Villa Gardens Health Care Unit

In the surveyor’s words

From the most serious findings on record at Villa Gardens Health Care Unit, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Dec 5, 2025

  Based on interview and record review, the facility failed to ensure there was a Registered Nurse (RN, a healthcare professional who completed an Associate Degree in Nursing [AND] or Bachelor of Science in Nursing [BSN] from an approved program. Then, they pass a comprehensive national test [NCLEX-RN] and meet state licensure and certification requirements that develop care plans, give treatments and medications, perform diagnostic tests, work with physicians to coordinate care, and supervise Licensed Vocational Nurse [LVN] and Certified Nursing Assistant [CNA] ) for eight (8) consecutive hours, seven (7) days a week on 1/18/2025, 1/19/2025, 1/21/2025, and 1/22/2025 based on the facility assessment. […]

• No harm, potential for more than minimal, patternF755Dec 5, 2025

  Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of two (2) of three (3) sampled residents (Residents 5 and 40) in accordance with its Policy and Procedure (P&P) by failing to ensure:1.a. Resident 5's Famotidine (medication used to treat and prevent conditions caused by too much stomach acid such as heartburn [burning chest pain] and gastroesophageal reflux disease [GERD, stomach acid flows back up the esophagus (canal that connects the throat to stomach)], was not left unattended on top of the medication cart on 12/3/2025. […]

• No harm, potential for more than minimal, patternF812Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was handled, prepared, and stored in accordance with the facility's policy by failing to ensure:1. Expired products were removed from the kitchen dry storage.2. Food items were dated, labeled, and kept clean after opening in the dry storage area and walk in refrigerator. These failures had the potential to result in harmful bacteria growth that could lead to food borne illnesses to 38 of 38 medically compromised residents who receive food in the kitchen.During a concurrent observation and interview on 12/2/2025 at 7:49 AM in the kitchen dry storage area and walk in refrigerator with [NAME] 1, the following were observed:1. […]

• No harm, potential for more than minimal, patternF814Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure two (2) of three (3) dumpsters (large trash container designed to be emptied into a truck), containing garbage (mostly decomposable food waste or yard waste) and refuse (dry material such as glass, paper, cloth or wood that does not readily decompose) were covered or entirely covered as indicated on the facility's Solid Waste Disposal policy. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry disease such as rodents, parasitic worms , or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas and pose a disease… […]

• No harm, potential for more than minimal, patternF880Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure by failing to: 1. Ensure an opened box of disposal gloves was left on top of Resident 31's dirty linen container. This failure had the potential to result in the spread and development of infection through cross contamination (when bacteria or other microorganisms are unintentionally transferred from one person or object to another). 2. Resident 36's used nasal cannula was left on the resident's wheelchair. […]