Villa Maria Health and Rehab CTR

In the surveyor’s words

From the most serious findings on record at Villa Maria Health and Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 25, 2025

  Based on interview and record review, the facility failed to protect a resident's right to be free from abuse. The facility did not protect residents from abuse by a visitor or protect the resident immediately after the abuse occurred. This affected 1 of 4 residents (R1) reviewed for abuse. On 02/27/25, Certified Nursing Assistant (CNA) C witnessed R1 and Visitor G engaging in sexual conduct in R1's bathroom. CNA C left R1's room to report the incident. R1 was left alone with Visitor G for approximately 30 seconds. This left R1 at risk for further abuse from Visitor G. The facility's failure to protect vulnerable residents from sexual abuse created a finding of immediate jeopardy that began on 02/27/25. […]

• No harm, potential for more than minimal, widespreadF880Feb 25, 2026

  Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections that has the ability to affect all 56 residents (R) with transporting clean linens uncovered through the facility, and Certified Nursing Assistant (CNA ) C not doffing prior used PPE or santizing hands, and applying clean gloves brfore assisting 1 of 1 residents observed (R16).-Facility staff did not transport linens in a manner to prevent the spread of infection.-Facility staff did not doff gloves, sanitize hands, and apply new gloves between residents R37 and R16. […]

• No harm, potential for more than minimal, widespreadF886Oct 26, 2022

  Based on record review and interview, the facility did not conduct testing of facility staff that is consistent with current standards of practice for conducting COVID-19 testing. This had the potential to affect all 59 residents. Facility failed to test symptomatic staff or document testing results for the COVID-19 virus for 16 of 19 staff members on the line list that were reviewed. This is evidenced by the following: On 10/26/22, Surveyor reviewed the facility employee vaccine matrix. The facility had a total of 84 employees including the contracted therapy staff, with 66 of those employees vaccinated and 18 with exemptions for a total of 78.6% vaccinated. The community transmission rate was Substantial. […]

• No harm, potential for more than minimal, patternF880Nov 8, 2023

  Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff did not perform or offer resident hand hygiene prior to meal service for 7 of 7 residents (R) R1, R2, R10, R13, R15, R30, and R56 who eat independently in their room. Staff did not perform sanitizing of durable medical equipment to prevent the spread of infection when warranted between resident transfers potentially affecting all 5 residents (R) R9, R10, R13, R15 and R30 who require a mechanical lift for transfers on the 300 wing. […]

• No harm, potential for more than minimal, isolatedF697Feb 25, 2026

  Based on observation, interviews, and record review, the facility did not ensure pain management interventions were provided for 1 out of 1 resident (R) reviewed for pain management (R49).R49 did not have an individualized pain assessment completed to monitor, assess, and evaluate for efficacy for pain management.This is evidenced by:Facility policy titled, Pain Management Policy revised 6/20/2025, states in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences. Pain Assessment: 1. […]