Villa Marina Health and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that an allegation of misappropriation of money was thoroughly investigated for 1 of 2 residents (R) reviewed (R63) out of 5 sampled residents. On 05/15/26, the facility was made aware of R63's allegation of missing money. The facility did not complete interviews with all staff and residents to ensure a thorough investigation into the allegation. This is evidenced by:Facility's policy titled Resident Abuse- Prevention/Investigation with the revised date of February 2026, documented 1. The Administrator, Director of Nursing/Charge Nurse and/or the Social Worker will conduct an in-depth investigation, when the initial investigation determined that misconduct did occur or is still suspected. Interviewing other residents to determine if they have been abused or mistreated. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure to accurately code the Minimum Data Set (MDS) assessments for 1 of 5 sampled residents (R) reviewed. (R54) The facility did not complete a discharge MDS when R54 was discharged from the facility on 04/03/26. This is evidenced by:The facility policy titled MDS Completion and Submission Timeframes with the revised date of September 2010 documented The Assessment Coordinator or Designee shall be responsible for entering that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guideline. Discharge Assessment - return not anticipated: [...]

Inspectors wroteBased on record review and interview, the facility did not conduct a Preadmission Screening and Resident Review (PASRR) Level II screen for R9, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure they receive care and services in the most integrated setting appropriate to their needs. The facility practice affected 1 of 1 resident reviewed (R9) out of 5 sampled residents.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately to other officials including the State Agency (SA) in accordance with State law through established procedures for 1 of 3 sampled residents (R). (R1)The facility did not report R1's injury of unknown origin within two hours, as the allegation involved potential abuse. The facility did not submit the misconduct incident reportwith investigation findings for R1 within five business days of discovery of the incident. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a thorough investigation of the alleged violation, maintain documentation that an alleged violation was thoroughly investigated, and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation of an alleged violation is in progress for 1 of 3 residents (R) reviewed. (R2)The facility did not update R2's physician regarding the allegation of sexual misconduct by staff. The facility did not suspend accused staff of making inappropriate sexual statements while the investigation was being conducted. The facility did not re-educate staff regarding abuse/misconduct policies and procedures following the incidents for R2. The facility policy dated 10/15/17, titled, Resident Abuse-Prevention/Investigation, indicates: .2. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not prepare, distribute and serve food in accordance with professional standards for food service safety for 64 of 64 residents resulting in possible contamination of all residents' food. Facility staff did not wear gloves during preparation and serving of food,Facility staff did not perform hand hygiene and don new gloves after touching contaminated surfaces. This is evidenced by:The facility policy titled, Handling Raw Foods, updated 06/25/2012, states in part, Plastic food service gloves will be worn .when hands will be in direct contact with food and for preparing food to eat .Single use gloves will be used for only one task, used for no other purpose and discarded when damaged, soiled or interruptions occur in operation. Regulations also state in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. This had the potential to affect 9 of 64 residents. (R3, R32, R14, R43, R48, R58, R12, R46 and R51) Staff did not perform hand hygiene during water pass and in between residents. This had the potential to affect 7 of 7 residents (R) observed during water pass (R3, R32, R14, R43, R48, R58, R12). Staff did not maintain a clean environment during dressing change. This had the potential to affect 1 out of 2 residents (R) observed for wound care (R46). [...]

Inspectors wroteBased on record review and interview, the facility did not provide Notice of Bedhold, Notice of Transfer and/or did not notify the Ombudsman of a resident who was transferred from the facility to a hospital for 3 of 4 residents (R) (R4, R11 and R76). Evidenced by:The facility provided Surveyor with a one-page document titled Notice of Transfer or Discharge, which is a blank document that is provided to the residents/resident representatives upon transfer or discharge that explains the reason for transfer/discharge and an area for resident/representative signature and indicated this was the facility's policy. On 05/15/25, R76 was admitted to the facility and discharged home on [DATE]. R76 received a Notice of Transfer, but the Ombudsman was not notified of the discharge. On 08/04/25, R11 was admitted to the facility and discharged home on [DATE]. [...]

Inspectors wroteBased on observation and interviews, the facility did not ensure they distributed and served food in accordance with professional standards for food service safety. Facility did not take temperatures of food served to residents from the anytime menu; this had the potential to affect 3 residents (R9, R58, and R65) out of 70. The temperature log was not completely filled out; this has the potential to affect all 70 residents. Temperatures of beverages served were not being done; this has the potential to affect all 70 residents.

Inspectors wroteBased on interview and record review, the facility did not describe building water systems using a flow diagram where legionella and other opportunistic waterborne pathogens can grow and spread. This has the potential to affect all 70 residents in the facility. This is evidenced by: The facility policy, entitled, Water Management Program to Reduce Legionella Growth & Spread, indicates, in part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella . 1. Legionella can grow in parts of building water systems that are continually wet ., and certain devices can spread contaminated water droplets via aerosolization. 2. Legionellosis outbreaks are generally linked to locations where water is held or accumulates and pathogens can reproduce . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain confidentiality of resident medical record information for 4 of 7 sampled and supplemental residents (R) (R55, R25, R70, and R1) reviewed. This is evidenced by: Surveyor requested and reviewed the facility policy titled Security of Medication Cart dated April 2007. The policy in part reads: ~2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart doors and drawers should be facing the resident's room . Surveyor requested and reviewed the facility policy titled Annual HIPAA Privacy and Security Training dated 2014. The training document in part reads: ~indicates that staff should make HIPAA Compliance a daily habit by locking computers when stepping away from staff's desks and turning over sensitive documents when stepping away . [...]

Inspectors wroteBased on interview and record review, the facility failed to follow procedures that prohibit and prevent abuse, neglect, and exploitation of residents. The facility did not perform a Wisconsin background check for a staff member that has direct contact with residents and works in a Wisconsin facility. This was found for 1 of 8 staff members investigated for background check compliance.

Inspectors wroteBased on the interview and record review, the facility did not report 2 of 3 (R49, R33) potential misconduct incidents to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure activities of daily living (ADL) of grooming, personal hygiene, and oral hygiene were provided for 1 of 3 residents (R425) reviewed. This is evidenced by: The facility policy entitled, Activities of Daily Living (ADL), Supporting, stated in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. R425 was admitted to the facility on [DATE] with diagnoses including left femur fracture, diabetes, pressure ulcer left buttock and sacrum, chronic leukemia, and severe kidney disease with ileostomy. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a resident received treatment based on current standards of practice for Gastrostomy (G) tube for 1 of 2 residents (R) with a G-tube. (R1) Staff did not check for proper placement of R1's G-tube when providing treatment and administering nutrition via G-tube. This is evidenced by: Facility policy entitled Administering medications through Enteral Tube, no revision date known, stated in part, .Verify placement of feeding tube: If suspect improper tube positioning, do not administer feeding or medication, notify the charge nurse or physician . [...]

Inspectors wroteBased on observation and interview, the facility did not provide pharmaceutical services, including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, for 1 of 1 medication rooms reviewed. The facility did not accurately label open dates on 2 of 2 resident (R25 and R73) controlled medications observed stored in the refrigerator of the medication room. The facility did not ensure destruction of controlled medication occurred timely after resident (R73) passed away in the facility April 26, 2024.

Inspectors wroteBased on observation and interview, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and did not ensure only authorized personnel had access to medication carts. This occurred for 1 of 2 medication carts observed.