Imperial, A Villa Center

In the surveyor’s words

From the most serious findings on record at Imperial, A Villa Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Nov 29, 2021

  Based on observation, interview, and record review, the facility failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control and Prevention (CDC) guidance and professional standards of practice, while caring for residents who were confirmed to be Covid-19 (a highly contagious and severe respiratory infection disease) positive or suspected Persons Under Investigation (PUI) for being positive of Covid-19, affecting 10 Residents (R600, R601, R602, R603, R604, R605, R606, R607, R608 and R609) and up to an additional 38 residents (totaling 48 residents) who resided on the memory care unit. […]

• Immediate jeopardy, isolatedF689Oct 23, 2025

  This citation pertains to Intake 2648112. Based on observation, interview, and record review, the facility failed to identify elopement risk and implement interventions to safeguard one (R901) of one resident, resulting in R901 exiting the front door of the facility on 9/8/25 and again on 10/11/25 without staff awareness of the resident's whereabouts. The Immediate Jeopardy (IJ) was identified on 9/8/25 at 4:08 PM, as a result of failure to identify an elopement risk resident and implement interventions to prevent further elopement leading to a second time exiting the facility and the likelihood of other residents affected due to lack of assessment that could lead to serious harm, injury, impairment or death. […]

• Actual harm, isolatedF684May 14, 2025

  Based on interview and record review, the facility failed to transfer one (R901) of one resident to a higher level of care after complaints of unresolved, severe abdominal pain resulting in hospitalization . Findings include: On 5/14/25 at 9:23 AM, an interview was completed with Family Member A who explained on 5/6/25, R901 contacted them at approximately 5:00pm stating they were experiencing abdominal pain and the nurse provided them with a laxative. Family Member A further explained at approximately 1:26am, R901 again contacted them via phone screaming out in pain stating their abdomen continued to hurt. […]

• Actual harm, isolatedF692Nov 29, 2021

  This citation pertains to: MI 345 and MI 383. Based on interview and record review the facility failed to ensure significant weight loss was communicated to the attending physician, the care plan was updated with interventions for weight loss and weights were monitored weekly upon admission per facility policy for one sampled resident (R913) of three whose weights were reviewed, resulting in significant weight loss of 62 pounds over four months without notification of the medical team. Findings include: A review of the facility record for R913 revealed R913 was admitted into the facility on [DATE] and discharged by family/resident request to the hospital on 06/01/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF921Dec 13, 2023

  Based on observations, interviews, and record reviews, the facility failed to clean and maintain the physical plant effecting 227 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, potential cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies, and decreased illumination. Findings include: On 12/12/23 at 09:30 A.M., A common area environmental tour was conducted with Director of Maintenance L, Director of Environmental Services M, District Manager N, and Regional Maintenance Director O. The following items were noted: Lobby Restroom: The over hand sink basin three light assembly was observed heavily soiled with accumulated dust and dirt deposits. […]