Epworth Villa Health Services

In the surveyor’s words

From the most serious findings on record at Epworth Villa Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 8, 2025

  On 05/08/25, a past non-compliance Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to provide supervision to protect residents with exit seeking behaviors. Resident #1 had exit seeking behaviors and exited the facility on 04/28/25. Resident #1 was located by security to be lying on the ground on the sidewalk outside of one of the exit doors from household #3. Resident #1's care plan did not address elopement. Based on observation, record review, and interview, the facility failed to provide supervision and interventions to prevent elopement for 1 (#1) of 3 sampled residents reviewed for wandering and elopement. The administrator identified 70 residents resided in the facility and Resident #1 was the only resident able to walk independently. […]

• Actual harm, isolatedF697Jul 26, 2022

  Based on record review, observation and interview the facility failed to ensure a Resident was provided pain medication for complaints of pain during the provision of wound care for one (#28) of three sampled Residents who were reviewed for pain management. Resident #28 stated they were in pain before and during incontinent care and wound care, when asked by LPN #1 and CNA #1. Resident #28 moaned and cried out Oh and Ow several times during incontinent care and wound care and stated, Someone is hurting me. The staff did not stop the incontinent or wound care, asssess and intervene for Resident #28's pain. Resident #28 recieved pain medicaiton one hour and 29 minutes after the first complaint of pain. […]

• No harm, potential for more than minimal, patternF684Jul 26, 2022

  Based on record review, observation , and interview the facility failed to ensure physician's orders were followed for treatments related to [CONDITION(S)] and pressure ulcer prevention for one (#28) of two sampled residents who had pressure ulcers and one sampled resident who had [CONDITION(S)]. The Resident Census and Conditions of Residents documented eight residents had pressure ulcers. The DON identified seven residents who had [CONDITION(S)]. Findings: Resident #28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for [CONDITION(S)], dated 02/10/22, read in parts, .I will .have decrease in [CONDITION(S)] in the next 90 days . […]

• No harm, potential for more than minimal, patternF880Jul 26, 2022

  Based on record review, observation and interview, it was determined the facility failed to have system in place to ensure employees consistently screened for COVID-19 symptoms prior to starting their shift for five of five employees reviewed for COVID-19 screening. The Resident Census and Conditions of Residents documented 63 residents resided in the facility. Findings: An undated facility policy titled, COVID-19 Employee Protocols, pages 4 and 5, read in parts, .Screening .All employees, regardless of what area they work, must screen prior to working in the community .compliance with screening is monitored by the supervisor/leadership of each department with random audits by leadership Upon entrance to the facility on each day of the survey a screening station was observed at the… […]

• No harm, potential for more than minimal, isolatedF689Aug 6, 2026

  Based on observation, record review, and interview, the facility failed to ensure two staff members were present when a mechanical lift was used for transfers to prevent a laceration for 1 (#53) of 3 sampled residents reviewed for lifts. The administrator identified 12 residents required the use of a mechanical lift for transfers. Findings: On 08/04/26 at 1:54 p.m., Resident #53 was observed setting in a wheelchair with a lift sling under them out in the common area in front of a television. There were two pillows observed under their feet. The bed in the room of Resident #53 was observed to have a draw sheet and a crocheted blanket. […]