Country Villa Wellness & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored safely, physician orders and care plans were updated, and medication administration was documented appropriately, in accordance with facility policy, for one resident of five residents reviewed for self-administration of medication (Resident #1). The census was 85. Review of the facility's Ordering Self Administration of Medications policy, dated 12/15, showed:-Facility responsibility: Individual residents may self-administer medication if the following criteria are met: --Must have physician order to self-administer each particular medication; --Charge nurse must complete the self-administration of medication assessment form; --The interdisciplinary team must determine that it is safe for the resident to self-administer drugs before the resident may exercise that right; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for documenting medication administration records for two of 13 sampled residents (Resident #7 and #5) who received intravenous (IV-injected directly into a person's vein) medications. The census was 79. Review of the facility's Medication Administration policy dated 01/26, showed:-Purpose: To provide standards for safe administration of medications for residents in the facility;-Policy: --Medication will be administered by a licensed nurse via the order of an attending physician or licensed independent practitioner, or as consistent with state law; --Medications must be given to the resident by the licensed nurse preparing the medication or as consistent with state law;-Documentation: Record the time, dose and initials of the nurse administering medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to administer physician-ordered medications to 10 residents (Resident #8, #6, #4, #7, #17, #5, #9, #10, #2, and #3). The sample was 17. The census was 80. Review of the facility's Physician Orders policy, revised 6/2020, showed: -Purpose: This will ensure that all physician orders are complete and accurate;-Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary;-Procedure:--Medication/treatment orders will be transcribed onto the appropriate resident administration record. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment in accordance with acceptable standards of practice when facility staff failed to complete and document neurological assessments (neuro checks) following unwitnessed falls for three residents (Residents #3, #10 and #15). The sample was 17. The census was 80. Review of the facility's Fall Evaluation and Prevention policy, dated 8/2020, showed:-Purpose: To ensure that the resident's environment remains as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance to prevent accidents;-Policy: The facility will evaluate residents for their fall risk and develop interventions for prevention. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify interventions to reduce the likelihood of another fall for four residents who had unwitnessed falls (Residents #3, #10, #1, and #15), and facility staff failed to notify the resident's family/resident representative (RR) of falls for two residents (Residents #3 and #10). In addition, the facility failed to ensure three staff performed an assisted transfer for one resident (Resident #8) as instructed by the resident's physician orders and care plan, and staff failed to document an incident report and to notify the resident's physician and RR when the resident was injured during a staff-assisted transfer. The sample was 17. The census was 80. Review of the facility's Fall Management Program Policy, undated, showed:-Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when staff failed to administer seizure medication as ordered for one resident who experienced increased seizures (Resident #10). The sample was 17. The census was 80. Review of the facility's Physician Orders policy, revised June 2020, showed:-Purpose: This will ensure that all physician orders are complete and accurate;-Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary;-Procedure: --Medication/treatment orders will be transcribed onto the appropriate resident administration record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free of hazards by not maintaining water temperatures in resident bathrooms on the 100 hall between 105 degrees Fahrenheit (F) and 120 F. This affected 10 resident bathrooms, including Residents #10 and #25. The temperatures at the bathroom sinks measured as high as 148 F. The sample size was 22. The census was 94. Review of the facility's Monitoring Water Temperatures policy, revised 11/2022, showed: -Policy: The water temperature will be maintained between 110 degrees F and 120 degrees F; -Procedure: Environmental staff will check random water temperatures weekly, including three resident room sinks on each wing, common area sinks and bathing rooms; -Water temperatures will be documented on the Water Temperature Monitoring Log; -Procedure for checking water temperatures from water faucets: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with wounds requiring treatments for two residents (Resident #40 and Resident #14) and while administering medications through one resident's (Resident #58) gastrostomy tube (g-tube, a surgically inserted tube into the abdomen that is used for liquid nutrition and medications). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect when a staff member took a video of a resident from a personal phone and posted in social media (Resident #39). In addition, staff used their personal phones while monitoring residents during mealtime. The census was 94. The sample was 22. Review of the facility's undated Resident Rights, showed: -Your right to be treated with dignity and respect is the foundation of which all other resident rights and responsibility are based; -Your right to privacy and confidentiality is as important to you as it is to any other person. Review of the facility's Social Media and Electronic Devices Policy, dated 11/2019, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required activities of daily living (ADLs, bathing, dressing and toileting) received necessary services to maintain adequate personal hygiene when staff left two residents soiled for an extended period (Resident #61 and Resident #40). The sample size was 22. The census was 94. Review of the facility's Perineal Care (cleansing of the genitals and anal area) policy, revised March 2021, showed: Purpose: To establish routine practices for providing perineal care, which will cleanse, prevent skin breakdown, prevent infection, and prevent odors. All residents will receive perineal care, as needed, in the morning before breakfast every evening with evening care at bedtime, as needed after bowel movement or urination, and each time the resident is incontinent. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of one resident (Resident #61). The sample was 22. The census was 94. Review of the facility's Urine Specimen Collection Guidelines, reviewed, June 2021, showed: -Purpose: The reported prevalence of asymptomatic bacteriuria (the presence of bacteria in the urine) is higher than that of the symptomatic urinary tract infections (UTI). Therefore, the quality of urine specimens sent for culture and sensitivity testing must be assured. The quality and accuracy of the results relies directly on the manner in which the specimens are obtained, stored, and processed. -Procedure guidelines: [...]

Inspectors wroteBased on interview and record review, facility staff failed to keep residents free from accidents when staff failed to use safe, professional standards of care when transferring two residents (Residents #1 and #2) using a Hoyer lift (a mechanical device that helps people with limited mobility move from one place to another, such as from bed to a wheelchair). This failure caused an injury requiring hospitalization and surgery for one resident (Resident #1). The facility also failed to investigate two improper Hoyer transfers involving one resident (Resident #2) and did not put corrective measures in place to prevent further injuries to both residents. The sample was three. The census was 88. Review of the facility's Incident/Accident Policy, dated December 9,2016, showed: -Purpose: to record any unusual situation or injury to a resident, staff member or visitor; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all areas of the facility in a safe, functional, sanitary and comfortable environment for visitors, staff and residents. The census was 95. Review of the facility's Preventative Maintenance and Inspections policy, reviewed 2022, showed: -Policy: To provide a safe environment for residents, employees, and visitors, a preventative maintenance program has been implemented to promote the maintenance of equipment in a state of good repair and condition; -A schedule is developed to delineate all inspections that are to be completed on a regular basis. inspections verify that ail equipment and furnishings are in working order and free from safety hazards. During an interview on 9/26/24 at 11:28 A.M., Employee E said: -He/She heard there was mold found in the building from a fellow employee; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care that met professional standards of quality by failing to follow physician orders for wound care and failed to accurately document in the Medication Administration Record (MAR) for two residents (Resident #2 and #5). The facility also failed to notify the Primary Care Physician when a resident was struck in the head, document an incident fully and failed to follow their policy to initiate and document complete neurological assessments (exam to identify signs of disorders affecting the brain, spinal cord and nerves) for one resident (Resident #2) after the resident was hit in the head. The sample was three. The census was 95. Review of the facility's Following Physician Orders policy, dated 6/29/21, showed: -Policy: [...]

Inspectors wroteBased on observations, interviews, and facility document and policy review, the facility failed to ensure housekeeping services were provided to maintain clean floors in resident rooms on 2 (Unit 200 and Unit 300) of 3 units. Specifically, the facility failed to ensure resident rooms were vacuumed and/or mopped daily to prevent food and debris from remaining on the floor.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for 1 (Resident #155) of 3 residents reviewed for pressure ulcers. Specifically, the facility failed to implement wound treatment orders from the hospital and obtain physician's orders for wound treatment after pressure ulcers were found upon admission. Therefore, the facility failed to ensure Resident #155 received pressure ulcer treatment for approximately three days.

Inspectors wroteBased on interview and record review, the facility failed to follow their infection control policy when staff failed to complete the second step of employee tuberculosis (TB, a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests for two employees. The census was 104. Review of the facility's Tuberculosis Control Policy, Employee and Resident, undated, showed the following: -Purpose: It is the policy of the facility to comply with Occupational Safety and Health Administration (OSHA) and state regulations in regard to tuberculosis control. This document is an interim policy until the final OSHA standard is released; -Procedure: -Employees: -1. All new employees will be screened on hire by using the Two Step Mantoux skin test unless they have a documented previous significant reaction; -2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure opened medications were labeled with residents' names and date opened. The facility also failed to discard outdated, opened eye drop medication for one expanded sample resident (Resident #26) and one sampled resident (Resident #50) for four of four medication carts checked. The sample size was 23. The census was 118 with 113 residents in certified beds. 1. Observation on 9/24/19 at 8:30 A.M., of the 200 Hall nurses' medication cart, showed the following: -One opened 4 once (oz) tube of Sensicare (moisture) cream, not labeled with resident's name; -Two opened 3.53 oz jars of Vicks vapor rub (topical ointment), not labeled with resident's name. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the cleanliness of the vent in the dishwasher area, which could blow air on clean dishes. The facility also failed to store dishes in a manner to protect them from dust and debris. The census was 118 with 113 residents in certified beds. 1. Observations of the kitchen between 9/24/19 at 8:20 A.M. and 9/27/19 at 6:30 A.M., showed the following: -A ceiling vent, inside the back exit door, had a heavy build-up of dark gray dust inside the grates of the vent. The vent was directly over a stack of face-up saucers and bowls; -A heavy build-up of dust on the ceiling, adjacent to the serving area. 2. Observations of the kitchen on 9/24/19 at 8:30 A.M. and 11:00 A.M., 9/25/19 at 6:00 A.M. and 10:00 A.M., 9/26/19 and 9/27/19 at 6:30 A.M., showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect, dignity and care in a manner and environment which promoted enhancement of his/her quality of life at meals in the dining room. Staff failed to serve four of four residents, seated at the same table, at the same time as each other or other residents in the dining room (Residents #72, #21, #68 and #29). The census was 118 with 113 residents in certified beds. Review of Resident #72's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/13/19, showed the following: -Moderate cognitive impairment; -Independent with eating, no help or staff oversight at any time; -No signs or symptoms of possible swallowing disorder; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs and risks within 48 hours of admission to properly care for two residents (Residents #261 and #259). The facility identified 21 newly admitted residents. Of those, two were chosen for the sample and problems were found with both of them. The census was 118 with 113 residents in certified beds. 1. Review of Resident #261's medical record, showed the following: -admitted on [DATE]; -Gastrostomy tube (G-tube-a tube surgically inserted into the stomach to provide hydration, nutrition and medications) placed in the hospital on 9/13/19; -Diagnoses included alcohol dependence, dysphagia (inability to swallow), cirrhosis of the liver (liver disease) and altered mental status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident (Resident #259) received treatment and care in accordance with professional standards of practice, facility policy and the comprehensive person-centered care plan, by failing to assess and treat an open area. The census was 118 with 113 residents in certified beds. Review of the facility's wound care protocol, revised August 2018, showed the following: -Goals of assessment: -Provide uniform description; -Facilitate communication among staff; -Adequate monitoring of progress or deterioration; -Assess the entire person not just the ulcer; -Assess for pain and implement interventions to relieve. -How to assess/document: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 37 opportunities, two errors occurred resulting in a 5.41% medication error rate (Resident #261). The census was 118 with 113 residents in certified beds. Review of Resident #261's medical record, showed the following: -admission face sheet, showed admission date of 9/18/19; -Diagnoses included elevated blood pressure (BP) reading without diagnosis of high blood pressure and status post placement of gastrostomy (g-tube, a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications). Review the resident's physician's order sheet (POS), dated September 2019, showed the following; [...]