Villa Health Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF578Jun 12, 2025

  5. On June 10, 2025, at 11:41 a.m., an interview was conducted with Resident 37. Resident 37 stated she was not sure if she had an AD and would like more information. A review of Resident 37's admission Record indicated Resident 37 was admitted to the facility on [DATE], with diagnoses which included dysphasia (difficulty to speak or understand speech) following cerebral infarction (stroke). A review of Resident 37's Advance Directive/POLST Acknowledgment Form, dated November 6, 2024, indicated, .I have not executed an Advance Directive for Health Care .I do not wish to do so at this time . A review of Resident 37's POLST, dated November 6, 2024, did not indicate Resident 37 had an AD. […]

• No harm, potential for more than minimal, patternF812Jun 12, 2025

  Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when five large plastic basins used for ice and food items were stacked and stored wet. This failure had the potential to cause foodborne illnesses in 52 medically vulnerable resident population who consumed food in the facility. Findings: During the initial tour in the kitchen, an observation and concurrent interview with the Dietary Services Supervisor (DSS) on June 9, 2025, at 9:05 a.m. was conducted. Five large plastic basins were observed stacked wet and stored on a metal storage shelf. The DSS stated the plastic basins were wet and stacked on top of each other. […]

• No harm, potential for more than minimal, patternF880Feb 29, 2024

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The facility failed to notify the California Department of Public Health (CDPH) of an outbreak of COVID-19 (a contagious respiratory infection) and respiratory synctial virus infection (RSV - a contagious respiratory infection) according to the facility's policy and procedure and CDPH guidelines; 2. The facility staff failed to wear the appropriate personal protective equipment (PPE - equipment used to prevent or minimize exposure to infections) while providing care to a COVID-19 positive resident, in accordance with the facility's policy and procedure and Centers for Disease Control and Prevention (CDC) guidelines; and 3. […]

• No harm, potential for more than minimal, patternF803Oct 3, 2022

  Based on observation, interview, and record review, the facility failed to ensure the planned menu was followed when: 1. Nine out of 16 residents (Resident 1, 3, 5-11), that had a physician''s order for a mechanical soft diet (regular diet modified in texture to a soft, chopped or ground consistency, designed for a person who experiences chewing or swallowing limitations) were served regular corn with tomatoes instead of the creamed corn as indicated on the menu; and 2. Resident 4 on a NAS (diet with no added salt), CCHO (consistent carbohydrate- used in the treatment for diabetes mellitus [abnormal sugar in the blood]), Renal (used in treatment for [CONDITION(S)] or end stage kidney disease) received ice-cream as dessert instead of half a cup of diet pineapple as indicated on the menu. […]

• No harm, potential for more than minimal, patternF684Jul 2, 2021

  Based on observation, interview, and record review, the facility failed to ensure necessary care and treatment services were provided, for two of 23 residents reviewed (Residents 32 and 10) when: 1. For Resident 32, the uncontrolled blood sugar levels were not evaluated and referred to the physician for appropriate management. This failure had the potential for Resident 32 to be at risk for complications related to diabetes mellitus (abnormal blood sugar); and 2. For Resident 10, a plan of care was not developed and staff failed to monitor and manage the implantable cardiac defibrillator (ICD - a device placed under the skin to monitor heart rhythm and detect irregular heartbeats). […]