Villa Manor Care Center

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Construction Deficiencies

Use approved construction type or materials.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

A complaint survey, prompted by #CO39090 and #CO39248 was conducted on 3/19/25. Two deficiencies were cited. Based on record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#1, #2 and #3) of four residents reviewed for bathing out of four sample residents.Specifically, the facility failed to ensure Resident #1, Resident #2 and Resident #3, who were dependent on staff for bathing, received their scheduled showers.Cross-reference F725: failure to have adequate nurse staffing. Findings include:I. Facility policy and procedureThe Activities Of Daily Living (ADLs) policy, revised 2/12/24, was provided by the nursing home administrator (NHA) on 3/19/25 at 2:21 p.m. It read in pertinent part, "The resident will receive assistance as needed to complete ADLs. A resident who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene."II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 9/28/12. According to the March 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS), age-related osteoporosis, neuromuscular dysfunction of the bladder (urinary incontinence), muscle weakness and irritable bowel syndrome. The 2/4/25 minimum data set (MDS) assessment revealed the resident was c.. Based on record review and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required in a timely manner.Specifically, the facility failed to ensure residents received their showers as scheduled and incontinence care in a timely manner for residents dependent on staff for their care. Cross reference F677: failure to provide activities of daily living for dependent residents.Findings include:I. Facility policy and procedureThe Staffing policy, revised 8/7/23, was provided by the nursing home administrator (NHA) on 3/19/25 at 2:21 p.m. It read in pertinent part, "The facility maintains adequate staff on each shift to meet the residents' needs. The facility utilizes the facility assessment as the foundation to determine staffing levels necessary to ensure that residents' needs are met."II. Resident and family interviewsResident #1 was interviewed on 3/19/25 at 10:15 a.m. She said the facility did not have enough staff to care for her needs. She said when the facility was short staffed and had only two certified nurse aides (CNA) working, she did not receive her showers and incontinence care was not provided. She said it could take up to 45 minutes to receive incontinence care. She said she was supposed to receive her shower on Tuesday, Thursday, Saturday and Sunday.Resident #2' s representative was int..

A complaint survey, prompted by #CO35349 was conducted on 3/25/24 to 3/27/24. Two deficiencies were cited. Based on observations, interviews and record review the facility failed to provide a safe, functional and comfortable environment to meet resident needs in six of nine resident rooms.Specifically, the facility failed to:-Ensure resident room temperatures on the 100 unit resident hallway were between 71-81 degrees Fahrenheit.-Fix a broken furnace blower on the 100 unit hallway, which would have provided back up heat to the facility rooms when thermostats were below 71 degrees; and, -Ensure the resident' s living room area on the 100 unit had heat between 71-81 degrees. Findings include:I. Facility policy and procedureThe Keeping a Resident' s Room in Order policy, revised 7/17/23, was provided by the director of nursing on 3/27/24 at 11:14 a.m. It revealed in pertinent part that the facility was to follow federal regulations and provide,"Comfortable and safe temperature levels."Maintain a temperature range of 71 to 81°F."It is the responsibility of all staff to create a ' homelike' environment."Ensure the room is a comfortable temperature for the resident."II. ObservationsOn 3/25/24 at 3:30 p.m. the room temperatures were taken in several random rooms on unit G where the 100 rooms were. The city the facility was in had experienced a snowstorm on 3/25/24 with a recorded weather temperature of 27 degrees for daytime and 25 degrees that evening.The following .. Based on observations, interviews and record review, the facility failed to ensure appropriate services and assistance to maintain or prevent further decrease in range of motion was provided for one (#1) of three residents out of seven sample residents.Specifically, the facility failed to:-Follow programs physical therapy (PT) and occupational therapy (OT) had written for restorative nursing to provide for Resident #1 who required range of motion (ROM) services; and, -Have trained staff provide consistent ROM for Resident #1 who needed the exercises to maintain his physical abilities or help to prevent further decrease in his ROM. Findings include:I. Facility policy and procedureThe Restorative Nursing policy, revised 9/11/23, was provided by email by the director of nursing (DON) on 3/27/24 at 11:14 a.m. It revealed in pertinent part,"To promote the resident' s optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring of a resident' s assessments and indicators. Nursing Assistants must be trained in the techniques that promote resident involvement in restorative activities. Restorative programs may be initiated by nursing and/or therapy."Restorative nursing program-Refers to nursing interventions that promote the resident' s ability to adapt and adjust to living as independently and safely as possible. This concept actively focu..

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1.Annual Inspection showed there were detectors not tested 2.No 2 year smoke detector sensitivity report available for review3.Heat Detectors in attic are n.. Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:1.No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding bla.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1.No generator inspection paperwork available Jan - Apr 2023 8.1.1 The routine Ma.. Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 1011.Emergency and Exit lighting no inspection documentation available for Jan - Apr 20232.Exit light by room 603 battery needs replaced NFPA 101 7.9.2.1* .. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain hazard areas in accordance with NFPA 101.1.Helium stored in basement NON RATED room with combustibles 8.7.1.1* Protection from any area having a degree of hazard greater than that normal to the gen.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1.H level aux drain room hole in ceiling2.Dry riser repair holes in room and cover for flow switch 3.Hole in rehab room ceiling NFPA 101, .. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1.Dining room delayed egress door inop | Door did drop with fire alarm2.Tables in dining room path of egress 3.Need delayed egress signage upstairs H level st.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96. 1.Need to clean suppression stove piping above griddle areas has grease build upNFPA 96 11.2.1* Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water .. Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1.No annual Fire/Smoke door inspection report available for review2.Both kitchen doors needs door closers replaced 3.Door to rehab need magnets replaced for door holders4.F hallway fire does not latch and hardware needs .. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011.Dry system report incomplete | Does not indicate size of system, report reviewed during inspection stated that it took 6 minutes for wa.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61.No Fire Drills Documented 1st Quarter 2023 (Jan - Apr)NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and a.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on January 10, 2024 for compliance with the National Fire Protection Association, (NFP..

A recertification survey was conducted from 12/11/23 to 12/14/23. Twelve deficiencies were cited. An Emergency Preparedness survey was conducted from 12/11/23 to 12/14/23. No deficiencies were cited. Based on interviews and record review, the facility failed to honor resident choices for two (#66 and #134) of two out of 44 sample residents.Specifically, the facility failed to:-Provide a schedule for Resident #66 for rehabilitation servi.. Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#62) of one resident reviewed for pain out of 44 sample residents. Specifically, the fac.. Based on interviews and record review, the facility failed to obtain informed consent for the use of psychotropic medication for two (#62 and #134) of five residents reviewed for unnecessary medication of out 44 sample residents... Based on observation and interviews, the facility failed to ensure medications and biologics were stored and labeled properly on two of four medications carts and one of two medication storage rooms.Specifically, the facility failed to.. Based on observations and interviews the facility failed to ensure medications were dispensed according to professional standards of practice.Specifically, the facility failed to follow accepted standards of practice for medica.. Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infecti.. Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one residents (#132) of eight reviewed for medication administration out of 44 samp.. Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent.Specifically, the facility had a medication error rate of 11.11%, which was three errors out of 27 op.. Based on record review and interviews the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one resident (#1.. Based on record review and interviews, the facility failed to develop an acute/baseline care plan for two (#139 and #134) of two reviewed for baseline care plans out of 44 sample residents.Specifically, the facility failed to ensure res.. Based on record review and interviews, the facility failed to ensure one out of five nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs.Specifically, the facility failed to conduct an.. Based on record review and interviews, the facility failed to ensure residents who required dialysis received dialysis services consistent with professional standards of practice for one resident (#8) of one resident reviewed for dialysis ..