Villa Maria Post Acute

In the surveyor’s words

From the most serious findings on record at Villa Maria Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jun 6, 2024

  Based on observation, interview and record review, the facility failed to ensure: 1. Pasteurized eggs were used for egg preperations not cooked through completely according to the facility's policy and procedures (P&P). 2. Food was stored properly in accordance with professional standards of food service safety when an uncovered and undated bag of shredded mozzarella cheese was found in the refrigerator and an opened staff personal water bottle was stored in the freezer. 3. Resident food refrigerator temperatures located in the nursing station were monitored daily and corrective actions implemented for out-of-range temperature readings by the food and nutrition representative according to the facility's P&P on foods brought by family or visitor. 4. […]

• No harm, potential for more than minimal, patternF679Jun 22, 2023

  Based on observation, interview, and record review, the facility failed to implement its policy for activities when: 1. One of eighteen sampled residents (Resident 59) was not observed in any activities during onsite four-day survey. 2. The activity director was not documenting activity pursuit patterns or activity attendance for any of the 75 residents in the facility. This failure has the potential for psychosocial and physical harm to all 75 residents. Findings: During a review of the facility's policy and procedure (P&P) titled, Activity Assessment, dated 01/2021, the P&P indicated, POLICY: It is the policy of this facility to provide ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities… […]

• No harm, potential for more than minimal, patternF759Jun 22, 2023

  Based on observation, interview and record review, the facility failed to ensure its medication error rate was less than five percent when: 1. Licensed Nurse 5 (LN 5) left medications intended for Resident 38 unattended on the medication cart. 2. LN 5 did not educate and provide Resident 38 water to rinse mouth out after inhalation of Ellipta powder medication. 3. LN 5 left Resident 38's medications unattended on bedside table and did not witness medication consumption. These failures resulted in a 10% medication error rate and had the potential for Resident 38 to have medication complications. Findings: Review of the facility's policy and procedures (P&P) titled, 6.0 General Dose Preparation and Medication Administration, revised 1/1/13, the P&P indicated in part, . […]

• No harm, potential for more than minimal, patternF812Jun 22, 2023

  Based on observation, interview, and record review the facility failed to store two boxes containing eggs inside of refrigerator and off the kitchen floor in accordance with professional standards of food safety for a total of 72 residents who received food from the kitchen. These failures had the potential to result in foodborne illnesses among residents. Findings: According to the Food Code 2022, Annex 3. Public Health Reasons/Administrative, 2-103.11, page 308 All food must be appropriately stored in a safe and secure manner within the food establishment. For example, time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41 F or below. […]

• No harm, potential for more than minimal, isolatedF658Jul 25, 2025

  Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 83) had a qualified licensed nurse perform their initial comprehensive nursing assessment.This failure had the potential for Resident 83 to not have a complete initial comprehensive nursing assessment and not have all their needs met.During a review of Resident 83's admission Record (AR), dated 7/25/25, the AR indicated, Resident 83 was a [AGE] year old, admitted [DATE] with diagnoses including, heart failure (the heart not able to pump enough blood to meet the body's needs), atrial flutter (uncoordinated beating of the heart), diabetes (the body is not able to turn food into energy), and cognitive communication deficit (problems with communication).During a review of Resident 83's… […]