The Villa Rehab

In the surveyor’s words

From the most serious findings on record at The Villa Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 5, 2026

  Based on interview and record review, the facility failed to ensure 1 of 3 residents sampled was provided with adequate supervision and assistance devices to prevent accidents (Resident #1), by failing to systematically evaluate the effectiveness of interventions or revise care plan interventions after falls occurred. As a result, Resident #1 suffered a fall and sustained significant fractures in both ankles. This is a repeat deficiency with the violation cited during a previous complaint survey dated 7/30/25. Findings include:Per record review, Resident #1 is assessed as having cognitive impairment, with diagnoses which include Alzheimer's Disease, osteoarthritis of the knee and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF628Jul 30, 2025

  Based on interview and record review, the facility failed to have a system to ensure transfer notices and ombudsman notices were provided for 2 of 2 sampled residents transferred to the hospital. This has the potential to impact all residents. Findings include: 1.) Per record review, Resident #16 was admitted to the facility after a stay at the hospital for treatment of a stroke. A progress note dated 7/12/2025 reveals that Resident #16 was transferred to the hospital for evaluation of altered mental status. There is no evidence in the Resident's medical record that a bed hold, or transfer/discharge notice was provided to the Resident or their family member. […]

• No harm, potential for more than minimal, widespreadF726Jul 30, 2025

  Based on observation, interview, and record review the facility failed to ensure that staff were competent in medication administration for 4 of 5 licensed nurses and failed to ensure that 10 of 10 direct care staff were competent in infection control measures. Findings include:Per review of the Facility Assessment, last reviewed 5/5/25, indicates that the facility offers medication management, and infection prevention and control as services and care offered to meet the residents' needs. The Facility Assessment reveals that the training program :included an orientation process and ongoing training for all new and existing staff . and is based on staff need and resident characteristics.1.) Medication administration errors were observed during survey. […]

• No harm, potential for more than minimal, widespreadF812Jul 30, 2025

  Based on observation, interview, and record review the facility failed to ensure that food was prepared in a safe sanitary manner and environment. This has the potential to impact all residents in the facility. Findings include: Per record review of the facility's Food Safety Requirements policy [last revised 1/1/25] states, Food safety practices shall be followed throughout the facility's entire food handling process .Elements of the process include the following:.b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.6. […]

• No harm, potential for more than minimal, widespreadF838Jul 30, 2025

  Based on interview and record review the facility failed to ensure that the facility assessment provided adequate information related to competencies and training and failed to address needed positions. Findings include: 1. Per review of the facility Infection Preventionist job description implemented on 5/1/2025 section 6. states The IP must be employed at least part-time and the amount of time should be determined by the facility assessment, to determine the resources it needs for its IPCP [Infection Prevention Control Program]. Designated IP hours per week may vary based on the facility and its resident population. Section 7. States The facility based on the facility assessment will determine if the individual functioning as the IP should be dedicated solely to the IPCP. […]