Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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'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 Facility policy mandates safe storage and disposal of outdated drugs.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.
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 | — | 0 | 0 |
| Father Murray, A Villa Center | 1.1 mi | — | 5 | 0 |
| Autumn Woods Residential Health | 2 mi | — | 2 | 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 August 2026) and official state health department websites.