Villa Scalabrini Special Care

In the surveyor’s words

From the most serious findings on record at Villa Scalabrini Special Care, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605Feb 26, 2026

  Based on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 26) drug (medication) regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) by failing to provide a detailed clinical rationale for continuing Temazepam (a psychotropic medication used as a hypnotic [relating to, producing, or inducing sleep] for insomnia [inability to sleep or stay asleep]) at the original prescribed dose on 8/29/2024 for Resident 26. […]

• No harm, potential for more than minimal, patternF755Feb 26, 2026

  Based on observation, interview, and record review the facility failed to: 1.Reconcile (the process of comparing transactions and activity to supporting documentation) three (3) medication emergency kitS ([eKIT] - kit containing medications needed to be used during emergencies) containing ([CS] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM]) for February 2026, in one (1) of one (1) inspected Medication Rooms (Medication Room.) 2. […]

• No harm, potential for more than minimal, patternF759Feb 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Six (6) medication errors out of 31 total opportunities contributed to an overall medication error rate of 19.35% affecting three (3) of five (5) residents observed for medication administration (Resident 7, 39 and 47.) The medication errors were as follows: 1.Resident 7 did not receive folic acid (a supplement used for osteoarthritis [a joint disease where the cushions at the ends of bones breaks down causing pain, stiffness, and reduced function]) as ordered by Resident 7's physician. 2. […]

• No harm, potential for more than minimal, patternF812Feb 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and distribution when: 1. Pasta was stored in a container with a lid that was not tightly sealed. 2. One tomato and one onion were cut in half and stored in the refrigerator in plastic wrap with no date. These failures had the potential to result in harmful bacterial growth, cross contamination (transfer of harmful bacteria or allergens from one place to another), and foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 53 residents who received food from the kitchen out of 56 total residents. 3. […]

• No harm, potential for more than minimal, patternF880Feb 26, 2026

  Based on observation, interviews and record review, the facility failed to maintain infection control measures when: a. Certified Nursing Assistant (CNA 1) was not wearing a face mask (personal protective equipment that serves as a mechanical barrier to interfere with air flow from the nose and mouth) while in the dining room assisting residents. b. The Director of Dietary Services (DODS) was not wearing a mask (personal protective equipment that serves as a mechanical barrier to interfere with air flow from the nose and mouth) while in the dining room. This deficient practice increased the potential of spreading respiratory illnesses to the residents in the facility. Findings: a. During a concurrent observation an interview on 2/23/2026 at 1:10 p.m. […]