Villa Maria Nursing Center

Inspectors wroteBased on observation, record reviews and interviews, the facility neglected to provide a secure environment for one (Resident #1) out of three sampled resident that displayed exit seeking behaviors and intent of elopement. As evidenced by cognitively impaired Resident #1 whose diagnoses include Dementia, and unsteady gait exited the facility undetected by staff on 8/04/2025 at 4:24 PM and ambulated 0.7 miles from the facility in temperatures that temperature ranged between a high of 92 degrees and a low of 80 degrees Fahrenheit according to AccuWeather, and was found by law enforcement at 4:46 PM wandering in a neighborhood that has high traffic volume and busy intersections. [...]

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to provide a secure environment that with adequate supervision and an effective monitoring system; for one (Resident #1) out of three sampled residents that displayed exit seeking behaviors and intent of elopement; as evidenced by: 8/04/2025 at 4:24 PM Resident #1 who is impaired cognitively with diagnoses of Dementia and unsteady gait left the facility undetected by staff and was found at 4:46 PM on 8/04/25 by law enforcement 0.7 miles from the facility wandering in a neighborhood that has high traffic volume and cross streets this deficient practice increased the risk for the resident to be hit by an automobile that could have resulted in the likelihood of an adverse outcomes, sustained serious injury, serious harm or death. [...]

Inspectors wroteBased on observations, record reviews and interviews the facility's administration failed to implement, provide and ensure an effective and efficient preventative measures were in place to prevent the neglect and elopement of one resident (Resident #1) out of three sampled residents who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included failure to ensure residents were not able to leave the premise of the facility and failure by staff to implement assigned level of supervision for resident #1 who was a high risk for elopement. These deficient practices enabled resident #1 to exit the facility undetected at 4:24 PM through an electronic gate in the front of the facility on foot on 8/04/25 placing the resident at risk for harm and or injury. There were 191 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interviews, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to adequate supervision resulting in repeated deficient practice. The facility's history includes deficient practice for failing to supervise residents resulting in possible accidents. The facility was cited for Free of Accident Hazards, Supervision, Devices, Administration and Quality Assurance and Assessment on July 31, 2025. On 8/04/2025, the facility was negligent and failed to provide adequate supervision and effective services to prevent the elopement of one (Resident #1) out of three sampled residents with exit seeking behaviors, resulting in Resident #1 eloping from the facility at 4:24 PM, through an electronic gate in the front of the facility on foot undetected. [...]

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to ensure one (Resident #72) out of the eleven residents that eat independently had a dignified dining experience. As evidence by during the lunch meal in the dining room Resident # 72 did not receive a meal tray while the table mate had received her meal and had started eating.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to ensure a sanitary clean homelike environment as evidenced by six resident areas observed unsanitary and in disrepair on the facility's third floor (North Unit and East Unit).

Inspectors wroteBased on observation, interview and record review, the facility failed provide a safe environment in accordance with the facility's policy related to accident hazards for two vulnerable residents (Resident #10 and Resident #73) out of five sampled residents; as evidenced Resident #10 who is at risk for falls was observed in bed with the right-side floor mat positioned against the wall, presenting a potential safety hazard and an unattended open container with disinfecting wipes with ingredients that pose serious health and safety risks observed on Resident #73's bedside table.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for one (Resident #44) out of one resident who has a primary diagnosis of acute respiratory failure. As evidenced by observations of Resident # 41's Nasal Canula not in the resident's nostrils increasing the resident's risk for respiratory distress.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to demonstrate that effective actions were implemented through its Quality Assurance and Performance Improvement (QAPI) program to correct previously identified quality deficiencies under F550 (Resident Rights) related to failing to ensure Resident # 72 had a dignified dining experience, as evidenced by Resident #72 was not provided with a meal tray in a timely manner while her table mate was served and had started eating.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure infection control standards and procedures were followed for two out of two residents (#25 and Resident #201) sampled for tube feeding. As evidenced by enteral feeding caps were noted stored uncovered on Resident #25 bedside chair and Resident #201's enteral feeding tube line open stored with the open end uncapped.

Inspectors wroteBased on observation, interview and records reviewed, the facility failed to ensure a safe environment endangering the life of all occupants in the facility. The facility failed to maintain the Fire Alarm system and failed to maintain the faulty fire panel. These deficient practices places all occupants of the facility at risk for smoke inhalation, serious burns, or death in the event of fire. The facility also failed to notify the residents and their representatives of the system failures. These findings resulted in the determination of Immediate Jeopardy that started on January 5th, 2024.

Inspectors wroteBased on interview and record review facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. This deficiency had the potential to affect 197 residents residing in the facility, staff, and visitors at the time of survey.

Inspectors wroteBased on observations, interview and record review facility failed to ensure dignity for a one resident (Resident #175) with an indwelling catheter out of 10 residents sampled as evidenced by the resident's urinary drainage collection bag not fully covered.

Inspectors wroteBased on interview and record review, facility failed to electronically transmit the Discharge- Return Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 159) out of four residents who were discharged to a short-term general hospital.

Inspectors wroteBased on Interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for three residents (Residents # 86, # 29 and #166 ) out of three resident's whose MDS assessments were reviewed at the time of survey.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide a safe environment by following physician orders to place floor mats for four residents ( #36, #71, #23 and #171) out of four residents reviewed for fall precautions. As evidenced by the Residents had a physician's order for bilateral floor mats while in bed and they were not in place.

Inspectors wroteBased on observation, interview and record review the facility failed to provide care and services for central venous access devices in accordance with professional standards of practice for 2 out of 2 residents with midline catheters ( Resident #167 and #458) out of a a total sample of 54 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on record review and interview the facility failed to ensure a minimum data set (MDS) assessment was completed in a timely manner for 1 resident, Resident #152, of 4 residents reviewed for timely submission of the MDS.

Inspectors wroteBased on record review and interview the facility failed to accurately document the dental status of one resident (Resident #59) out of two sampled for dental the discharge status for one (Resident #199) out of four residents sampled for discharge status review.

Inspectors wroteBased on observation, interview and record review the facility failed to follow accepted infection control practice standards for intravenous medication administration in 2 out of 2 observations of intravenous medication administration out of a total of 6 medication administration observations.

Inspectors wroteBased on record review and interview the facility failed to ensure the arbitration agreements presented to 3 residents, Resident #55, Resident #124 and Resident #201, of 3 residents reviewed explicitly granted the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing the agreement.

Inspectors wroteBased on record review and interview the facility failed to ensure the arbitration agreements presented to 3 residents, Resident #55, Resident #124 and Resident #201, of 3 residents reviewed provided for the selection of a venue convenient to both parties.