Villa Crest Nursing and Retirement Center

In the surveyor’s words

From the most serious findings on record at Villa Crest Nursing and Retirement Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Aug 6, 2026

  Based on interview and record review, the facility failed to include all the required components in the facility water management program to prevent the potential growth and spread of waterborne pathogens in a facility with a census of 124 residents. Findings include:Review on 8/4/26 of the facilities Legionella Water Management Plan, undated revealed the following areas were not identified as a potential risk: eye wash stations or oxygen humidification and continuous positive airway pressure (CPAP) machines.Observation on 8/4/26 at approximately 11:20 a.m. of a resident room revealed oxygen with humidification and a CPAP machine that requires humidification.Observation on 8/6/26 at approximately 8:45 a.m. […]

• No harm, potential for more than minimal, patternF812Jul 31, 2025

  Based on observation, interview and record review, it was determined that the facility failed to ensure that the dishes were sanitize according to manufacturer's instruction for 1 of 1 kitchen observed. Findings include:Observation on 7/29/25 at approximately 8:40 a.m. in the kitchen with Staff B (Dietary Services Director) revealed that two dietary aides were using the low temperature dishwasher. Staff B used a chlorine test strip and tested the chemical sanitizer (chlorine) of the dishwasher. The chlorine test strip did not change color indicating a lack of chlorine. Interview on 7/29/25 at approximately 8:40 a.m. with Staff B revealed that the dishwasher was a low-temperature chemical sanitizing dishwasher. […]

• No harm, potential for more than minimal, patternF880Jun 20, 2024

  Based on observation, interview, and record review, it was determined that the facility failed to follow infection control and prevention guidelines to prevent cross-contamination by not wearing gowns when handling soiled linen and clothing in the laundry. Findings include: Review on 6/20/24 of the Centers for Disease Control and Prevention (CDC) Environmental Infection Control Guidelines, Section G. Laundry and Bedding, retrieved 6/20/24 from: https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html#:~:text=Handling%20contaminated%20laundry%20with%20a,aerosols%20in%20patient%2Dcare%20areas.&text=Sorting%20or%20rinsing%20contaminated%20laundry,occurred%20is%20prohibited%20by%20OSHA. […]

• No harm, potential for more than minimal, isolatedF761Aug 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure that medications were stored according to manufacturer's instructions for 1 of 2 medication rooms observed. Findings include:Observation on 8/4/26 at approximately 10:33 a.m. with Staff C (Licensed Practical Nurse) of the North Medication Room revealed that the thermometer in the medication refrigerator read 52 F (degrees Fahrenheit). Further observation revealed that the following unopened residents' medications were stored in the refrigerator:Two Lantus (insulin glargine) pensSeven Latanoprost Ophthalmic Solution 0.005% (percent) bottlesFive Novolin N (insulin isophane human) pensThirteen Novolin R (insulin human) pens Interview on 8/4/26 at approximately 10:33 a.m. […]

• No harm, potential for more than minimal, isolatedF605Jul 31, 2025

  Based on record review and interview, it was determined that the facility failed to ensure that a resident receiving psychotropic medications received a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications in a final sample of 24 residents. (Resident identifier is #76.)Findings include:Review on 7/31/25 of Resident #76's medical record revealed that the Resident #76 was admitted to the facility in 2014 and had a diagnosis of dementia with psychotic disturbance. […]