Villa Maria West Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Villa Maria West Skilled Nursing Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jul 29, 2021

  Based on observation, interview and record review, the facility failed to ensure proper temperature in the reach-in refrigerators and safe holding temperature during tray line. As evidenced by two reach-in refrigerators and cold sandwiches in the cooler on the tray line were over 41 degrees (°) Fahrenheit (F). This has the potential to affect all residents (twenty-six) residing in the facility at the time of the survey. The findings included: Review of the Policy and Procedure for Food Handling Guidelines (HACCP), revised 1/21 revealed Prior to preparation, chill potentially hazardous ingredients to 41° F for food that will be eaten without further cooking. Examples include salads, sandwiches, cut leafy greens and produce and reconstituted food. […]

• No harm, potential for more than minimal, patternF679Dec 29, 2022

  Based on records review, observation and interview, the facility failed to offer and provide group activities to residents, with the potential to affect all residents in the facility, including Resident #175. The census at the time of the survey was 17 residents. The findings included: The facility's Admission Packet documented, Recreational activities that are fun and therapeutic are regularly planned for residents. These include arts and crafts, exercise, films, games, and sports. We also offer group discussions of current events. A member of the Recreational Therapy department will meet with you to discuss your special interests, hobbies, and talents. Music is enjoyed regularly in the facility, especially during the holiday and birthday celebrations. […]

• No harm, potential for more than minimal, patternF803Dec 29, 2022

  Based on observation, interview, and record review, it was determined that the facility failed to follow the approved menu to ensure that the nutritional needs of 17 of 17 facility residents (Includes sampled Resident #4, Resident #30, Resident #36, Resident #75, Resident #76, Resident #77, and Resident #78) were being met. The findings included. During the observation of the lunch tray line in the main kitchen on 12/28/22 at 11:30 AM, it was noted that the serving portion of the Chili -Texas Cowboy (entree) was a 4-ounce ladle portion and the pureed Chili was a 4-ounce scoop for Regular, Carbohydrate Controlled, Mechanical Soft, and No Added Salt diets. […]

• No harm, potential for more than minimal, isolatedF655Sep 11, 2025

  The facility failed to develop a baseline care plan that included respiratory care for Resident #49, as evidenced by: Resident #49, was admitted on [DATE] and receiving multiple respiratory treatments, did not have a baseline care plan developed until six days after admission.The findings included:On 09/09/2025 at 9:45 AM, Resident #49 was observed seated in a wheelchair watching television. The resident reported no concerns and revealed she had two weeks remained in rehabilitation following a fall at home. On 09/10/2025 at 8:34 AM, the resident actively participated in therapy, with no concerns noted or reported. During the observation on 09/11/2025 at 10:15 AM, the resident was again seated in a wheelchair, and no concerns were noted or reported. […]

• No harm, potential for more than minimal, isolatedF867Sep 11, 2025

  Based on observations, staff interviews, and records review, the facility failed to implement effective corrective actions to address previously identified deficiencies. This is evidenced by the repeated citation of F655 - Development of a Baseline Care Plan. Despite prior citations and the opportunity for corrective action, the facility did not demonstrate sustained compliance. At the time of the survey, 22 residents were residing in the facility. The findings included:Review of the facility's survey history revealed, during a recertification survey with exit date 05/15/ 2024, F655 Development of a baseline care plan was cited related to facility's failure to develop a baseline care plan for oxygen use for one resident.During this survey with exit dated 09/11/2025, the facility did not… […]