Resident 114 arrived at Villa Del Rio with diagnoses including stroke, total paralysis of her right side, and severe cognitive impairment. Her physician ordered physical and occupational therapy evaluations on January 1, 2023. When inspectors visited in April 2025, no evaluations had been performed.
The resident lay in bed during inspector observations on April 21 and April 24, positioned on her back with bent arms and legs while receiving feeding tube nutrition. She was entirely dependent on staff for bathing, toileting, hygiene, and transfers from bed to chair.
"Resident 114 would have benefited from long-term RNA services to maintain Resident 114's ADL abilities and range of motion," the Director of Rehabilitation told inspectors on April 23. RNA services are restorative nursing aide programs designed to maintain basic functions.
The director said he thought nursing staff had been carrying out his 2023 recommendation for treatment. "The lack of RNA orders and services for Resident 114 placed Resident 114 at risk for the development of contractures and ADL decline," inspectors found.
Contractures are permanent muscle and tissue tightening that make joints stiff and immobile.
Another resident faced similar therapy denials. Resident 28 had multiple sclerosis, brain dysfunction, and a stage four pressure ulcer exposing muscle and bone on his right buttock. His physician ordered physical and occupational therapy evaluations on October 3, 2024.
No evaluations were completed.
When inspectors interviewed Resident 28 on April 21, both elbows were bent and both hands were clenched in fists. The resident said he received no therapy from the rehabilitation department or restorative nursing aides.
The rehabilitation director initially told inspectors that Resident 28's severe contractures prevented therapy because of his stage four pressure ulcer. "The rehab department did not want to perform any range of motion exercises," he said on April 23.
The facility's wound specialist contradicted this reasoning. She told inspectors on April 23 that although she was familiar with Resident 28's wound and had been monitoring its progress, "she did not give any directive to restrict Resident 28's ROM exercises."
By April 24, the rehabilitation director had changed his explanation. He said it was "standard of practice to not provide ROM exercises to a resident who had an active wound" but admitted he never consulted with the wound specialist about restrictions.
"The DOR stated he did not consult with WS 1 about Resident 28's ROM restrictions but should have to create a collaborative plan for Resident 28," inspectors documented. The director acknowledged that Resident 28 would benefit from range of motion exercises to prevent his contractures from worsening.
The Director of Nursing told inspectors she had "never heard of a resident not receiving ROM exercises because of the presence of wounds."
A third resident experienced treatment interruptions after hospitalization. Resident 21 had been receiving restorative nursing aide services five times per week to help him walk with a front-wheeled walker. The services were scheduled to continue through March 20, 2025.
On March 11, Resident 21 was transferred to a hospital. When he returned to the facility on March 25, his therapy services were not resumed. A new physician order for physical and occupational therapy evaluations was written on March 25, but no evaluations were performed by the time of the April inspection.
The rehabilitation director said he didn't resume services because "he was not notified by the nursing staff" of the resident's return. A restorative nursing aide who had worked with Resident 21 before his hospitalization confirmed the resident had benefited from the services but was no longer receiving them after readmission.
The Director of Nursing explained that "RNA services do not continue once a resident is readmitted to the facility" and that residents would need re-evaluation to determine if services should continue. She said nursing staff were not responsible for notifying the rehabilitation department about residents requiring evaluations upon readmission.
The facility's own policy stated that residents would receive services from restorative aides or therapists as needed and that residents entering without limited range of motion should not experience reduction unless clinically unavoidable.
Beyond therapy failures, the facility struggled with basic safety protocols. Resident 82, who was at risk for falls, was found on multiple occasions with his call light out of reach or disconnected.
On April 21, a nursing assistant observed the call light hanging behind Resident 82's bedside dresser, stating it was not within reach. The following day, inspectors found the call light cord coiled on the dresser and disconnected from the wall outlet.
During that same observation, Resident 82 got out of bed barefoot and walked unsteadily to press the call button on the wall above his dresser. A nursing assistant said he could fall attempting to reach the call light without assistance.
Resident 82's care plan specifically required keeping his call light within reach and ensuring he wore appropriate footwear as fall prevention measures.
Medication errors also endangered residents. Resident 60, who had diabetes, was prescribed Glipizide with specific instructions to hold the medication if his blood sugar dropped below 120. Despite these parameters, staff administered the diabetes medication on five occasions when his blood sugar was below the threshold, including once when it was 97.
A nurse explained that giving Glipizide when blood sugar was already low "could cause Resident 60's BS to drop further," potentially causing dangerous hypoglycemia.
The facility also failed to provide proper oversight for residents with swallowing difficulties. Resident 2, who had dysphagia and was on a mechanical soft diet due to aspiration risk, was observed taking food from other residents' meal trays in the hallway.
On April 21, inspectors watched Resident 2 roll her wheelchair to a food cart containing partially eaten meals, grab a roll, and bite into it. She also took an open milk carton back to her room. Staff said she could choke or have allergic reactions from eating food not prescribed for her diet.
The facility's infection preventionist said he had observed similar incidents and immediately summoned nurses because of "diet and choking issues." He noted that someone should have been watching Resident 2 and redirecting her from the food cart.
After a fall on December 18, 2024, Resident 134 sustained facial redness and knee pain. The facility's fall checklist required an interdisciplinary team meeting within 24 hours to analyze the incident and develop prevention strategies.
No meeting occurred.
The Director of Nursing acknowledged that every part of the fall checklist had to be completed and that the team meeting's purpose was for departments "to come together to determine the cause of Resident 134's fall and to develop interventions to preventing serious injury." Without the collaborative analysis, she said, Resident 134 remained at risk for repeat falls and potentially serious injuries.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Villa Del Rio from 2025-04-24 including all violations, facility responses, and corrective action plans.