Villa Maria Post Acute and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF600Oct 3, 2024

  Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2). The deficient practice could result in further resident abuse. Findings include: -Resident #1 was admitted on [DATE] with diagnoses of dementia, non-displaced bimalleolar fracture of the lower right leg, alcohol abuse, and type 2 diabetes. The resident's bed assignment in the electronic health record (EHR) revealed that the resident was moved to a different bed in a different unit on September 21, 2024. A 5-day MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident had no cognitive impairment. […]

• Actual harm, isolatedF694Apr 12, 2024

  Based on clinical record review, staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to provide care and services related to a peripherally inserted central catheter (PICC) line resulting in the hospitalization for one resident (#75). The deficient practice resulted in complications related to the PICC line not being removed. Findings include: -Resident #75 was admitted to the facility on [DATE] with diagnoses of urinary tract infection (UTI), weakness, pneumonia, hepatitis C, and hypertension. An antibiotic care plan, initiated March 14, 2024 revealed that resident #75 was on intravenous medications due to a diagnosis of complicated UTI. […]

• No harm, potential for more than minimal, patternF645Jan 23, 2026

  Based on the interview, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure PASSAR screening and referral were accurate and completed for 6residents (#3, #5, #9, #13, #21, and #55). This deficient practice can result in residents medically related social and emotional needs not being met. The sample size was 8. The census was 56. -Regarding Resident # 9 Resident # 9 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with clinical diagnoses that included borderline personality disorder, post-traumatic stress disorder, chronic pain syndrome, insomnia, recurrent depressive disorders, other specified anxiety disorders, and factitious disorder imposed on self, with predominately physical signs and symptoms. […]

• No harm, potential for more than minimal, patternF684Jan 23, 2026

  Number of residents sampled: 15Number of residents cited: 2Universe: 56Based on review of records, staff interviews and review of policy and procedures, the facility failed to ensure that timely care and services, including physician notification and a physician order for oxygen, were provided upon a change of condition for one resident (#50). The deficient practice could lead to a medical decline and/or physical harm of a resident.Findings include:Resident #50 was admitted to the facility November 14, 2025, with diagnoses of type 2 diabetes mellitus, chronic pain syndrome, spinal stenosis, malignant neoplasm of overlapping sites of right female breast, and pressure ulcer of sacral region, stage 4.A care plan focus initiated November 18, 2025, revealed Resident #50 had an alteration in… […]

• No harm, potential for more than minimal, patternF755Jan 23, 2026

  Based on observations, interviews, facility documentation and policy, the facility failed to ensure that safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances for two of three medication carts sampled. The deficient practice could result in inventory loss and potential diversion. An observation of the 100 Medication Cart narcotic reconciliation log was conducted on January 20, 2025 at 2:52 p.m., and reviewed with with Licensed Practical Nurse (LPN/Staff #45),who revealed the missing nurse signature entries on 6 shifts from January 1-19, 2026, were not supposed to be left blank. […]