Villa Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Villa Healthcare & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 2, 2021

  Based on observations and employee interviews, the facility failed to distribute and serve food in accordance with professional standards for food service safety, by failing to practice appropriate hand hygiene and glove use during food preparation activities to prevent cross-contamination. This failure potentially affected all residents receiving food from the facility's kitchen. The findings include: A food service observation was conducted in the kitchen at 11:55 AM on 12/2/2021. At 12:00 PM, the Chef was observed setting up the food items for lunch service. The Chef was observed with a pair of gloves on during the set up. […]

• No harm, potential for more than minimal, isolatedF677Sep 18, 2025

  Based on observations, interviews and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL), specifically nail care, received necessary services to maintain good grooming and personal hygiene for one (Resident #59) of a total survey sample of 32 residents.The findings include: On 09/15/25 at 2:00 PM, an observation was made of Resident #59's fingernails, which had grown approximately 1/2 to ¾ inch beyond the tip of the nailbed on both her right and left hands. The resident reported that she did not like her fingernails as long as they were, and that she was afraid she might scratch herself with such long nails. She could not recall whether or not staff had offered to trim her fingernails. […]

• No harm, potential for more than minimal, isolatedF761Apr 23, 2025

  Based on observation, staff and resident interviews, medical record review, and facility policy review, the facility failed to appropriately store resident's medication by leaving medication at bedside for one (Resident #4) of three residents sampled for unsecured medication. Resident #4 who had not been assessed for self-administration of medication was observed taking medications that had been left on his overbed table. These medications were also accessible to other residents who should not have access to them. The findings include: During an interview with Resident #4 on 04/23/2025 at 10:22 AM, the resident picked up a medicine cup from his overbed table containing multiple pills in it. When asked if the pills were his morning medications he stated, yes and then took them. […]

• No harm, potential for more than minimal, isolatedF658Sep 28, 2023

  Based on staff interviews, medical record review, and facility policy and procedure review, the facility failed to ensure that services provided met professional standards of quality for one (Resident #74) of 28 residents in the total sample. Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. The findings include: During medication reconciliation completed for Resident #74, an order was reviewed, which read: Start date 5/23/23: Midodrine 5 milligrams (mg): Give 5 mg by mouth one time a day for low blood pressure; hold if systolic blood pressure is greater than 120. […]

• No harm, potential for more than minimal, isolatedF686Sep 28, 2023

  Based on observation, medical record review, staff interview, and a review of the facility's policies and procedures, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #26) of 12 residents receiving pressure ulcer treatment, from a total sample of 28 residents. The findings include: On 9/27/23 at 11:50 a.m., Registered Nurse (RN) A was observed preparing wound care supplies from the treatment cart for Resident #26. He dispensed Zinc Oxide 20% into a small medication cup. He was asked to explain the treatment order. He stated, It's Zinc Oxide ointment to his sacral area daily. […]