Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to provide needed nail care for a resident with ADL/self-care deficits. A resident with Parkinsonism, weakness, cognitive communication deficit, tremor, malnutrition, and depression was observed twice with fingernails 1/2 to 3/4 inch beyond the nailbed on both hands. The resident said she did not like her nails that long and was afraid of scratching herself. Staff interviews showed mixed responsibility for nail care, while the care plan and facility policy both addressed limited assistance and regular nail trimming/cleaning.
A resident was found taking medications that had been left unsecured on the overbed table by nursing staff, despite not having an assessment or physician's order for self-administration. The medications were accessible to other residents, and staff interviews confirmed that no formal assessment for self-administration was conducted, contrary to facility policy.
A resident with a pressure ulcer did not receive prescribed wound care on specific days, and physician recommendations for supplements were not added to their orders. The LPN responsible for wound care did not consistently check progress notes for new orders, and the DON confirmed a lapse in documentation and communication.
A resident with complex medical conditions did not receive Sevelamer as prescribed due to unavailability, and the facility failed to accurately document the administration in the MAR. Despite daily communication with the pharmacy, the medication was not delivered on time, and the lack of documentation of these efforts contributed to the deficiency.
The facility failed to maintain effective communication and coordination of care for two residents, leading to inadequate treatment and monitoring. One resident did not receive prescribed medication due to unavailability, and the nursing staff documented administration when it was not available. Another resident experienced issues with dialysis coordination, including incomplete transfer forms and lack of documentation. These deficiencies highlight a breakdown in communication and coordination of care.
A resident with a pressure ulcer did not receive the necessary care and services as ordered by the physician. The facility failed to perform wound care on specific days and did not update the resident's care plan with new medication orders. The LPN admitted to not checking the physician's notes for new orders, and the DON confirmed the care nurse did not follow through with the physician's recommendations. The facility's policy required documentation of treatments, which was not adhered to.
The facility failed to maintain effective communication and collaboration between nursing staff and medical providers, leading to inadequate treatment for two residents. One resident did not receive the prescribed medication due to unavailability, and the nursing staff documented its administration despite it not being available. Another resident required regular dialysis treatments, but the facility failed to ensure proper communication and documentation related to the resident's dialysis schedule and post-treatment care. The lack of proper documentation and communication contributed to the deficiency in care.
A resident's medication administration was inaccurately documented in the MAR, with Sevelamer not consistently available or administered as prescribed. Despite contacting the pharmacy and notifying the physician, the medication was documented as given when it was not. The DON acknowledged the need for accurate documentation, but the facility's practices did not meet the required standards.
A CNA in an LTC facility failed to follow proper infection control practices by handling soiled linens and using PPE incorrectly. The CNA was observed carrying a bag of dirty linens while wearing a glove, entering another resident's room, and removing the glove without performing hand hygiene. The CNA admitted to being overwhelmed with tasks and not following the facility's policy, which was confirmed by the DON.
Failure to Provide Needed Nail Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received necessary nail care to maintain good grooming and personal hygiene. Resident #59 was observed with fingernails approximately 1/2 to 3/4 inch beyond the nailbed on both hands on two separate observations, and the resident stated she did not like her nails that long and was afraid she might scratch herself. She could not recall whether staff had offered to trim her fingernails. Resident #59’s record showed diagnoses including Parkinsonism, generalized muscle weakness, cognitive communication deficit, tremor, protein-calorie malnutrition, and major depressive disorder. Her MDS assessment showed a BIMS score of 13 out of 15, indicating intact cognition, and she was noted to require limited assistance with personal hygiene. The care plan identified an ADL/self-care performance deficit and included an intervention that she required limited assistance for personal hygiene. Staff interviews showed differing practices and responsibility for nail care. A CNA assigned to the resident stated she had not provided nail care at the facility and believed Employee C or the Activities Director handled it, while also stating long nails were too long and posed a scratching hazard. RN B stated she checked nail length and always cleaned residents’ nails, and also stated that fingernails beyond 1/4 inch past the nailbed were too long for female residents. Employee C stated she helped with nail care for non-diabetic residents, and the Activities Director stated she provided fingernail care three times per week and kept a list of residents needing it. The facility policy stated nail care includes regular cleaning and trimming unless contraindicated or refused, and that trimmed and smooth nails can help prevent accidental scratching and skin injury.
Unsecured Medication Left at Bedside Without Self-Administration Assessment
Penalty
Summary
A resident was observed taking multiple pills from a medicine cup that had been left on his overbed table by nursing staff. The resident confirmed that these were his morning medications and that, while it did not happen often, medications were sometimes left for him to take later. The medications included Aspirin, Atorvastatin, Clopidogrel Bisulfate, Glipizide, Jardiance, Meloxicam, and Sodium Chloride. The resident had a BIMS score indicating intact cognition, but there was no physician's order or assessment authorizing self-administration of medications, nor was there a care plan in place for self-administration. Facility staff interviews revealed that the nurse responsible became distracted and left the medications at the bedside, contrary to standard procedures. The Assistant Director of Nursing acknowledged that while there was a policy for self-administration, no formal assessment was conducted to determine the resident's capability, relying instead on BIMS scores and staff familiarity. The facility's policy requires an assessment of mental and physical abilities before allowing self-administration, but this was not followed in this case. The medications left unsecured were accessible to other residents as well.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with a pressure ulcer (PU), as evidenced by the lack of documented care on specific dates. The resident, who was at risk for pressure injuries and had a surgical wound, was supposed to receive daily treatment as per physician orders. However, the Treatment Administration Record (TAR) and progress notes indicated that care was not performed on two specific days. Additionally, the physician's recommendations for vitamin C and sulfate supplements were not included in the resident's orders, indicating a lapse in communication and documentation. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for wound care did not consistently check the physician's progress notes for new orders, relying instead on verbal communication. The Director of Nursing (DON) confirmed that the facility had a policy requiring documentation of wound care and expected nurses to update the resident's care log with any new physician recommendations. The DON acknowledged that the care nurse did not follow through with the physician's recommendations for the resident, and there was no documentation of care on the specified dates.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #9 was gathered through a historical document review and interview process. On , the nurse contacted the physician for resident #9 who gave orders for with C and as recommended. On the physician for resident #9 assessed the areas of skin with continued healing noted. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On , the Director of Nursing/designee completed a 14 day look audit of active residents requiring care to identify other residents having the potential to be affected to ensure: 1. Treatments were performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental , were communicated with the physician and implemented in accordance with physician orders. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On , the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on ensuring: 1. Treatments are performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental are communicated with the physician and implemented in accordance with physician orders. Newly hired licensed nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents requiring care 3 times weekly X 4 weeks and then weekly X 2 months to ensure: 1. Treatments are performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental , are communicated with the physician and implemented in accordance with physician orders. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was admitted with diagnoses including an aneurysm of the upper extremity and rapidly progressive nephritic syndrome, had a physician's order for Sevelamer to be administered three times daily. However, the MAR showed discrepancies in the administration times and doses, with some doses documented as given when the medication was not available. Progress notes indicated that the medication was not available on multiple occasions, and the pharmacy was contacted, but the medication was not delivered in a timely manner. The Transitional Care Unit Manager acknowledged that the medication was not available and that she had contacted the pharmacy daily, but these communications were not documented in the resident's medical record. The Director of Nursing stated that she expected accurate documentation and communication with the physician if a medication was not given, but there was uncertainty about the steps taken by the facility's Unit Managers to address the unavailability of Sevelamer. The facility's policy on maintaining medical records emphasized accurate documentation, but this was not adhered to in this instance.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #3 was obtained during a historical document review and interview process. On , the physician for resident #3 was notified of the medication variation/inaccuracy of documentation of administration; new orders to administer the Sevelamer once a day at 5pm while the resident was in the facility instead of administration at the clinic. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On , the Director of Nursing/designee completed a 7 day look audit of active residents to ensure accuracy of the medical record and accurate documentation of medication administration to identify other residents having the potential to be affected. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On , the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on ensuring accuracy of the clinical record and accurate documentation of medication administration. Newly hired licensed nurses will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents clinical records 3 times weekly X 4 weeks and then weekly X 2 months to ensure accuracy of the clinical record with emphasis on documentation of medication administration. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.
Communication and Coordination Failures in Resident Care
Penalty
Summary
The facility failed to maintain effective communication between nursing staff and medical providers, leading to inadequate treatment and monitoring for two residents. Resident #3, who was admitted with a diagnosis of rapidly progressive nephritic syndrome, did not receive the prescribed medication Sevelamer due to unavailability. Despite multiple communications with the pharmacy, the medication was not delivered in a timely manner, and the nursing staff documented administration of the medication when it was not available. This lack of communication and documentation resulted in a failure to provide the necessary medication for the resident's condition. Resident #4, who required dialysis treatment, experienced issues with the coordination of care. The resident's transfer forms from the dialysis center were incomplete, and there was no evidence that the facility addressed the notes from the dialysis center regarding the resident's late arrival and abbreviated treatment. Additionally, the resident did not receive breakfast or snacks before leaving for dialysis, and there was a lack of documentation in the electronic medical record regarding the resident's condition upon return from treatment. The facility's failure to ensure proper communication and documentation between nursing staff, medical providers, and external centers resulted in inadequate care for both residents. The Director of Nursing and the Unit Manager acknowledged the issues but did not provide evidence of corrective actions taken at the time of the survey. The deficiencies highlight a breakdown in communication and coordination of care, impacting the residents' treatment and overall well-being.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #3 was obtained during a historical document review and interview process. On [date], the physician for resident #3 was contacted with new orders to administer the Sevelamer once a day at 5pm while the resident was in the facility instead of administration at the clinic. Information related to resident #4 was obtained during a historical document review and interview process related to the incomplete communication forms on [date] when the resident returned from [location]. Resident #4 discharged from the facility on [date] to the community. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On [date], the Director of Nursing/designee completed a 14-day look audit of active residents receiving treatments to identify other residents having the potential to be affected by: 1. Ensuring medications are administered in accordance with physician orders and documented in the clinical record with emphasis on binders. 2. Ensuring communication sheets are completed prior to [event], completed by the center and then completed by the facility upon return from [location] or appropriately documented in the clinical record. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On [date], the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on: 1. Ensuring medications are administered in accordance with physician orders and documented in the clinical record with emphasis on binders. 2. Ensuring communication sheets are completed prior to [event], completed by the center and then completed by the facility upon return from [location] or appropriately documented in the clinical record. Newly hired licensed nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents receiving services 3 times weekly for 4 weeks and then weekly for 2 months to ensure: 1. Medications are administered in accordance with physician orders and documented in the clinical record with emphasis on binders. 2. Communication sheets are completed prior to [event], completed by the center and then completed by the facility upon return from [location] or appropriately documented in the clinical record. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a pressure ulcer (PU) for a resident, as ordered by the physician. The resident, who was admitted with diagnoses including aftercare following replacement surgery and type 2 diabetes, required assistance with activities of daily living and was identified at risk of developing pressure injuries. Despite having a care plan in place, the facility did not perform the required treatment on specific dates, and the physician's orders for additional medications were not included in the resident's care plan. The resident's medical record indicated a new open area was noted, and the physician was notified, resulting in new treatment orders. However, the Treatment Administration Record (TAR) and progress notes showed that care was not performed on certain days. The Licensed Practical Nurse (LPN) involved admitted to not checking the physician's notes for new orders and acknowledged the oversight in not updating the resident's orders with the recommended medications. The Director of Nursing (DON) confirmed that the facility had a system in place for wound care, but the care nurse did not follow through with the physician's recommendations for the resident. The facility's policy required documentation of treatments performed according to physician orders, but this was not adhered to, as evidenced by the lack of documentation on the TAR and progress notes for the specified dates.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #9 was gathered through a historical document review and interview process. On the nurse contacted the physician for resident #9 who gave orders for with, C and as recommended. On the physician for resident #9 assessed the areas of skin with continued healing noted. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On the Director of Nursing/designee completed a 14 day look audit of active residents requiring care to identify other residents having the potential to be affected to ensure: 1. Treatments were performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental, were communicated with the physician and implemented in accordance with physician orders. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On, the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on ensuring: 1. Treatments are performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental, are communicated with the physician and implemented in accordance with physician orders. Newly hired licensed nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents requiring care 3 times weekly X 4 weeks and then weekly X 2 months to ensure: 1. Treatments are performed and documented in the clinical record in accordance with physician orders. 2. Recommendations for care, including supplemental, are communicated with the physician and implemented in accordance with physician orders. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.
Communication and Documentation Failures in Resident Care
Penalty
Summary
The facility failed to maintain effective communication and collaboration between nursing staff and medical providers, resulting in inadequate treatment and continuity of care for two residents. Resident #3, who was admitted with diagnoses including an aneurysm and rapidly progressive nephritic syndrome, did not receive the prescribed medication Sevelamer due to unavailability. Despite multiple notifications to the pharmacy and the physician, the medication was not provided in a timely manner, and there was a lack of documentation regarding the administration of the medication. The nursing staff documented the administration of Sevelamer even when it was not available, and the Director of Nursing acknowledged the challenges with a new regulation requiring centers to provide certain medications. Resident #4, admitted with conditions including intoxication and acute injury, required regular dialysis treatments. The facility failed to ensure proper communication and documentation related to the resident's dialysis schedule and post-treatment care. The resident did not receive breakfast or snacks before leaving for treatment, and the transfer forms used for communication between the facility and the dialysis center were incomplete. The Licensed Practical Nurse and Unit Manager were unaware of the resident's missed meals and transportation issues, and there was no documentation in the Electronic Medical Record regarding the resident's condition post-treatment. The facility's agreement with the dialysis center required immediate communication of any changes in a resident's medical condition, but this was not adhered to. The Director of Nursing stated that assessments were documented on the Treatment Administration Record, but there was no evidence of this in the resident's medical record. The lack of proper documentation and communication between the facility and the dialysis center contributed to the deficiency in care for resident #4.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #3 was obtained during a historical document review and interview process. The physician for resident #3 was contacted with new orders to administer the Sevelamer once a day at 5pm while the resident was in the facility instead of administration at the clinic. Information related to resident #4 was obtained during a historical document review and interview process related to the incomplete communication forms on and when the resident returned from. Resident #4 discharged from the facility on to the community. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On , the Director of Nursing/designee completed a 14 day look audit of active residents receiving treatments to identify other residents having the potential to be affected by: 1. Ensuring medications are administered in accordance with physician orders and documented in the clinical record with emphasis on , binders. 2. Ensuring , communication sheets are completed prior to completed by the center and then completed by the facility upon return from or appropriately documented in the clinical record. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On , the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on: 1. Ensuring medications are administered in accordance with physician orders and documented in the clinical record with emphasis on, binders. 2. Ensuring communication sheets are completed prior to center and then completed by the facility upon return from or appropriately documented in the clinical record. Newly hired licensed nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, ie., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents receiving services 3 times weekly X 4 weeks and then weekly X 2 months to ensure: 1. Medications are administered in accordance with physician orders and documented in the clinical record with emphasis on, binders. 2. Communication sheets are completed prior to completed by the center and then completed by the facility upon return from or appropriately documented in the clinical record. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident. The resident, who was admitted with diagnoses including an aneurysm of the upper extremity and rapidly progressive nephritic syndrome, had a physician's order for Sevelamer to be administered three times daily. However, the MAR showed discrepancies in the administration times and doses, indicating that the medication was not consistently available or administered as prescribed. The progress notes revealed multiple instances where Sevelamer was not available, and the pharmacy was contacted repeatedly for delivery. Despite these efforts, the medication was documented as administered even when it was not available, and the physician was notified of the unavailability. The Transitional Care Unit Manager confirmed that the medication was not in the facility before a recent delivery, and a nurse admitted to documenting the administration without actually giving the medication. The Director of Nursing acknowledged the expectation for accurate documentation and communication with physicians regarding medication availability. However, there was uncertainty about the steps taken by the facility's Unit Managers to document their communication efforts. The facility's policy emphasized the importance of maintaining accurate and accessible medical records, but the documentation practices did not align with these standards, leading to the deficiency.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #3 was obtained during a historical document review and interview process. On __, the physician for resident #3 was notified of the medication variation/inaccuracy of documentation of administration; new orders to administer the Sevelamer once a day at 5pm while the resident was in the facility instead of administration at the clinic. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On __, the Director of Nursing/designee completed a 7 day look audit of active residents to ensure accuracy of the medical record and accurate documentation of medication administration to identify other residents having the potential to be affected. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On __, the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on ensuring accuracy of the clinical record and accurate documentation of medication administration. Newly hired licensed nurses will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents clinical records 3 times weekly X 4 weeks and then weekly X 2 months to ensure accuracy of the clinical record with emphasis on documentation of medication administration. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.
Improper Handling of Soiled Linens and PPE Use
Penalty
Summary
The facility failed to adhere to proper hygiene and use of personal protective equipment (PPE) practices as per infection control standards when handling soiled linens. A Certified Nursing Assistant (CNA) was observed leaving a room with a bag of dirty linens in a plastic bag while wearing a glove on her right hand. She entered another resident's room, interacted with the resident, and removed the glove without performing hand hygiene. The CNA then grabbed hospital gowns from a chair with her ungloved hand and left the room without placing them in a plastic bag, subsequently leaving them in the soiled utility room. The CNA acknowledged her actions, stating she was overwhelmed with tasks and did not have time to follow proper procedures. She admitted to bringing soiled linens from one room to another and wearing gloves in the hallway, which was against the facility's infection control policy. The Director of Nursing confirmed that the CNA's actions were not in line with the facility's policy, which requires staff to remove and discard PPE before leaving a resident's room and to handle soiled linens appropriately to prevent the spread of infection.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: On the Unit Manager re-educated CNA (C) on control techniques including ensuring soiled linens are not brought from resident room to resident room, gloves are not worn in the hallway and proper hygiene is to be completed prior to donning gloves and after doffing gloves. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On the Director of Nursing/designee completed an observational audit of nursing staff to identify other residents having the potential to be affected by ensuring: 1. Soiled linens are not brought from resident to resident rooms. 2. Gloves are not worn in the hallway. 3. Proper hygiene is conducted prior to donning of gloves and after doffing of gloves. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On the Director of Nursing/designee re-educated the nursing staff on the components of this regulation and completed an observational audit of nursing staff with emphasis on ensuring: 1. Soiled linens are not brought from resident to resident rooms. 2. Gloves are not worn in the hallway. 3. Proper hygiene is conducted prior to donning of gloves and after doffing of gloves. Newly hired nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an observational audit of at least 10 nursing staff members 3 times weekly X 4 weeks and then weekly X 2 months to ensure: 1. Soiled linens are not brought from resident to resident rooms. 2. Gloves are not worn in the hallway. 3. Proper hygiene is conducted prior to donning of gloves and after doffing of gloves. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 194 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Deland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Parkside Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Athens Post Acute Llc | 1.4 mi | ★★★★★ | 14 | 0 |
| Blue Lake Post Acute | 2.1 mi | ★★★★★ | 24 | 0 |
| Blue Palms Health And Rehabilitation Center Of Del | 2.4 mi | ★★★★★ | 0 | 0 |
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