Villa Rosa Nursing and Rehabilitation, LLC

Inspectors wroteBased on record review and interview it was determined the facility failed to have a qualified full-time staff person to carry out food and nutrition services in the facility. This has the potential to affect all residents in the facility.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to conduct regular inspections of resident beds. This has the potential to affect all residents in the facility.

Inspectors wroteBased on observation and interview it was determined the facility staff failed to maintain a safe functional and sanitary environment. This was evident for 8 of 8 resident hallways observed on both floors of the facility.

Inspectors wroteBased on medical record review, and resident and staff interview, it was determined that the facility failed to include a copy of the written notification of transfer or discharge in the resident's medical record. This was evident for 1 (#4) of 3 residents reviewed for complaints.

Inspectors wroteBased on review of staff records and facility staff interviews, it was determined the facility failed to ensure that all nursing staff had competency skill evaluations. This was evident for 5 Geriatric Nursing Assistants (GNA) (GNA #2, GNA #3, GNA #6, GNA #7, GNA#18) of 5 GNA records reviewed.

Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety in the kitchen. This practice had the potential to affect all residents that eat food prepared by the facility's kitchen.

Inspectors wroteciteBased on interview and observation, it was determined that the facility failed to (1) implement measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water systems, and (2) ensure proper storage of clean linens. These deficiencies were identified during the Infection Control review conducted as part of the annual survey and have the potential to affect all residents.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to ensure 1) medication carts were locked and resident health information was protected. This was found to be evident for 2 out of 3 medication carts observed and 7 out of 29 opportunities to protect resident health information, 2) a physician order was implemented. This was found to be evident for 1 (Resident #2) out of 1 Resident reviewed for physician orders, 3) behavior monitoring was conducted. This was found to be evident for 3 (Resident #56, #12 & #66) out of 3 Residents reviewed for behavior monitoring, and 4) medication was properly administered. This was found to be evident for 1 (Resident #22) out of 1 Resident reviewed for medication administration. [...]

Inspectors wrotecite:Based on record review and interview, it was determined that the facility failed to educate and offer the COVID-19 immunization to residents. This was found to be evident for 4 (Resident #3, #6, #4 and #56) out of 5 Residents reviewed for vaccination status.

Inspectors wroteBased on observation, interviews, and record review it was determined that the facility failed to ensure an environment that promotes resident dignity. This was evident for 2 (Resident #56 and #61) of 2 residents observed for dignity during the recertification survey.

Inspectors wrotecite:Based on record review and interviews, it was determined that the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to resident who was discharged from Medicare Part A services but had benefit days remaining and intended to remain at the nursing facility receiving non-skilled care. This was evident for 1 resident (#11) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.

Inspectors wrotecite:Based on observation and interview, it was determined that the facility failed to ensure adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and safe environment. This was evident during the Infection Control review conducted as part of the annual survey. This deficiency has the potential to affect all residents.

Inspectors wroteBased on observations, interview and record review, it was determined that the facility failed to ensure that 1) an allegation of neglect was reported to the Office of Health Care Quality no later than 2 hours after the allegation was made. This was evident for 1 (Resident #61) out of 6 residents reviewed for neglect allegations and 2) to report the malfunction of the HVAC heating system to the State Agency the Office of Health Care Quality (OHCQ) in a timely manner. This was found to be evident for 1 out 8 Facility Reported Incidents (FRI) reviewed during the recertification survey.

Inspectors wrotecite:Based on record review and interview, it was determined that the facility failed to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. This was found to be evident for 1 (Resident #61) out of 6 residents reviewed for allegation of neglect.

Inspectors wroteBased on record reviews and facility staff interview, it was determined that the facility failed to ensure 1) the resident/resident representative received the bed hold notification form in writing. This was evident for 1 (resident #79) of 2 residents reviewed for transfers during the recertification survey and 2) the local ombudsman was notified of facility discharges. This was evident for 2 (Residents #76 & #80) of 2 residents reviewed for discharges during the recertification survey. The facility implemented effective and thorough corrective measures after discovering the delay in ombudsman reporting prior to the start of this survey. Therefore, this deficiency was found to be past noncompliant with a compliance date of [DATE]. The findings Include: [...]

Inspectors wroteBased on review of records and interviews, it was determined that the facility failed to ensure a comprehensive care plan was developed and implemented for 1 (Resident #7) out of 1 residents reviewed for care plans during the recertification survey.

Inspectors wroteBased on interview and record review it was determined that the facility failed to ensure a resident was provided quarterly care plan meetings. This was evident for 3 (Resident#35,# 8 and #1) out of 26 Residents reviewed for care plan meetings during the recertification survey.

Inspectors wroteBased on medical record reviews, observations and interviews it was determined that the facility staff failed to follow procedures during wound care to a resident with a pressure ulcer. This was evident for 1 (#22) out of 5 residents reviewed for pressure ulcer care during the recertification survey.

Inspectors wrotecite:Based on medication administration observation, medical record review, and staff interviews, it was determined that licensed facility staff failed to maintain a medication error rate of less than five percent during the medication pass observation. This was evident for 2 Residents (#85 and #16) of 10 residents observed. A total of 29 medication administration opportunities were reviewed, resulting in a medication error rate of 10.34%.

Inspectors wroteciteBased on observation and staff interviews, it was determined that the facility failed to properly store medications, as evidenced by medications not being properly labeled or dated. This was evident in 1 of 2 medication rooms and 4 of 4 medication carts observed during the recertification and complaint survey.

Inspectors wroteBased on review of resident medical records and facility staff interviews, it was determined the facility failed to maintain an accurate medical record. This was evident for 1 (Resident #56) of 1 resident reviewed during the annual recertification survey.

Inspectors wroteBased on observations, interviews, and record reviews it was determined that the facility failed to ensure the environmental equipment was functional. This was found to be evident for 2 out of 2 Solariums observed during the recertification survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide residents with reasonable accommodations of needs. This was found evident of 5 (Resident #18, #11, #66, #81 & #2) out of 62 residents reviewed.

Inspectors wroteBased on observations and facility staff interview it was determined the facility failed to maintain a safe, clean and comfortable home like environment free of possible hazards. This was evident for 5 residents ( # 40, #67, #24, #85, & #542) out of 62 residents observed for home like environment and 4 out of 6 shower and bathing environments observed in the facility.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to timely report an allegation of abuse to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours after the abuse allegation was made. This was evident for 5 (Resident #57, #34, #93, #51, and #19) out of 30 residents reviewed for facility self-report incidents during an annual survey.

Inspectors wroteBased on record review, and interviews, it was determined that the facility failed to: 1) thoroughly investigate alleged violations of abuse, and 2) prevent further potential of abuse while an investigation was in process. This was found evident of 6 (Resident #91, #108, #2, #19, #93, & #21) of 30 residents investigated for Facility Reported Incidents(FRI).

Inspectors wroteBased on interviews and medical record review it was determined the facility failed to provide notification to the Ombudsman and the Responsible Party of the residents that transferred to the hospital. This was evident for 7 residents (#19, #44, #6, #41, #62, #71, and #40) out of 7 residents reviewed for hospitalizations.

Inspectors wroteBased on medical record review and staff interviews, it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 4 (#41, #62, #71, and #40) of 7 residents reviewed for hospitalizations during the annual survey.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a baseline care plan was created within the required 2 days and ensure a written summary of the baseline care was provided to the resident/resident representative. This was evident for 4 Residents (#542, #41, #58, and #71) out of 62 residents in the survey sample.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for: 1) residents with a history of seizure disorder currently taking medication for the condition, 2) a resident prescribed opioids for pain relief, and 3) a resident's pressure ulcer and a fungal skin infection. This was evident for 4 residents (Residents #60, #65, #96 and #64) out of 62 residents with care plans reviewed during the annual survey.

Inspectors wroteBased on record review and interviews with staff, it was determined that the facility failed to ensure care plans were reviewed and revised after 1) a resident's hospitalization and quarterly assessment and 2) a resident whose medication for depression was discontinued. This was found to be evident for 2 residents ( Res. #60 and Res. #64) out of 8 residents reviewed for care plans during the annual survey.

Inspectors wroteBased on observation, medical record review and interview, it was determined that the facility failed to provide on-going personalized activities to meet the resident's needs and failed to inform or offer a resident the opportunity to attend facility activities. This was evident for 4 (Resident #34, #60, #65, & #542) out of 6 residents reviewed for the personalized activities during the annual survey.

Inspectors wroteBased on employee record reviews and interviews it was determined that the facility failed to ensure that the required Geriatric Nursing Assistant performance reviews were completed. This was evident in 4 out of 4 Geriatric Nursing Assistants (GNA) #6,12, 23 and 24 employee files reviewed for required performance reviews.

Inspectors wroteBased on observation and interviews, it was determined that the facility staff failed to ensure the safety of food products and food service areas. This was evident for food storage areas reviewed during an annual survey.

Inspectors wroteBased on employee record reviews and interviews it was determined that the facility failed to ensure that the required in-service training for Geriatric Nursing Assistants was completed. This was evident in 2 (Geriatric Nursing Assistants (GNA) #23 and #24) out of 4 employee files reviewed for required in-service training records.

Inspectors wroteBased on observation, record review, and interview with residents and staff it was determined that the facility failed to maintain and enhance the dignity of residents. This was evident for 1 (Resident #81) out of 3 residents reviewed for dignity during the annual survey.

Inspectors wroteBased on observation, record review, and interview with staff it was determined that the facility failed to support resident choices. This was evident for 2 (Resident #85 and #542) out of 4 residents reviewed for choices during the annual survey.

Inspectors wroteBased on observation, record review, and interview with staff, it was determined that the facility failed to protect a resident, who was dependent on staff for turning and repositioning, from falling out of bed during care. This was evident for 1(Resident #65) of 1 resident reviewed during the annual survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility staff failed to initiate appropriate bladder and bowel interventions to maintain dignity for (Resident #85). This was evident for 1 of 61 residents reviewed during an annual survey.

Inspectors wroteBased on observations, interviews and medical record review it was determined that the facility failed to label and store medications appropriately. This was evident in 1 (Resident #27) out of 1 Resident for medication labeling and storage.

Inspectors wroteBased on record review and interview with residents and staff, it was determined that the facility failed to ensure a resident requesting dental services received a timely appointment. This was evident for 1 (Resident #60) out of 2 residents investigated for dental services during the annual survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure medical records were complete by voiding old MOLST forms when new MOLST forms were completed. This was evident for 1 (Resident #60) of 62 residents reviewed during the annual survey.

Inspectors wroteThe facility failed to ensure that a staff member implemented appropriate processes related to handling and storing of a shared resident medical equipment. As a result, the potential existed for transmission of organisms between residents who received assessments of their blood pressure during medication observation. This was evident for 2 Residents (#2 and #68) of 5 observed during medication administration.

Inspectors wroteBased on observation and interview, it was determined that the facility staff failed to maintain an adequate functioning call system in resident bathrooms. This was evident for 2 (Resident #85 and #542) of 62 residents reviewed during the annual survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that a handrail was secure. This was found to be evident for 1 out of 5 handrails tested during the annual survey.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of a pest in the hallway. This was found to be evident for the 1B hallway.

Inspectors wroteBased on record review, and interviews it was determined that the facility failed to accurately assess a resident. This was found evident of 1 (Resident #96) out of 62 residents reviewed during an annual and complaint survey.

Inspectors wroteBased on record review, and interviews it was determined that the facility failed to accurately dispense and record medications as per scheduled ordered time. This was found evident of 1 (Resident #103) of 5 Residents reviewed for pain management.