Villages Healthcare and Rehabilitation Center, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who require nephrostomy services receive such care consistent with professional standards of practice for 1 (Resident #2) of 3 residents reviewed for indwelling catheter care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in a manner that maintains each residents' dignity for 1 of 7 residents, Resident #2, reviewed for personal clothing.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received post operative care per the physician's orders for 1 of 3 residents, Resident #1, reviewed for wound care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the recurrence of pressure ulcers for 1 of 3 residents, Resident #2, reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to recognize, evaluate, and address the needs of residents, including but not limited to, residents at risk or already experiencing impaired nutrition, for 3 of 5 residents, Residents #1, #2, and #7, reviewed for nutrition and weight loss. Findings Include: 1) Review of Resident #1's medical record documented an admission date of 5/09/2025, with medical diagnoses that included displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing and unspecified severe protein-calorie malnutrition Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] documented under Section C - BIMS [Brief Interview for Mental Status] Score 09 = moderate cognitive impairment. Section K - Feeding tube; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the possible spread of infection via indwelling urinary catheters for 1 of 3 residents, Resident #2, reviewed for urinary catheters. Findings Include: During an observation on 12/11/2025 at 2:10 PM, Resident #2 was dressed in a hospital-style gown, lying on his back in bed. The Resident's urinary catheter collection bag was lying on the floor. Review of Resident #2's care plan dated 09/15/2025 read, Focus: Baseline Care Plan: Resident has a urinary catheter. Date initiated: 09/15/2025. Interventions: Resident has a urinary catheter in place and needs the following care: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs, specifically without adequate monitoring or adequate indications for use, in 1(Resident #1) out of 3 residents reviewed for unnecessary pain medications.

Inspectors wroteBased on interview and record review, the facility failed to notify the provider for 1 of 3 residents, Resident #2, reviewed for change in condition and transfer.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to prevent the possible spread of infection by failing to ensure staff performed hand hygiene during medication administration for 2 of 2 residents, Residents #11 and #12, reviewed for medication administration.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure proper hydration for 1 of 3 residents, Resident # 363.

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer enteral nutrition for 1 of 3 residents, Resident #92, and fluids as ordered for hydration and water flushes as order by the physician.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 2 of 4 residents, Resident #36 and #363, reviewed for oxygen therapy. Findings Include: 1) During an observation on 05/05/25 at 09:55 AM, Resident #36 was observed lying in bed wearing nasal cannula (NC) with oxygen being administered at 3 liters/minute (l/min). There was no date on the oxygen tubing. Review of the electronic medication administration record (MAR) read, Change, date oxygen tubing and bag weekly every Thursday midnight shift every night shift every 7 day(s) Wash concentrator air filters with soap and water weekly on Thursday midnight shift, be sure oxygen in use sign is on the door. Start Date 05/03/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain the kitchen equipment in a clean and sanitary manner for 3 of 4 nourishment rooms. Findings Include: During an observation on 5/5/25 beginning at 9:28 AM with the Assistant Dietary Manager showed at 9:54 AM in the 500 Hall nourishment room, there were brown and red splattered substances on the interior base of the freezer. There was an orange sticky substance splattered on the inside walls of the microwave. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain complete and accurately documented medical records for 2 of 5 residents, Residents #365 and #363, reviewed for medication administration and unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prevent the possible spread of infection by failing to adhere to posted infection control signage and standards of practice, failing to maintain hand hygiene during medication administration, failing to maintain hand hygiene during wound care, and failing to handle and store tube feeding products per the manufacturer's recommendations. (Photographic evidence obtained)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly labeled or discarded upon expiration, failed to ensure test strips were not expired, and failed to ensure the kitchen environment and equipment were kept clean (Photographic evidence obtained).

Inspectors wroteBased on record review and interview, the facility failed to conduct a comprehensive assessment in a timely manner for 1 of 5 residents reviewed for unnecessary medications, Resident #146.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure PICC (Peripherally Inserted Central Catheter) line dressing was changed for 1 of 1 resident with PICC line, Resident #69.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety and maintain kitchen equipment in a clean and sanitary condition in the main kitchen and 4 of 4 neighborhood kitchens, potentially affecting all 114 residents, and the facility failed to serve food in accordance with professional standards for food service safety in 1 of 2 neighborhoods observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles in 3 of 6 medication carts reviewed, and the medications were not left unattended in the resident rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene and cleaned the needleless connectors of midline catheters during medication administration in 7 of 9 observations of medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with an indwelling urinary catheter were assessed for removal of the urinary catheter or had an appropriate diagnosis for catheterization for 1 of 3 residents reviewed, Resident #96.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care services were provided in accordance with professional standards of practice for 1 of 2 residents reviewed for oxygen administration, Resident #17.