Villa del Rio

In the surveyor’s words

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

• Immediate jeopardy, patternF880Sep 28, 2023

  Based on observation, interview, and record review, the facility failed to maintain an infection control and prevention program by failing to: 1. Implement proper infection prevention and control interventions for one of 15 residents, (Resident 1), who was positive for coronavirus virus (COVID-19, a highly contagious viral infection). Resident 1 walked out of her isolation room, grabbed a cup from the top of the facility's medication cart and touched other clean medical supplies on the left side of the medication cart without staff intervention. 2. Ensure three of the 15 COVID-19 positive residents (Residents 1, 2, and 3) did not co-mingle with the five COVID-19 negative residents (Residents 4, 5, 6, 7, and 8) who were smoking in the patio with staff supervision. 3. […]

• Immediate jeopardy, isolatedF689Jun 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was assessed as at risk for elopement (the act of leaving a facility unsupervised and without prior authorization) and diagnosed with paranoid schizophrenia (a mental illness that was characterized by disturbances in thought), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hypertension (HTN- high blood pressure), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) did not leave the facility through an unlocked and disarmed door, by failing to: 1. […]

• Immediate jeopardy, isolatedF684Jul 23, 2021

  Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person entered care plan, and the residents' choices. Based on observation, interview, and record review, the facility failed to treat one of five sampled resident's (Resident 1) right eye corneal abrasion (a scratch or scrape on the surface of the cornea, the eye's clear, protective outer layer), by failing to: 1. Follow the general acute care hospital (GACH) physician's referral orders for an ophthalmologist (specialist in the treatment and study of disorders and diseases of the eye). […]

• Actual harm, isolatedF684Sep 18, 2024

  Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Resident Examination and Assessment, which indicated the facility will assess a resident for any abnormalities in health status, such as abdominal distention, pain duration, severity and factors that worsen the pain, for one of three sampled residents (Resident 65), when Resident 65 complained of severe abdominal pain on 8/24/2024 at 11:00 p.m. and on 8/25/2024 at 2:30 p.m. This failure caused Resident 65 to be emotionally distressed (angry, scared, and frustrated), suffer severe pain for an extended period and was transferred to a general acute care hospital (GACH) for evaluation and treatment. […]

• Actual harm, isolatedF688Apr 22, 2024

  Based on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for four of six sampled residents (Resident 91, Resident 92, Resident 93, and Resident 113) with limited range of motion ([ROM] full movement potential of a joint (where two bones meet) and mobility by failing to: 1. Monitor Resident 91's ROM in both arms and legs quarterly (every three months) in accordance with Resident 91's care plan between 4/21/2021 and 3/27/2024 (approximately 3 years). 2. […]