Villa Maria Nursing and Rehabilitation Community

In the surveyor’s words

From the most serious findings on record at Villa Maria Nursing and Rehabilitation Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684May 7, 2024

  Based on record review and interviews for one sampled resident who received an anticoagulant (blood thinner, increases risk for bleeding) medication (Resident ID #1) the facility failed to obtain an order to discontinue the anticoagulant medication prior to a dental procedure where twenty-three (23) teeth extracted. Subsequently Resident #1 continued to receive the anticoagulant medication, experienced bleeding requiring sutures, had a change in condition, was sent to the hospital where he/she suffered cardiac arrest and expired. This resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included paroxysmal atrial tachycardia (atrial arrythmia), hypertension, and anxiety. […]

• Actual harm, isolatedF686Mar 30, 2026

  Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for pressure injuries, the facility failed to ensure implementation of physician-ordered interventions, ongoing skin monitoring, and timely identification and reporting of changes in skin condition for a resident at very high risk for pressure injury development, resulting in the development of a facility-acquired, medical device-related Stage IV pressure injury to the right ankle. The findings include: Resident #1 was admitted to the facility with diagnoses that included fracture of the right femur and dementia. Resident #1 had a Power of Attorney for care. […]

• Actual harm, isolatedF689Jan 2, 2025

  Based on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who was status post fracture of the right lower leg and required a knee brace and an assistive device for standing, the facility failed to apply the hinged knee brace to the right leg prior to standing the resident which caused the resident's leg to buckle resulting in a fall and the resident sustained an acute fracture of the proximal tibia. The findings include: Resident #1's diagnoses included dementia, fracture lower end of right femur, osteoarthritis of the right knee, and generalized weakness. […]

• Actual harm, isolatedF692Aug 10, 2021

  Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 of 6 sampled residents (Resident #2) reviewed for nutrition, the facility failed provide care and services to address a significant ongoing weight loss. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nutrition Risk assessment dated [DATE] identified Resident #2 has had no significant weight change, had a current food intake of 50 - 75%, required no therapeutic nutritional supplements, and had no swallowing difficulties. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weights and Vitals Summary dated 2/14/21 identified Resident #2 weighed 137 lbs. […]

• No harm, potential for more than minimal, widespreadF812May 11, 2026

  Based on observation, facility policies, and interviews for food and nutrition services, the facility failed to ensure food and drink items were labeled, expired food items were disposed of, and the Dining Room steam cart was clean and sanitary. Findings include:Tour of the facility on 5/11/26 at 10:45 identified the following:The Nourishment Room freezer contained expired ice pops, an unidentified frozen item in a cup, pancakes, and a water bottle and the Nourishment Room refrigerator contained expired yogurt cups and marshmallows, an unlabeled opened supplement drink, and multiple unlabeled supplements. The Nourishment Room supplement refrigerator contained expired supplemental ice creams and shakes. […]