Villa Maria Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled residents (Resident 83) had a qualified licensed nurse perform their initial comprehensive nursing assessment. This failure had the potential for Resident 83 to not have a complete initial comprehensive nursing assessment and not have all their needs met. During a review of Resident 83's admission Record (AR), dated 7/25/25, the AR indicated, Resident 83 was a [AGE] year old, admitted [DATE] with diagnoses including, heart failure (the heart not able to pump enough blood to meet the body's needs), atrial flutter (uncoordinated beating of the heart), diabetes (the body is not able to turn food into energy), and cognitive communication deficit (problems with communication). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sample residents (Resident 83), had a nursing note recorded in their medical record following the completion of the comprehensive assessment on admission to the facility. This failure resulted in an incomplete record of Resident 83's nursing home stay and had the potential to hinder communication among Resident 83's interdisciplinary team ([IDT], a group of healthcare professionals who work together to achieve resident comprehensive goals). During a review of the facility's policy and procedure (P&P) titled, Admission, dated 2/2023, the P&P indicated, Purpose. Obtain information about the resident to establish baseline data for the MDS and provide the basis for interdisciplinary assessment, care planning, and rehabilitation of each Resident. Licensed Nurses Procedure . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 6) had an appropriately sized waste bin for safely discarding used personal protective equipment (PPE), a gown worn over clothing for protecting the wearer from infection. This failure had the potential to result in the increased risk of spreading infection to residents, staff, and visitors. During an observation on 7/23/25 at 2:28 p.m. in Resident 6's room, there was a small, beige, uncovered, waste bin overflowing onto the floor with a discarded yellow PPE gown. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 1/2025, the P&P indicated, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure two of two sampled residents (Residents 72 and 49) had a comfortable environment when foul smelling dirty linen was left in the linen cart in the hallway. This failure resulted in an uncomfortable living environment. During a review of the facility's policy and procedure (P&P) titled, Environmental Conditions / Environmental Rounds, dated 1/2025, the P&P indicated, It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. During an interview on 7/23/25 at 10:15 a.m. with Resident 72, Resident 72 stated the smell out in the hallway gets really bad when staff put dirtied linen in the hamper and leave it there. Resident 72 further stated the staff should at least take it down to the end of the hallway. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when documentation of interventions for a change in condition were not accounted for. This failure had the potential to result in Resident 1 not receiving proper treatment during a change of condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Pasteurized eggs were used for egg preperations not cooked through completely according to the facility's policy and procedures (P&P). 2. Food was stored properly in accordance with professional standards of food service safety when an uncovered and undated bag of shredded mozzarella cheese was found in the refrigerator and an opened staff personal water bottle was stored in the freezer. 3. Resident food refrigerator temperatures located in the nursing station were monitored daily and corrective actions implemented for out-of-range temperature readings by the food and nutrition representative according to the facility's P&P on foods brought by family or visitor. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent for the use of psychotropic medications (medications which affects mood or behavior) for one of 20 sampled residents (Resident 37). This failure violated Resident 37's right to make an informed decision regarding the use of psychotropic medications and had the potential to result in resident misinformation regarding its benefits and side effects.

Inspectors wroteBased on interview and record review, the facility failed to complete and accurately document a Physician Order for Life Sustaining Treatment (POLST - care directives during life threatening situations) and Advance Directive (legal documentation consistent with the known requests or desires of the patient's medical preference) for two of 20 sampled residents (Residents 5 and 37). These failures had the potential to result in the delay of necessary treatment compatible with the legally recognized decision maker wishes during an emergency situation.

Inspectors wroteThis is the incorrect tag Based on observation, interview, and record review, the facility failed to follow their policy and procedure regarding loss or theft of resident property.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - a federally mandated process to help ensure that individuals are evaluated for a mental illness and/or intellectual disability and are not inappropriately placed in nursing homes for long term care) Level II evaluations (a person-centered evaluation that is completed for anyone identified by the Level I screening as having, or suspected of having serious mental illness, intellectual disability, developmental disability, or related condition) were completed for three of 20 sampled residents (Residents 15, 37 and 66) when: 1. A significant decline in Resident 15's mental health condition was assessed. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the State mental health authority was notified after a significant decline in the mental health condition of one of four sampled residents (Resident 15) was assessed. This failure had the potential to result in Resident 15 not receiving the necessary mental health care and services which had the potential to affect Resident 15's quality of life and resulted in the mental significant change of condition not having been properly screened/evaluated and reported to the state mental authority.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. A box of expired Povidone-Iodine prep pads. (antiseptic pads saturated with povidone iodine solution to help control bacteria and minimize infection) was discarded. 2. An opened vial of purified protein derivative (PPD - solution used in a skin test to help diagnose tuberculosis [a serious lung infection caused by bacteria]) solution was dated. 3. An open container of glucose test strips (used in a device to measure the amount of sugar in the blood) was dated. 4. Barium Sulfate (a contrast agent used to diagnose disorders of the esophagus, stomach and intestines) stored in the medication refrigerator had a documented physician order for specific resident use. These failures had the potential for the residents to receive expired, ineffective and unprescribed medications and treatments.

Inspectors wroteBased on observation and record review, the facility failed to: 1. Store Schedule II Drugs (schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) under double lock per facility's policy and procedure (P&P). 2. Sign the drug count sheet after administering medication per facility P&P. 3. Maintain refrigerator temperatures. These failures had the potential to result in (1) schedule II drugs being available to residents and visitors; (2) for drug diversion; and (3) medications to not be effective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement transmission-based precautions (infection control measures specific to how an infection is spread) for one of 20 sampled residents (Resident 5) when the resident was diagnosed with a known Multidrug Resistant Organism (MDRO - a germ that is resistant to many antibiotics). These failures had the potential to result in the spread of harmful microorganisms to staff, residents and visitors.

Inspectors wroteBased on interviews and record review, the facility failed to notify the resident representative (RR - person designated as being responsible for another person's medical and/or financial decisions) of one of two sampled resident (Resident 1) after a change of condition (CoC) when Resident 1 underwent debridement (removal of damaged tissue) on the sacrum (buttocks). This facility failure resulted in Resident 1's resident representative not being informed of their CoC or of the risks and benefits of the treatment options available to them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy for activities when: 1. One of eighteen sampled residents (Resident 59) was not observed in any activities during onsite four-day survey. 2. The activity director was not documenting activity pursuit patterns or activity attendance for any of the 75 residents in the facility. This failure has the potential for psychosocial and physical harm to all 75 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its medication error rate was less than five percent when: 1. Licensed Nurse 5 (LN 5) left medications intended for Resident 38 unattended on the medication cart. 2. LN 5 did not educate and provide Resident 38 water to rinse mouth out after inhalation of Ellipta powder medication. 3. LN 5 left Resident 38's medications unattended on bedside table and did not witness medication consumption. These failures resulted in a 10% medication error rate and had the potential for Resident 38 to have medication complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to store two boxes containing eggs inside of refrigerator and off the kitchen floor in accordance with professional standards of food safety for a total of 72 residents who received food from the kitchen. These failures had the potential to result in foodborne illnesses among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, and implement a person-centered activity care plan for one of 18 sampled residents (Resident 59). This failure had the potential for isolation, psychosocial and physical decline for Resident 59.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure physician orders were followed for one resident (Resident 38) when the resident did not rinse their mouth after receiving a medication via an inhaler. This failure had the potential to cause a fungal infection in Resident 38's mouth and throat.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) receiving the medication Apixaban (an anticoagulant or medication that prevents the blood from clotting) was monitored for complications and the monitoring documented in the resident's clinical record. This oversight failure had the potential to result in serious harm to Resident 278.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 278) was properly assessed for the continued use of the medication Quetiapine (brand name: Seroquel - a medication used to treat certain mental or mood conditions such as schizophrenia, bipolar disorder, and depression) as required by its policy and procedures on psychotropic (drugs that affect the brain and behavior) drug use. This failure resulted in Resident 278 receiving an unnecessary psychotropic medication which had the potential to result in serious complications from prolonged use without proper monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services policy and procedure (P&P) for medication disposal was followed when medication pills were observed inside a trash receptacle. This failure had the potential for misuse of medications and jeopardize residents' health and safety.