Villa at Blue Ridge, The

In the surveyor’s words

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

• Actual harm, isolatedF692May 18, 2023

  Based on observation, interview, and record review, the facility failed to implement dietary recommendations and follow physician's orders for one resident (Resident #18) who had a significant weight loss, which resulted in additional weight loss. The facility census was 70. 1. Review of the facility's Nutrition Policy, dated March 2015, showed the facility will provide nutrition as determined by a physician and in cooperation with a dietician for all residents according to State and Federal guidelines. Review of the facility's Supplements for Weight Loss Policy, dated March of 2015, showed when a resident was in need of a supplement, the charge nurse will obtain an order from the physician. The nurse will write the order on the Medication Administration Record (MAR). […]

• No harm, potential for more than minimal, widespreadF728May 5, 2026

  Based on interviews and record review, facility staff failed to ensure five Nurse Aides (Na's) (NA C, NA D, NA E, NA F, and NA G) out of five NA's completed the nurse aide training program within four months (120 days) of their employment in the facility. The facility's census was 91.1. Review of the facility's policies showed staff did not provide a policy for NA training and requirements.Review of the facility's Job Description for Certified Nursing Assistant (CNA), undated, showed a minimum qualification is to be licensed as a CNA in accordance with the requirements of the state governing the facility.2. Review of NA C's personnel file showed a hire date of 04/02/25, and he/she began work as an NA in 09/2025. […]

• No harm, potential for more than minimal, widespreadF638Oct 10, 2024

  Based on interview and record review, facility staff failed to assess residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, no less frequently than once every 92 days as directed by the Resident Assessment Instrument (RAI) manual for 19 residents (Resident #6, #9, #12, #20, #26, #28, #29, #31, #32, #33, #41, #44, #46, #51, #57, #63, #69, #70, and #71) out of 20 sampled. The facility census was 83. 1. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. […]

• No harm, potential for more than minimal, widespreadF880Oct 10, 2024

  Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 84. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. […]

• No harm, potential for more than minimal, widespreadF812May 18, 2023

  Based on observation, interview and record review, the facility staff failed to change gloves and perform hand hygiene as often as necessary to prevent cross-contamination. The facility census was 70. 1. Review of the facility's Glove Use policy, dated May 2015, showed the policy directed staff to remove their gloves and wash their hands when they change or walk away from a specific task. Review also showed the policy directed staff to wash their hands after they dispose of trash or food, after handling dirty dishes, after they pick up anything from the floor, when they change tasks, and any other time deemed necessary. Observation on 05/01/23 at 10:28 A.M., showed Dietary Aide (DA) D washed soiled dishes in the mechanical dishwashing station. […]