La Villa Grande Care Center

In the surveyor’s words

From the most serious findings on record at La Villa Grande Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Dec 18, 2025

  Based on record review and interviews, the facility failed to prevent a significant medication error for warfarin (a blood thinner medication) for one (#8) of three residents reviewed for medication errors out of 10 sample residents.Specifically, the facility failed to prevent a significant medication error when Resident #8 received warfarin, a blood-thinning medication, twice a day (once in the morning and once in the evening), instead of once a day at bedtime.Resident #8 was admitted on [DATE] and discharged to home on 9/22/25. Resident #8's diagnoses included hypertension, kidney disease, diabetes, stroke, and left-sided paralysis. […]

• Actual harm, isolatedF689May 22, 2025

  Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#28) of three residents out of 37 sample residents. Resident #28, who was at risk for falls, was admitted on [DATE] with diagnoses of dementia, history of falling, abnormalities of gait and mobility, weakness and insomnia. On 5/1/25 the physician recommended the resident transition to a walker without wheels for safety and have a physical therapy (PT) evaluation. However, Resident #28 continued to use her four-wheel walker and a PT evaluation was not conducted until 5/13/25. Resident #28 fell three times in less than a week (on 5/6/25, 5/9/25 and 5/10/25). […]

• Actual harm, isolatedF686Nov 16, 2023

  Based on observations, record review, and interviews the facility failed to ensure one resident (#83) of five sample residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrated they were unavoidable, and to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the facility failed to ensure timely interventions were put in place to prevent the development of pressure injuries to Resident #83's heels which resulted in two unstageable pressure injuries. Resident #83 was admitted to the facility after a fall resulting in her impaired mobility. […]

• Actual harm, isolatedF689Mar 21, 2023

  Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#1) of three residents reviewed for falls out of eight sample residents. Specifically, the facility: -Failed to ensure certified nurse aide (CNA) #4 followed proper procedure while providing cares to Resident #1 and ensure the resident was safe; -Failed to implement two-person assistance when providing cares to Resident #1, which was identified as a resident need on their minimum data set (MDS) assessment, and, -Failed to implement a care-planned intervention to provide two-person assistance when providing cares to Resident #1. […]

• Actual harm, isolatedF689Aug 11, 2022

  Based on observations, record review and interviews, the facility failed to ensure effective and timely fall prevention practices to prevent falls for two (#19 and #49) of 12 residents out of 30 sample residents. Specifically, the facility failed to: -Conduct timely post fall investigations or at all; -Review residents' falls with the interdisciplinary team (IDT); -Update residents' care plans to reflect interventions to prevent falls; -Educate new staff on fall preventions for residents; and, -Follow care planned interventions to prevent falls. […]