Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa Manor Care Center during CMS and state inspections, most recent first.
Incomplete COVID-19 Vaccine Education and Documentation: The facility failed to document COVID-19 vaccine education, offers, refusals, or medical contraindications for five reviewed residents. Records for residents with significant medical histories and varying cognitive status showed their COVID-19 vaccination was not up to date, but the EMR did not show that the vaccine was offered or why it was not received. Staff said education was provided verbally and that residents who declined did not sign anything, while one cognitively intact resident stated she did not remember being offered the vaccine and never refused a shot.
Failure to Follow EBP During High-Contact Care: Staff did not consistently wear gowns and gloves while providing direct care to residents on EBP. Observations showed an unidentified staff member assisting a resident with dressing and transfer without a gown, two staff transferring a resident with a foley catheter and colostomy bag without gowns, and RN/CNA staff providing transfers, toileting, and wound-related care to another resident without the required PPE. Interviews confirmed staff knew residents with wounds or indwelling devices were on EBP and that gowns and gloves were required for high-contact care activities.
Resident exposed during shower transport: A cognitively intact resident with quadriplegia and dependence for ADLs was observed being moved through hallways in a shower chair with inadequate covering after bathing. The resident was seen with the back, lower torso, thighs, feet, and later the knees to mid-waist exposed while other residents were present. RN, DON, and CNA interviews stated residents should be fully covered to preserve dignity and privacy.
Failure to Report Alleged Resident Abuse: The facility did not report an allegation of abuse involving two residents to the State Agency or the abuse coordinator. One resident with dementia-related behaviors was reported to have called another resident names and made an obscene gesture, and an RN also observed the gesture but did not report it. The cognitively intact resident said she told the social worker and a unit manager, but staff interviews and record review showed the allegation was not documented as reported.
Fall interventions were not consistently implemented for two residents. One resident with dementia, muscle weakness, and a history of falls was repeatedly observed without a fall mat by the bed and wearing regular socks instead of non-skid socks, despite a care plan calling for both interventions; records also showed multiple unwitnessed falls. Another resident with severe cognitive impairment, heart disease, COPD, and a T11-T12 fracture was observed several times in bed without the fall mat on the floor by the bed, and staff noted they were not aware the mat needed to be placed there.
Failure to Follow Ordered Oxygen Flow Rates: The facility did not ensure ordered respiratory care was carried out for two residents on continuous oxygen. One resident with respiratory failure and CHF was observed multiple times with the concentrator turned off and oxygen not applied, despite an order for 4 LPM via NC. Another resident with emphysema, acute respiratory failure with hypoxia, and pneumonia was observed with the concentrator set at 1 LPM instead of the ordered 4 LPM, and staff acknowledged the order should have been followed.
Expired and discontinued medications were found in two medication carts, including a discontinued methocarbamol order left in a resident’s drawer and an expired guaifenesin tablet on another cart. An LPN said discontinued medications should be removed from the cart and discarded, and the DON stated unit managers were responsible for keeping carts free of expired and discontinued meds.
The facility failed to provide necessary bathing assistance to three residents due to inadequate staffing. Despite the facility's policy to assist residents with ADLs, shower logs and interviews revealed that residents did not receive scheduled showers. Staff reported a shortage of CNAs, impacting their ability to provide care, while management attributed the issue to documentation errors.
The facility failed to provide sufficient nursing staff, resulting in delayed showers and incontinence care for residents. Interviews with CNAs revealed chronic understaffing, with only two CNAs often available for 50 residents, leading to rushed care and unmet needs. Despite management's confidence in staffing levels, grievances and staff accounts highlighted significant issues with timely resident care.
Incomplete COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to develop and implement policies and procedures related to immunizations for five reviewed residents (#4, #6, #12, #38, and #58). For each of these residents, the medical record did not show that the resident or resident representative was provided education about the benefits and potential risks of the COVID-19 vaccine, and the records also did not document whether the vaccine was refused or not given because of a medical contraindication. The deficiency was identified during record review and interviews with facility staff. Resident #4 was over age 65 and had diagnoses including stroke, CAD, hypertension, hyponatremia, hyperlipidemia, dementia, hemiplegia or hemiparesis, and malnutrition; the MDS showed a BIMS score of 5 out of 15 and that the resident’s COVID-19 vaccination was not up to date, without stating whether the vaccine was offered or why it was not received. Resident #6 was also over age 65 with diagnoses including stroke, anemia, hypertension, diabetes mellitus, hyperlipidemia, dementia, and hemiplegia or hemiparesis; the MDS likewise showed a BIMS score of 5 out of 15 and no documentation of vaccine offer or reason for non-receipt. Resident #12 was over age 65, cognitively intact with a BIMS score of 14 out of 15, and had diagnoses including anemia, hypertension, hyponatremia, hyperlipidemia, aphasia, and hemiplegia or hemiparesis; the MDS stated the COVID-19 vaccination was not up to date but did not document whether it was offered or why it was not received. Resident #38 was over age 65 with diagnoses including CAD, heart failure, hypertension, PVD, GERD, renal failure, arthritis, and respiratory failure; the MDS showed a BIMS score of 15 out of 15 and again did not document whether the COVID-19 vaccine was offered or why it was not received. Resident #38 stated she remembered receiving the flu shot at the facility and receiving a vaccination sheet showing she was due for a COVID-19 vaccine, but she did not remember being offered the vaccine in October 2025 and said she never refused a shot. Resident #58 was over age 65 with diagnoses including CAD, hypertension, heart failure, hyperlipidemia, dementia, fracture, anxiety, and depression; the MDS showed severe cognitive impairment with a BIMS score of 3 out of 15 and did not document whether the vaccine was offered or why it was not received. Staff interviews indicated the COVID-19 vaccine was offered with the flu vaccine in the fall, education was verbal, residents who wanted the vaccine signed up, and those who declined did not sign anything; the DON also stated consent was obtained for residents who received the vaccine, while the immunization documentation reviewed did not include the education or refusal details.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program by not ensuring staff wore the required PPE during high-contact care for residents on enhanced barrier precautions (EBP). The report states that EBP requires gown and glove use during activities such as dressing, bathing, transferring, providing hygiene, changing linens, toileting, device care, and wound care for residents with wounds or indwelling medical devices. The facility policy also required standard and transmission-based precautions to prevent the spread of infections. On 3/24/26, an unidentified nursing staff member entered Resident #6’s room, where a sign indicated the resident was on EBP, and assisted with dressing and transferring the resident from bed to chair without donning a gown. The report also documented that Resident #70, who had a foley catheter and colostomy bag, was transferred into a shower chair via mechanical lift by two unidentified nursing staff members wearing gloves but not gowns, and later the same resident was transferred from bed to a mechanical wheelchair by two unidentified staff members who again did not wear gowns. Additional observations showed RN #4 assisting Resident #76 with transfers and toileting without wearing a gown and gloves despite an EBP sign posted on the door. CNA #5 wore gloves but not a gown while assisting Resident #76 with blood pressure measurement and toileting, and an unidentified CNA placed heel protector boots on Resident #76, who had a wound, without wearing a gown and gloves. Staff interviews confirmed that residents with wounds, catheters, ostomy bags, PICC lines, and other devices were considered appropriate for EBP, and multiple staff acknowledged that gowns and gloves should be worn for high-contact care activities.
Resident exposed during shower transport
Penalty
Summary
The facility failed to ensure dignity and respect for Resident #70 by not keeping the resident appropriately covered during transport through the hallway and common areas. Resident #70 was admitted and readmitted with diagnoses including quadriplegia, type 2 diabetes, muscle weakness, contractures of both upper arms, major depressive disorder, and anxiety. The 2/17/26 MDS showed the resident was cognitively intact with a BIMS score of 15/15 and was dependent on staff for showers, toileting hygiene, dressing, oral hygiene, and transfers. During observations, Resident #70 was transported in a shower chair from one shower room to another while covered only with a white bed sheet that exposed the resident's back, lower torso, thighs, and feet, with four other residents present in the hallway. Later, the resident was transported to his room covered with two towels while naked underneath, with visible exposure from the knees to the mid-waist on each side, and four residents were present in the common hallway area. The care plan documented the resident needed assistance from two staff for transfers and shower hygiene. Staff interviews stated residents should be fully covered after showers, that sheets or towels could be used to preserve privacy, and that residents should not be brought through the hall with skin exposed.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #85 and Resident #79 to the State Survey and Certification Agency in accordance with state law. The deficiency was identified during record review and staff interviews, and the facility was unable to provide documentation that the allegation had been reported to the State Agency or to the facility’s abuse coordinator. The facility policy reviewed by surveyors stated that staff must report alleged violations of abuse, neglect, exploitation, and misappropriation of resident property without fear of retaliation and within required time frames. Resident #85 was greater than 65 years old and had diagnoses including hypertensive heart disease with heart failure, COPD, congestive heart failure, vascular dementia, and peripheral vascular disease. His MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15, need for substantial to maximum assistance with some ADLs, and verbal behavioral symptoms directed toward others, including threatening, screaming, and cursing. His psychosocial care plan documented labile mood related to dementia with behaviors and a history of isolation and decreased socialization. Resident #79 was greater than 65 years old and had diagnoses including cancer, hypertension, peripheral vascular disease, and renal failure. Her MDS showed she was cognitively intact with a BIMS score of 15 out of 15 and needed supervision with shower transfers. She told surveyors that Resident #85 called her names and made an obscene hand gesture toward her, and said she reported the incident to the social worker and a unit manager. Staff interviews showed an RN observed Resident #85 make an obscene gesture toward Resident #79 and did not report it, and the NHA stated staff had not reported the allegation to him or to the State Agency.
Fall interventions were not consistently implemented for two residents
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents by not consistently implementing their fall interventions. Resident #4 had diagnoses including muscle weakness, dementia, respiratory failure, and a history of falling. His MDS showed he was cognitively intact with a BIMS score of 5 out of 15 and required substantial to maximum assistance with transfers, toileting hygiene, and lower body dressing. His fall care plan included interventions such as non-slip socks, a low bed, and a fall mat next to the bed, but observations showed the fall mat was not consistently in place and he was often wearing regular socks instead of non-skid socks. During observations, Resident #4 was seen in bed without a fall mat next to the bed and wearing regular socks. At one point, his call light was on for several minutes before staff responded, and when staff entered the room, the fall mat was still not placed by the bed. Later, the resident was again observed sitting on the edge of the bed without the fall mat in place and still wearing regular socks. On another observation the next morning, the resident was lying in bed without non-slip socks and the fall mat remained folded behind a chair. Record review showed multiple unwitnessed falls, including falls on 2/22/26, 3/19/26, and 3/24/26, with staff notes describing the resident found on the floor or on his knees near the bed. Staff interviews confirmed that the fall mat and non-skid socks were intended interventions and that nursing staff were responsible for ensuring they were in place. Resident #58 had diagnoses including hypertensive heart disease with heart failure, endocarditis, COPD, restless leg syndrome, and a burst fracture of T11-T12. His MDS showed severe cognitive impairment with a BIMS score of 4 out of 15 and that he needed substantial assistance or was dependent for all ADLs. His fall care plan and Kardex identified a fall mat next to the bed as a safety intervention. However, observations showed the resident in bed without a fall mat on the floor by the bed on multiple occasions, with the mat folded in the corner against the wall. Staff passed by the room without moving the mat into place. An RN stated she was not aware the resident needed the fall mat on the floor when in bed, while the DON stated the mat was intended because of the resident’s prior fall history and fracture diagnosis.
Failure to Follow Ordered Oxygen Flow Rates
Penalty
Summary
The facility failed to ensure respiratory care was provided according to physician orders for two residents receiving oxygen therapy. The report states that oxygen is considered a medication and requires a prescription and continuous monitoring, and the facility’s oxygen policy required oxygen orders to include a specific flow rate. The deficiency involved Resident #4 and Resident #1, both of whom had physician orders for continuous oxygen at 4 LPM via nasal cannula. For Resident #4, the record showed diagnoses including respiratory failure and congestive heart failure, and the resident was receiving oxygen therapy. Observations found the oxygen concentrator next to the resident’s bed turned off, with the nasal cannula connected but oxygen not being administered. This was observed while the resident was in bed, in a wheelchair in the common area, in the kitchen, and when taken to the dining room. The resident’s physician order required oxygen at 4 LPM continuously via nasal cannula, and the MAR showed staff documenting oxygen as being provided even though observations on multiple occasions showed it was not applied. For Resident #1, the record showed diagnoses including emphysema, acute respiratory failure with hypoxia, pneumonia, pulmonary hypertension, and dependence on supplemental oxygen. The resident’s care plan and physician order required continuous oxygen at 4 LPM via nasal cannula. However, observations showed the oxygen concentrator set at 1 LPM while the resident was sitting in her room, and it remained at that setting later in the day. Staff interviews indicated the resident should have been on 4 LPM per the physician order, and there was no documentation of a current titration order changing the oxygen setting.
Expired and Discontinued Medications Left in Medication Carts
Penalty
Summary
Expired and discontinued medications were found stored in medication carts in two of five medication carts observed. On the 100 Hall medication cart, the drawer for Resident #82 contained methocarbamol 500 mg oral tablets even though the order had been discontinued on 1/18/26 after being ordered on 1/13/26 for leg pain. On the 500 Hall medication cart, guaifenesin extended-release tablets were present even though the medication had expired on 3/16/26. Staff interviews confirmed that the discontinued medication should not have remained in the cart and that nurses were responsible for removing discontinued medications and placing them in the basket for discontinued medications in the medication storage room. An LPN stated the expired or discontinued medication should have been discarded, and the DON stated unit managers were responsible for ensuring medication carts were free of discontinued and expired medications, with weekly rounds performed to dispose of them. The DON also stated the medications left in the carts were overlooked.
Inadequate Staffing Leads to Missed Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, three residents who were dependent on staff for bathing did not receive their scheduled showers. The facility's policy stated that residents would receive assistance as needed to complete ADLs, but this was not adhered to, as evidenced by the shower logs and resident interviews. Resident #1, who was cognitively intact and dependent on staff for bathing, reported that the facility did not have enough staff to meet her needs, resulting in missed showers. The shower logs confirmed that Resident #1 received only a fraction of the scheduled showers over a three-month period. Similarly, Resident #2, who had moderate cognitive impairments and required partial assistance with bathing, also did not receive adequate showers, as confirmed by the shower logs and the resident's representative. Resident #3, who required maximal assistance with bathing, experienced similar issues, although there was some improvement in March 2025. Interviews with staff, including CNAs and an LPN, revealed that the facility had been experiencing a shortage of CNAs, which impacted their ability to provide scheduled showers and other personal care. Staff reported working with insufficient numbers, sometimes caring for a large number of residents alone, which delayed or prevented the completion of scheduled showers. Despite these challenges, the Director of Nursing and the Regional Vice President attributed the missed showers to documentation errors, rather than acknowledging the staffing issues reported by the staff.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure residents received timely care and services, particularly in the areas of scheduled showers and incontinence care. The facility's staffing policy, revised in August 2023, stated that adequate staff would be maintained on each shift to meet residents' needs, but interviews and grievances indicated otherwise. Residents and their families reported delays in receiving showers and incontinence care, with one resident stating it could take up to 45 minutes to receive incontinence care. The facility assessment documented a desired per patient day (PPD) for CNAs of 2.26 hours, but staffing levels were reportedly insufficient to meet this standard. Interviews with CNAs revealed that the facility had been short-staffed for over a year, with instances where only two CNAs were available to care for 50 residents. This shortage led to delays in providing scheduled showers and incontinence care, with CNAs having to prioritize residents with bowel movements over those who were wet. CNAs reported that management did not assist with resident care when short-staffed and that they were often told to do what they could with the available resources. The lack of sufficient staff also resulted in CNAs having to rush through resident care and stay late to complete charting. The Director of Nursing (DON) and the Regional Vice President (RVP) were interviewed and expressed confidence in the facility's staffing levels, attributing missed showers to documentation errors. However, the grievances and staff interviews indicated ongoing issues with staffing and resident care. The RVP acknowledged staff turnover and efforts to increase CNA pay but did not recognize a staffing concern. The facility's failure to provide adequate staffing resulted in residents not receiving necessary care in a timely manner, as documented in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mapleton Post Acute | 2.2 mi | ★★★★★ | 0 | 0 |
| Oakwood Care And Rehabilitation | 2.6 mi | ★★★★★ | 30 | 0 |
| Lakewood Post Acute And Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
| Western Hills Health Care Center | 3.1 mi | ★★★★★ | 0 | 0 |
| Allison Care Center | 3.2 mi | ★★★★★ | 1 | 0 |
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