Inspection Reports for
Villa Lorena Senior Living

The complaint alleged that facility staff handled Resident #1 roughly resulting in bruises due to an altercation between Resident #1 and Staff #1. The allegation was substantiated. Another complaint alleged the licensee did not follow the resident's plan of care regarding standby assistance for showering; this was unsubstantiated.

The investigation substantiated that staff member S1 handled Resident #1 roughly, causing bruising and skin tears, and that the licensee failed to report the incident to the licensing agency. A deficiency was cited for failure to protect residents from physical abuse. A plan of correction was developed including termination of S1 and staff training. Another allegation that the licensee did not follow the resident's plan of care was found to be unsubstantiated based on records and interviews showing that more care was provided than outlined in the care plan.

The complaint investigation was substantiated for allegations that licensee staff did not follow COVID-19 guidance, the facility was in disrepair, and staff spoke inappropriately to residents. The allegations that staff did not meet resident's needs, including incontinence needs, and that staff retaliated against a resident were unsubstantiated.

The investigation substantiated allegations that the licensee staff failed to follow COVID-19 guidance, the facility was in disrepair with mold issues in room #106, and staff spoke inappropriately to a resident. The allegation that staff retaliated against a resident and did not meet resident's needs was unsubstantiated. Three Type B deficiencies were cited related to buildings and grounds, personal rights, and infection control.

The complaint investigation was triggered by allegations that the licensee did not assist a resident with medication administration, charged residents for items never provided, failed to provide itemized statements, did not meet transportation, housekeeping, and dining needs, and did not respond to residents' communication requests. The communication allegation was substantiated; others were unsubstantiated.

The investigation substantiated that the licensee failed to respond promptly and appropriately to residents' communication requests, resulting in one cited deficiency. Other allegations including medication assistance, billing for unprovided items, transportation, housekeeping, and dining services were found unsubstantiated based on interviews, records review, and observations.

The complaint was substantiated. The allegations included failure to provide records to the resident's responsible party, failure to notify the responsible party of an incident, and failure to update the resident's records. Evidence included record reviews, interviews, and written correspondence. The facility was cited for three deficiencies and developed a plan of correction.

The investigation substantiated the allegations, finding that the licensee staff failed to provide prompt access to records, did not notify the resident's responsible party of an incident within seven days, and did not update the resident's records to reflect the incident. Three deficiencies were cited related to these failures.

The complaint investigation was substantiated for the allegation of staff falsifying documents related to COVID-19 test results for Resident #1. The allegation that staff did not notify the authorized representative of a change of condition was unsubstantiated.

The investigation substantiated that staff falsified a COVID-19 RT-PCR test document for Resident #1, posing a potential personal rights risk. The allegation that staff did not notify the authorized representative of Resident #1's change of condition was found to be unsubstantiated due to lack of documentation and contradictory evidence.

The complaint investigation was substantiated for allegations that staff tampered with a resident's personal belongings by covering the resident's laptop camera without proper consent and that the resident was not provided with safe equipment due to an inoperable wander guard bracelet. The allegation that the facility withheld the resident's medical records was unsubstantiated.

The investigation substantiated that staff covered a resident's laptop camera without proper consent, violating personal rights, and that the resident's wander guard safety equipment was inoperable for approximately three days, posing a safety risk. The allegation that the facility withheld the resident's medical records was found unsubstantiated.

No deficiencies were cited during the visit; however, a technical violation was issued. The facility was found to be generally compliant with regulations, including proper food storage, medication management, and resident care.

The visit was triggered by two incident reports involving Resident #1, which were self-submitted by the licensee. The resident was found safe and no substantiation of deficiencies was noted.

During the unannounced case management incident visit, the resident was found safe, pertinent records were reviewed, and staff interviewed. No deficiencies were cited, but one Technical Violation related to Reporting Requirements was issued.

The complaint alleged that staff did not meet minimum qualifications. The allegation was substantiated based on record review and interviews, confirming that staff member S1 lacked required annual training hours for 2020 and 2021.

The investigation substantiated that staff member S1 did not complete the required 20 hours of annual training for 2020 and 2021, posing a potential safety risk to all 67 residents in care. Staff files showed current background clearances and health screenings, but the training requirement was not met.

The complaint investigation was substantiated regarding failure to address multiple falls for residents R1 and R2 resulting in minor injuries. The allegations of insufficient staffing and failure to notify responsible parties of incidents were unsubstantiated.

The investigation substantiated that the facility failed to implement updated care plans or fall mitigation strategies for residents who experienced multiple falls resulting in minor injuries. However, the allegation that the facility lacked sufficient staffing was unsubstantiated based on staff interviews and records. Additionally, the facility failed to notify responsible parties of some incidents, which was also unsubstantiated.