out of 13 sample residents. Specifically, facility staff failed to report an allegation of abuse by Resident #85 towards Resident #79 to the facility's abuse coordinator and the State Agency.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for two (#4 and #58) of three residents reviewed for accidents out of 36 sample residents. Specifically, the facility failed to ensure Resident #4 and Resident #58's fall interventions were consistently implemented.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for two (#4 and #1) of four residents reviewed for oxygen services out of 37 sample residents. Specifically, the facility failed to ensure staff administered oxygen to Resident #4 and Resident #1 per physician's order.

Inspectors wroteBased on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in two of five medication carts. Specifically, the facility failed to ensure expired medications were removed from the medication cart and disposed of.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#1, #2 and #3) of four residents reviewed for bathing out of four sample residents. Specifically, the facility failed to ensure Resident #1, Resident #2 and Resident #3, who were dependent on staff for bathing, received their scheduled showers. Cross-reference F725: failure to have adequate nurse staffing.

Inspectors wroteBased on record review and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner. Specifically, the facility failed to ensure residents received their showers as scheduled and incontinence care in a timely manner for residents dependent on staff for their care. Cross reference F677: failure to provide activities of daily living for dependent residents.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide a safe, functional and comfortable environment to meet resident needs in six of nine resident rooms. Specifically, the facility failed to: -Ensure resident room temperatures on the 100 unit resident hallway were between 71-81 degrees Fahrenheit. -Fix a broken furnace blower on the 100 unit hallway, which would have provided back up heat to the facility rooms when thermostats were below 71 degrees; and, -Ensure the resident's living room area on the 100 unit had heat between 71-81 degrees.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure appropriate services and assistance to maintain or prevent further decrease in range of motion was provided for one (#1) of three residents out of seven sample residents. Specifically, the facility failed to: -Follow programs physical therapy (PT) and occupational therapy (OT) had written for restorative nursing to provide for Resident #1 who required range of motion (ROM) services; and, -Have trained staff provide consistent ROM for Resident #1 who needed the exercises to maintain his physical abilities or help to prevent further decrease in his ROM.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 11.11%, which was three errors out of 27 opportunities for error.

Inspectors wroteBased on observation and interviews, the facility failed to ensure medications and biologics were stored and labeled properly on two of four medications carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; -Ensure wound dressing supplies were not stored open next to medications in medication cart; -Ensure expired or discontinued medications were removed from medication carts and medication refrigerators; -Ensure medication that was stored in the refrigerator were stored at correct temperatures; -Ensure food were not stored in the medication refrigerators; and, -Ensure medication carts were kept locked.

Inspectors wroteBased on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure glucometers were cleaned according to standards of practice.

Inspectors wroteBased on interviews and record review, the facility failed to obtain informed consent for the use of psychotropic medication for two (#62 and #134) of five residents reviewed for unnecessary medication of out 44 sample residents. Specifically, the facility failed to ensure informed consent which included reason for medication use, risks and benefits associated with use and any black box warning was obtained from the resident or resident representative prior to the resident's use of a psychotropic medication for Resident #62 and Resident #134.

Inspectors wroteBased on interviews and record review, the facility failed to honor resident choices for two (#66 and #134) of two out of 44 sample residents. Specifically, the facility failed to: -Provide a schedule for Resident #66 for rehabilitation services so he felt like he could leave his room, attend group activities and socialize with others; and, -Ensure Resident #134 and Resident #66 received bathing according to their preference.

Inspectors wroteBased on record review and interviews, the facility failed to develop an acute/baseline care plan for two (#139 and #134) of two reviewed for baseline care plans out of 44 sample residents. Specifically, the facility failed to ensure resident involvement in the development and provide a copy to Resident #139 and Resident #134.

Inspectors wroteBased on observations and interviews the facility failed to ensure medications were dispensed according to professional standards of practice. Specifically, the facility failed to follow accepted standards of practice for medication administration by setting up three medications prior to administration.

Inspectors wroteBased on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#62) of one resident reviewed for pain out of 44 sample residents. Specifically, the facility failed to ensure parameters were in place for use of a scheduled topical pain medication for Resident #62.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis received dialysis services consistent with professional standards of practice for one resident (#8) of one resident reviewed for dialysis out of 44 sample residents. Specifically, the facility failed to: -Ensure communication forms between the facility and the dialysis center were completed consistently and accurately for Resident #8; and, -Ensure bruit and thrill were assessed upon return from dialysis and not signed as completed prior to Resident #8 return.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one out of five nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct an annual nursing competency for registered nurse (RN) #1. Cross-reference F658: the facility failed to ensure medications were not pre-poured prior to administration. Cross-reference F759: the facility failed to ensure it did not have a medication error rate above 5%. Cross-reference F760: the facility failed to ensure insulin was administered according to manufacturer guidelines. Cross-reference F880: the facility failed to ensure the glucometer was cleaned according to manufacturer guidelines and in between residents.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one residents (#132) of eight reviewed for medication administration out of 44 sample residents. Specifically, the facility failed to ensure insulin (medications used for blood glucose regulation) vials containing one or more types of insulins were mixed prior to medication administration for Resident #132. Cross-reference F759 failure to ensure the medication error rate was less than five percent.

Inspectors wroteBased on record review and interviews the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one resident (#14) of one reviewed for hospice services out of 44 sample residents. Specifically, the facility failed to ensure Resident #14's hospice agency care plan and notes were accessible to facility staff to coordinate care.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to file and follow up on resident grievances related to staffing and call lights.

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to ensure two (#2 and #8) of five residents reviewed for assistance with activities of daily living (ADL) out of 14 sample residents. Specifically the facility failed to ensure: -Resident #2 received timely incontinence care; and, -Resident #8 received her scheduled showers.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure that before a resident was allowed to self-administer medications, the interdisciplinary team (IDT) performed an assessment to determine if the resident could safely and reliably do so for one (Resident #64) of one sampled resident reviewed for self-administration of medications.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse was reported to the Administrator for one (Resident #181) of two sampled residents reviewed for abuse.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident received non-pressure-related wound treatment/care in accordance with physician's orders for one (Resident #40) of two sampled residents reviewed for wound care.