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 The Villa At City Center during CMS and state inspections, most recent first.
The facility failed to submit required MDS discharge assessments for five residents. Record review showed that one resident’s discharge MDS was 120 days overdue, and four other residents were discharged without a discharge MDS being submitted. The MDS Nurse and MDS Supervisor confirmed the assessments were not submitted, and the supervisor stated their vacation occurred around the time the discharge MDSs were due.
Incomplete Baseline Care Plan: A resident admitted with ICH, CHF, BPH, and urinary retention had an indwelling urinary catheter and was on EBP, but the baseline care plan did not include the catheter, infection control, ADLs, mobility, or the level of assistance required. The LPN unit manager confirmed the baseline care plan was not complete.
Failure to Document and Implement Post-Fall Interventions: A resident with dementia, weakness, poor coordination, and a history of falls became dizzy, lost balance in the hallway, and fell toward a handrail before staff assisted the resident back to the room. The record showed no documented care plan review or intervention update after the incident, and no progress note documentation of family or MD notification related to the event.
A resident had a change in mental status during PT, and the MD was notified and recommended a CBC and UA. However, the physician orders did not show the lab order or results, and an LPN/Unit Manager stated the order into the lab system had been entered incorrectly. The resident had diagnoses including intracerebral hemorrhage, CHF, and urinary retention, and was admitted with a urinary catheter.
A facility failed to honor resident food preferences and provide consistent menu information for multiple residents. Residents reported cold meals, missing requested items such as gravy or a sub sandwich, and repeated alternative choices like hot dogs instead of preferred options. Several residents and resident council members said they did not receive regular or alternate menus and could not plan meals in advance; an LPN also reported difficulty reaching the kitchen for resident requests.
The facility's kitchen operations were found deficient due to lack of handwashing signage, paper towels, and trash can liners, as well as improper food storage and cleanliness issues. A handwashing sink was blocked, and an ice scoop holder was dirty. An unlabeled pitcher with a white powder was also found.
The facility failed to serve meals at appropriate temperatures, as reported by a resident and confirmed by a group of residents. A lunch tray tested by the Dietary Supervisor showed food temperatures below the required 135 degrees Fahrenheit, which was acknowledged by the Dietary Service Director.
A facility failed to assess and document the need for bed rails for a resident with multiple health issues, including moderate cognitive impairment. The resident was observed with bed rails up, but there was no physician's order, assessment, care plan, or consent documented. Interviews with the DON and NHA confirmed the lack of required documentation, contrary to the facility's policy on bed rail safety.
The facility failed to discard expired medications and supplies, as observed in two medication carts and a storage room. An LPN found an expired cranberry supplement and aspirin in separate medication carts, while another LPN found an expired Silvadene cream and IV start kit in the storage room. The DON stated that pharmacy staff should discard expired items monthly, and nursing staff should check carts weekly. Facility policy mandates safe storage and disposal of outdated drugs.
A facility failed to notify a resident's responsible party about significant skin changes, including wounds on the buttocks and sacrococcyx. Despite the facility's policy requiring prompt notification of changes in a resident's condition, the responsible party was not informed until the resident was hospitalized. The Director of Nursing acknowledged the oversight, and the responsible party reported being unaware of most wounds, highlighting a deficiency in communication and documentation.
A facility failed to reposition a dependent resident, resulting in the reopening of a sacral wound. The resident was observed multiple times throughout the day lying on their back without any pressure offloading devices, despite requiring total care and being unable to move themselves. A skin observation revealed a wound on the coccyx area, and the resident's care plan included interventions for repositioning and skin protection that were not implemented.
Failure to Submit Required MDS Discharge Assessments
Penalty
Summary
The facility failed to timely submit MDS discharge assessments for five residents reviewed for resident assessment. Record review showed that one resident’s MDS discharge assessment was 120 days overdue, and that resident had been admitted to the facility and later discharged on 10/26/25 without a discharge MDS being submitted. Additional record reviews showed four other residents were admitted to the facility and later discharged on 12/7/25, 12/7/25, 12/13/25, and 12/8/25, respectively, and no discharge MDS was submitted for any of them. During interviews on 3/11/26, the MDS Nurse stated that the discharge MDSs for these residents were not submitted, and the MDS Supervisor confirmed that the discharge RAI assessments were not submitted, stating their vacation was around the time the discharge MDSs were due.
Incomplete Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for one resident who was admitted with diagnoses of intracerebral hemorrhage, congestive heart failure, benign prostatic hyperplasia, and urinary retention. The resident was admitted with an indwelling urinary catheter and was on Enhanced Barrier Precautions. The Minimum Data Set assessment showed a Brief Interview for Mental Status score of 13/15, indicating no cognitive impairment, and the resident required partial/moderate assistance with upper body activities and substantial/maximum assistance with lower body activities, including bathing and transfers. Review of the medical record showed the baseline care plan did not include the indwelling catheter, infection control, activities of daily living, mobility, or the level of assistance required. In interview, the LPN unit manager stated the baseline care plan was not complete.
Failure to Document and Implement Post-Fall Interventions
Penalty
Summary
The facility failed to implement post-fall interventions for a resident with diagnoses of difficulty walking, muscle weakness, lack of coordination, and dementia. On 03/10/2026, the resident was observed walking in the hallway, reported feeling dizzy and “like they were drunk,” turned to the right, and fell toward the handrail, catching themselves on it before being assisted by an LPN and other staff back to their room. Later that day and the next day, the resident was observed walking around the unit and in and out of their room, and the Director of Therapy reported the resident did not normally have balance issues and had not heard about any change in elevation or fall for the resident. Review of the record showed the resident had an active care plan addressing fall risk, wandering related to dementia, prior falls, and interventions such as anticipating needs, medication review, rest periods during ambulation, and education on safety measures. However, no care plan intervention or review was documented after the incident, and the most recent care plan entry was unrelated to the fall event. Progress notes for 03/10/2026 and 03/11/2026 also contained no documentation of notification of the family or medical practitioner related to the incident. The Unit Manager stated that any change in plane or condition should have been documented and the physician and family called, and that this was not done.
Failure to Follow Through on Ordered Lab Tests After Change in Mental Status
Penalty
Summary
The facility failed to follow through on physician recommendations after a resident experienced a change in mental status during a PT session. A progress note dated 3/9/26 documented that the resident became disorganized in thinking, was returned to his room, and MD K was called. Another note dated 3/9/26 stated that MD K was notified of the change in mental status and recommended a CBC and UA, but the physician orders did not show an order or results for either test. The resident had been admitted with diagnoses including intracerebral hemorrhage, CHF, and urinary retention, was admitted with a urinary catheter, and had a BIMS score of 13/15 indicating no cognitive impairment. On 3/12/26, an LPN/Unit Manager stated there were no physician orders or results entered for the recommended lab work and determined the order into the lab system had been entered incorrectly.
Food Preferences and Menu Alternatives Not Consistently Honored
Penalty
Summary
The facility failed to ensure resident food preferences were honored for four identified residents, three anonymous residents, and three anonymous resident council group residents. During observations and interviews, one resident reported that lunch was served cold, including rice served without gravy, and stated they did not receive a regular or alternative menu and would like one. An LPN reported it was hit and miss getting the kitchen on the phone for requests. The same resident later returned from a doctor’s appointment and said they would likely not get a warm lunch and had been told aides were not allowed to warm up food; when they returned to their room, they indicated they would not eat lunch. Another resident reported receiving a daily sub sandwich with lunch and said they used to have to order it but now it was placed on the meal ticket, though they did not always know what would be served because they did not consistently receive a menu. A different resident reported calling for a sub sandwich but not receiving it and instead being brought a salad, stating it was okay but not a sub. Another resident reported being offered hot dogs too often as the alternative and said they did not have a copy of the regular or alternate menu, preferring grilled cheese as an alternate choice. Anonymous residents and resident council group residents also reported food was often cold, menus were not provided, and alternative items were not communicated in advance, with council notes reflecting concerns about being uninformed of menu alternatives.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. At the handwashing sink near the dish machine room, there was no handwashing signage, no paper towels, and no liner in the trash can, which was confirmed by the Certified Dietary Manager (CDM). In the walk-in cooler, a pan of sloppy meat with a use-by date of 1/4 was found, which was past its safe consumption date, and was discarded by CDM E. Additionally, the grates of the vent hood were observed to have a grease buildup. The handwashing sink near the three-compartment sink was blocked by carts, making it inaccessible. The ice scoop holder in the ice machine room on the second floor was found with black debris on the bottom inside surface. Furthermore, an unlabeled, uncovered pitcher with a white powder substance was stored on a shelf near the oven. These observations indicate a failure to adhere to the 2017 FDA Food Code standards, which require proper labeling, cleanliness, and accessibility of handwashing facilities.
Deficiency in Serving Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure meals were served at a preferred and palatable temperature for one resident and four of eight confidential group residents reviewed for food palatability. On January 6th, a resident reported that the food was often cold, specifically mentioning cold sausage for breakfast. The following day, the same resident noted that breakfast was cool but an improvement from the previous day. During a confidential group meeting, four out of eight residents indicated that their food was frequently cold. On January 8th, a lunch tray from the second floor East food cart was tested by the Dietary Supervisor, revealing that the baked potato, glazed carrots, and baked ham were served at temperatures below the facility's policy requirement of holding hot foods at or above 135 degrees Fahrenheit. The Dietary Service Director confirmed the tray's temperature was cool and acknowledged the discrepancy with the facility's policy.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to complete necessary assessments to determine the need for bed rails for a resident with multiple diagnoses, including muscle weakness and moderate cognitive impairment. The resident was observed on multiple occasions with bilateral bed rails up, yet there was no documentation of a physician's order, a bed rail assessment, a care plan, or signed consent for their use. The resident, who had signed onto hospice services and received a hospital bed with bed rails, was unable to articulate the reason for the bed rails, only stating they kept them safe. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed the absence of required documentation and assessments for the use of bed rails. The facility's policy, which emphasizes the identification and reduction of safety risks associated with bed rail use, was not followed. The policy requires regular maintenance and individual evaluations of bed rail use, including data collection and analysis, and education on the risks and benefits of bed rail use, none of which were documented for this resident.
Expired Medications and Supplies Found in Facility
Penalty
Summary
The facility failed to ensure that medications and supplies were discarded when expired, as observed in two medication carts and one medication storage room. On January 7, 2025, an expired bottle of cranberry supplement with an open date of October 2023 was found in a medication cart on the low side of the two east unit with an LPN. Additionally, a bottle of aspirin with an expiration date of September 5, 2024, was found in another medication cart on the high side of the two west unit with a different LPN. On January 8, 2025, an expired tube of Silvadene cream dated 2022 and an IV start kit with an expiration date of May 2023 were found in the medication storage room on the two west unit with another LPN. The Director of Nursing explained that pharmacy staff is supposed to come monthly to stock items and discard expired medications, and that nursing staff should check the medication carts weekly for expired medications. The facility's policy on the storage of medications states that all drugs and biologicals should be stored safely, securely, and orderly, and that discontinued, outdated, or deteriorated drugs should not be used and must be returned to the dispensing pharmacy or destroyed.
Failure to Notify Responsible Party of Resident's Skin Changes
Penalty
Summary
The facility failed to notify the responsible party of a resident about significant skin changes, which is a deficiency in communication and documentation. The resident, who had diagnoses including dementia, chronic kidney disease, and high blood pressure, was found to have new skin issues on the right buttock and excoriation on the left buttock. Despite these findings, there was no documentation indicating that the responsible party was informed of these changes. Further review revealed that the resident had multiple wounds, including on the sacrococcyx and bilateral buttocks, which were not communicated to the responsible party until the resident was hospitalized. The Director of Nursing acknowledged that the responsible party should have been notified about the buttocks wounds. The responsible party reported being unaware of the buttock and sacral wounds until the resident was hospitalized and noted that they had only been informed of a leg wound. The facility's policy requires prompt notification of the resident's representative in case of significant changes in the resident's condition, which was not adhered to in this case. The lack of communication and documentation regarding the resident's skin condition and wound changes led to the deficiency identified in the report.
Failure to Reposition Resident Leads to Sacral Wound
Penalty
Summary
The facility failed to reposition a dependent resident, identified as R902, while in bed, which resulted in the reopening of a sacral wound. Observations on multiple occasions throughout the day revealed that R902 was consistently positioned on their back without any devices to offload pressure from the back and buttocks area. Despite being dressed in a hospital-style gown and having large puffy green boots on both feet, no pillows, wedges, or other devices were used to alleviate pressure. The resident was noted to require total care, including assistance with eating, bathing, and changing when incontinent, and was unable to move themselves. A skin observation conducted later in the day revealed a nickel to quarter-sized area of non-intact skin on the coccyx/tailbone area, with a dusky purple to pink color at the base of the wound. The resident's care plan, which was initiated in September 2022, included interventions such as applying barrier cream and using a wedge to improve positioning, as well as assisting with frequent repositioning while in bed. However, these interventions were not observed to be implemented during the survey, leading to the deficiency in skin management for the resident.
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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 Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Village Of Warren | 0 mi | ★★★★★ | 1 | 0 |
| Father Murray, A Villa Center | 1.1 mi | ★★★★★ | 6 | 0 |
| Autumn Woods Residential Health | 2 mi | ★★★★★ | 28 | 0 |
| The Orchards At Warren | 2.1 mi | ★★★★★ | 22 | 0 |
| Windemere Park Health And Rehabilitation Center | 2.5 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.