The Villas at the Park

In the surveyor’s words

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

• Actual harm, isolatedF688Nov 20, 2025

  Based on observation, interview and document review the facility failed to ensure a resident received appropriate interventions to prevent contractures for a resident who was admitted to the care facility without contractures (permanent shortening of tissue, such as muscle, tendon or skin leading to the inability to straighten joints fully and to permanent deformity and disability) for one of two residents (R20) reviewed for range of motion. This resulted in actual harm when R20 developed severe contractures of bilateral upper and lower extremities. Findings include:R20s significant change Minimum Data Set (MDS), dated [DATE], indicated R20 was admitted to the care facility on 3/20/19. The MDS indicated R20 was not on any range of motion or restorative nursing programs. […]

• Actual harm, isolatedF686Oct 24, 2024

  Based on observation, interview, and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions for 2 of 2 residents (R30, R33) identified at risk for pressure ulcers. This resulted in actual harm when R30 developed two deep tissue injuries which worsened to unstageable pressure injuries on the heels after admission, and R33 developed a stage two pressure ulcer after admission that worsened to an unstageable pressure ulcer. Additionally, the facility failed to reposition 1 of 2 residents (R30) in accordance with the current care plan, and failed to accurately stage a pressure ulcer and failed to accurately assess nutritional needs and implement provider ordered nutritional interventions to aide in healing for 1 of 2 residents (R33) reviewed… […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2023

  Based on observation, interview, and document review the facility failed to maintain appropriate temperature in a refrigerator used for cold food storage to prevent potential food borne illness for all residents who received food from the kitchen. Findings included: On 1/23/23, at 11:56 a.m. a kitchen tour was conducted with registered dietitian (RD) and cook (C) -A. The following was observed during the kitchen tour: Upright coolers: 80 oz (ounce) partial container of low-fat cottage cheese. Expiration date 1/16/23. 80 oz partial container of low-fat sour cream. Open date 1/8/23. Observed 4 orange-colored spots of discoloration inside the container. During an interview on 1/23/23 at 12:09 p.m. […]

• No harm, potential for more than minimal, widespreadF880Jun 29, 2021

  Based on observation, interview, and document review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) including eye protection and source control masks to prevent and/or minimize the spread of COVID-19. This had the potential to affect all 44 residents who resided at the facility. Findings include: On 6/28/21, at 11:15 a.m. upon facility entrance the front desk receptionist (R)-A was observed to be wearing a mask under her chin and was not wearing eye protection. An unidentified activities assistant was also noted to be sitting in the activities area/living room with no eye protection on. Two unidentified residents were noted to be in the activities area/living room and were listening to a woman singing. […]

• No harm, potential for more than minimal, patternF583Nov 20, 2025

  During observation and interview, the facility failed to implement interventions to ensure resident's personal care information was kept secured and out of public view when stored on 1 of 3 mobile medication carts. This had the potential to affect 14 residents (R3, R4, R9, R14, R27, R28, R30, R32, R35, R40, R43, R47, R48, and a discharged resident) on the long-term care unit whose personal information was left unattended on a medication cart in the hallway corridor. Findings include:During observation and interview on 11/19/25 at 9:05 a.m., an unattended medication cart had a form titled East nursing care sheet with 13 resident names, room numbers, and notations including other personal information such as nutritional needs such as tube feeding, blood sugars, blood pressures, heart rates,… […]