Villa Maria Post Acute and Rehabilitation

Inspectors wroteBased on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure adequate supervision to prevent one of one sampled resident (Resident #1) from eloping the facility while a Peripherally Inserted Central Catheter (PICC) line remained in place. The deficient practice could place the resident at risk for interruption of prescribed intravenous therapy, catheter-related infection, misuse of the PICC line, overdose, and death. Findings Include: Resident #1 was admitted on [DATE], and discharged on May 18, 2026, with a diagnosis that included cellulitis of the left lower limb, muscle weakness, abnormalities of gait and mobility, assistance with personal care, hypokalemia, opioid abuse, and depressive disorders. [...]

Inspectors wroteBased on the interview, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure PASSAR screening and referral were accurate and completed for 6residents (#3, #5, #9, #13, #21, and #55). This deficient practice can result in residents medically related social and emotional needs not being met. The sample size was 8. The census was 56. -Regarding Resident # 9 Resident # 9 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with clinical diagnoses that included borderline personality disorder, post-traumatic stress disorder, chronic pain syndrome, insomnia, recurrent depressive disorders, other specified anxiety disorders, and factitious disorder imposed on self, with predominately physical signs and symptoms. [...]

Inspectors wroteNumber of residents sampled: 15Number of residents cited: 2Universe: 56Based on review of records, staff interviews and review of policy and procedures, the facility failed to ensure that timely care and services, including physician notification and a physician order for oxygen, were provided upon a change of condition for one resident (#50). The deficient practice could lead to a medical decline and/or physical harm of a resident.

Inspectors wroteBased on observations, interviews, facility documentation and policy, the facility failed to ensure that safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances for two of three medication carts sampled. The deficient practice could result in inventory loss and potential diversion. An observation of the 100 Medication Cart narcotic reconciliation log was conducted on January 20, 2025 at 2:52 p.m., and reviewed with with Licensed Practical Nurse (LPN/Staff #45),who revealed the missing nurse signature entries on 6 shifts from January 1-19, 2026, were not supposed to be left blank. [...]

Inspectors wroteBased on clinical record review, interviews, facility documentation and policy, the facility failed to ensure the clinical record for one resident (# 9), contained an accurate representation of the actual experiences of a resident with an allegation of resident to resident abuse, and was accurate, complete and readily available for one resident (#50). The deficient practice could result in records that do not accurately and completely reflect the care and services provided to residents.

Inspectors wroteBased on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure insulin was administered according to provider instruction for one resident (#5). This deficient practice could result in side effects leading to negative resident outcomes. The sample size was 5. The universe was 56.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2). The deficient practice could result in further resident abuse.

Inspectors wroteBased on clinical record review, interviews, and policy review, and the State Agency (SA) complaint tracking system, the facility failed to ensure that one resident (#1) received treatment and care in accordance with professional standards of practice by failing to call a provider and emergency services in a timely manner. The deficient practice has the potential of the resident suffering from a life-threatening medical event.

Inspectors wroteBased on clinical record review, staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to provide care and services related to a peripherally inserted central catheter (PICC) line resulting in the hospitalization for one resident (#75). The deficient practice resulted in complications related to the PICC line not being removed.

Inspectors wroteBased on staff and resident interviews, clinical record review, facility records and facility policy, the facility failed to ensure that three residents (#2, 6, 8) were provided catheter related care as ordered. Failure to ensure that a physician's orders are implemented and failure to ensure care was provided can lead to increased risk of and late detection for urinary tract infections (UTIs) and other adverse effects.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#114) or their representative have the ability to request, refuse, or discontinue treatment. The census was 57. The deficient practice could result in residents receiving services which are not in accordance with their wishes.

Inspectors wroteBased on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one sampled resident's (#41) clinical record included the required information for transfer/discharge. The deficient practice could result in residents not having a safe and effective transition of care.

Inspectors wroteBased on review of the clinical record, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one section (O) of a Minimum Data Set (MDS) assessment for one sampled resident (#41) included that the resident is on oxygen. The deficient practice could result in residents not receiving the required care and services for an oxygen dependent resident.

Inspectors wroteBased on clinical record review, staff interviews, and policy, the facility failed to ensure one resident (#34) had a PASARR (Pre-admission Screening and Resident Review) Level I completed.

Inspectors wroteBased on observations, clinical record review, resident interview, staff interviews, and review of facility policies, the facility failed to ensure that one resident (#37) received adequate supervision to prevent medication accidents and that one resident (#41) received neurological checks after an unwitnessed fall. The deficient practices could result in resident #37 sustaining medication accident-related injuries and life-threatening injuries for resident #41.

Inspectors wroteBased on clinical record review, observations, resident and staff interviews, and review of facility policy and procedure, the facility failed to follow physician's orders prior to the administration of oxygen for one resident residents (#41).

Inspectors wroteBased on observation, clinical record reviews, resident and staff interviews and policy review, the facility failed to ensure pain management was provided to two residents (#37 and #115) consistent with professional standards of practice and the resident's goals and preferences.

Inspectors wroteBased on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 54. The deficient practice has the potential to negatively affect resident care.

Inspectors wroteBased on observation, clinical record reviews, staff interviews and policy review, the facility failed to ensure that a resident's wound care was conducted in accordance with current standards for 1 resident (115).

Inspectors wroteBased on clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure 3 residents (#34, #26, and #152) consistently received treatment and services consistent with professional standards of practice. The sample size was 3. The deficient practice could result in delayed healing of pressure ulcers.

Inspectors wroteBased on resident and staff interviews, facility documentation, and review of policy and procedures, the facility failed to ensure there was adequate staffing to meet the needs of the residents. The deficient practice increases the risk for residents' needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure a Level II PASRR (Preadmission Screening and Resident Review) evaluation and determination was completed for one resident (#13). The sample size was 4. The deficient practice could result in specialized services not being provided and needs not being met for residents with mental disorders.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#29) was administered an anticoagulant medication in accordance with the physician order. The sample size was 5. The deficient practice could result in adverse effects for residents.

Inspectors wroteBased on resident and staff interviews and clinical record review, the facility failed to ensure one resident (#10) received catheter care and services in accordance with professional standards of practice. The sample size was 2. The deficient practice may increase the risk for urinary tract infections (UTI).

Inspectors wroteBased on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that one resident (#12) was administered medications according to the parameters as ordered by the physician. The sample size was 5. The deficient practice could result in residents receiving unnecessary drugs.

Inspectors wroteBased on clinical record, staff interview, and policy review, the facility failed to consistently obtain PT/INR (prothrombin time/international normalized ratio) as ordered by the physician for one sampled resident (#12). The deficient practice could result in delayed treatment.