Saint Mary's Villa Nursing Hom

In the surveyor’s words

From the most serious findings on record at Saint Mary's Villa Nursing Hom, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 21, 2022

  Based on a review of clinical records, select facility policy and fall reports and staff interview it was determined that the facility failed to implement their established policy to identify and timely address potential contributing factors to resident falls and provide sufficient staff supervision and an effective individualized safety plan to repeated prevent falls, resulting in multiple fractures, thigh, pelvis and ankle, for one resident out of 18 sampled (Resident 72). Findings included: Review of the facility's policy, entitled Fall Prevention and Risk Assessment Program last reviewed by the facility December 2021, indicated that it is the facility policy to identify those residents at risk for falls and to evaluate an incident to determine any areas or risk that is amenable to… […]

• Actual harm, isolatedF600Oct 20, 2021

  Based on a review of the facility's abuse prohibition and transfer policies, employee personnel records, information submitted by the facility, select resident incident/accident and investigative reports, and clinical records and staff interviews it was determined that the facility neglected to provide the necessary care and services to avoid pain and serious bodily injury, a fractured leg, and necessary services post fall to prevent further harm to one resident out of five reviewed (Resident 1). […]

• Actual harm, isolatedF600Mar 12, 2021

  Based on observation, a review of clinical records, information submitted by the facility, select resident incident/accident and investigative reports, video surveillance footage and staff and resident interview it was revealed that the facility failed to ensure that one resident out of 18 sampled was free from physical abuse, which caused psychosocial harm and humiliation (Resident 6). Findings include: A review of the facility policy entitled Prevention of Abuse, Neglect and the Misappropriation of Resident Property reviewed by the facility July 17, 2020, revealed it is the policy of the facility to maintain an environment free of abuse, neglect, and misappropriation of resident property. […]

• No harm, potential for more than minimal, widespreadF814Mar 12, 2021

  Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage and provide a sanitary environment on the facility grounds. Findings include: Observation of the food and nutrition services dock area (area where the facility truck backs up to pick up the food and nutrition services department's garbage which is then transported to the facility's dumpsters) on March 12, 2021, at 10:55 AM revealed one bag of garbage directly on the concrete surface of the loading dock. There was also one tied trash bag of garbage in a garbage can with no lid. There were two garbage can rollers, which were visibly soiled stored on the loading dock. […]

• No harm, potential for more than minimal, patternF755Sep 12, 2025

  Based on review of select facility policy, controlled drug records, clinical records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate controlled drug records and failed to implement pharmacy procedures for timely disposition of resident medications to prevent misuse, diversion (unauthorized use or theft), or accidental exposure for one of three closed records reviewed (Resident 93).Findings include: Review of facility policy entitled, Disposition of Medications last reviewed by the facility on February 27, 2025, revealed guidance regarding disposition of medications. […]