Villa Maria

Inspectors wroteThe facility reported a census of 57 residents; the sample included three residents. Based on observation, interviews, and record review, the facility failed to ensure an environment free from accidents when staff failed to assess Resident (R) 1's ability to safely manage hot liquids resulting in a hot liquid spill. This deficient practice placed R1 at risk for burns and pain.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to provide dignity and quality of life for Resident (R)5, placing the resident at risk for embarrassment and an undignified living environment.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on record review and interview, the facility failed to provide three sampled residents, Resident (R)13, R16 and R146 (or their representative) the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, (CMS) Centers for Medicare and Medicare Services which placed them at risk to make uninformed decisions about their skilled care.

Inspectors wroteThe facility had a census of 57 residents. The sample included 16 residents with one resident reviewed for side rails. Based on observation, interview, and record review the facility failed to care plan the use of beds rails for Resident (R) 30. This deficient practice placed R30 at risk for impaired safety due to lack of staff direction for the use of the bed rails.

Inspectors wroteThe facility had a census of 57 residents. The sample included 16 residents of which four residents were reviewed for pressure ulcers (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, record review, and interview, the facility failed to implement interventions to prevent Resident (R) 33's left buttock pressure ulcer from worsening and failed to implement treatment for R34's facility acquired pressure ulcer when identified. These deficient practices placed R33 and R34 at risk for delayed healing or worsening pressure ulcers.

Inspectors wroteThe facility had a census of 57 residents and the sample included 16 residents, in which one resident was reviewed for weight loss, Resident (R) 33. Based on observation, record review, and interview, the facility failed to implement dietician's recommendations which placed the resident at risk for further weight loss, malnutrition, and delayed in wound healing.

Inspectors wroteThe facility had a census of 57 residents. The sample included 16 residents with one resident reviewed for side rails. Based on observation, interview, and record review the facility failed to assess Resident (R) 30 for risk of entrapment from bed rails, obtain informed consent, and ensure the bed rail dimensions were within recommended safe dimensions. This deficient practice placed R30 at risk for entrapment in the bed rail and potentially serious injury.

Inspectors wroteThe facility had a census of 57 residents. The sample included 16 residents. Based on observation, interview and record review the facility's staff failed to safely discard a fentanyl (controlled, narcotic pain medication at high risk for abuse, addiction, or overdose) patch properly for Resident (R)10, per facility policy. This deficient practice created a risk for diversion, illicit use and accidental overdose.

Inspectors wroteThe facility reported a census of 44 residents. Based on observation and interview, the facility failed to prepare and serve food under sanitary conditions, for the residents of the facility.

Inspectors wroteThe facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly.

Inspectors wroteThe facility reported a census of 44 residents. Based on observation, interview, and record review, the facility failed to follow the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prevent transmission of the pandemic COVID-19 virus. The facility failed to ensure staff were answering screening questions appropriately at the beginning of the shift, failed to quarantine residents when a staff member tested positive for COVID-19 that previously worked two shifts with respiratory symptoms, allowed the facility staff to continue to wear cloth or surgical masks while the facility was in outbreak status (the occurrence of one or more resident and/or staff that test positive for COVID-19), and failed to have a policy in place to provide instruction on the steps the facility should take when an outbreak occurred. [...]

Inspectors wroteThe facility reported census of 44 residents, with 12 residents selected for review, which included one reviewed for discharge summary. Based on record review and interview the facility failed to complete a discharge summary which included a recapitulation of stay, reconciliation, and disposition of medications for the one sampled resident (R)44, as required.

Inspectors wroteThe facility reported a census of 44 residents with 12 selected for review including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure equipment was in proper working condition, failed to implement a new intervention following falls, failed to implement appropriate interventions following two falls for one of the three residents, Resident (R)16.

Inspectors wroteThe facility reported a census of 44 residents with 12 residents selected for review including two residents reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to keep the catheter tubing from touching directly on the floor for one of the two residents reviewed, Resident (R)38, creating a risk for developing urinary tract infections.

Inspectors wroteThe facility reported a census of 44 residents with 12 selected for review including three residents reviewed for respiratory services. Based on observation, record review, and interview, the facility failed to provide appropriate cleaning and storage of two of the three sampled residents respiratory equipment including, Resident (R)34's nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) administration kit. R13 with the facility failure to clean the oxygen concentrator filter, failed to label the oxygen tubing when changed, and failed to label the distilled water container when opened and store appropriately. These practices increased the risk for R34 and R13 of developing a respiratory infection.

Inspectors wroteThe facility reported a census of 44 residents with 12 selected for review including five reviewed for unnecessary medications. Based on record review and interview, the facility failed to act upon recommendations timely from the consultant pharmacist for three of the five sampled residents, Resident (R)11, R16, and R27.

Inspectors wrote- Resident (R) 11's Medication Review Report, dated 04/10/21, included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R11 with a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. He received insulin injections six of the seven days of the assessment period. A standing physician order, dated 05/17/19, instructed the facility staff to contact the physician if the blood sugar was greater than 300. The Medication Review Report, dated 04/10/21, included an order with a start date of 03/23/21 for Novolog (insulin) flexpen solution, 100 unit/milliliter (ml) per sliding scale, inject 30 units subcutaneous with meals for diabetes mellitus. [...]

Inspectors wroteThe facility reported a census of 44 residents with 12 selected for review including five reviewed for unnecessary medications. Based on record review and interview, the facility failed to ensure two of the residents, Resident (R)27 and R16 were free of unnecessary psychotropic medications when the facility failed to address their orders for psychotropic (class of medications capable of affecting the mind, emotions, and behavior) medications.