Country Village Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions. Observed 3 of 3 Kitchen reviewed the facility stored outdated and deteriorated food. The facility failed to provide functional handwashing sinks with hot water. The facility failed to have monitor cold holding equipment temperatures due to non functional thermostats and lack of documented alternative checks. These failures had the potential to cause foodborne illness and cross contamination for residents. Observation on 01/06/2026 at 08:20 AM revealed the walk-in refrigerator had outdated and undated ready to eat foods, including containers lacking date marking. Brown, wilted lettuce was present and stored next to ready to eat foods. Cabbage was stored with no dates to show when received nor dates of expiration. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection for 4 (wound care nurse, CNA B, ADON, and HK L) of 6 staff observed for infection control. The wound care nurse failed to perform hand hygiene after removing Resident #3's soiled dressing from her sacrum. The wound care nurse failed to perform hand hygiene before performing wound care and applying clean dressing on Resident #3. The facility failed to ensure CNA B did not pick up a wipe from the floor and continued to provide Foley care, pulled wipes from the wipe pack, and did not wash her hands before she donned clean gloves during care for Resident #13. The facility failed to ensure the ADON did not place a wedge from Resident #13 on the floor while she assessed Resident #13. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 6 residents (Resident #124 and Resident #123) reviewed for call lights. The facility failed to have a call light within reach for Resident #124 while in bed and Resident #123 while she was seated in her wheelchair. This failure could have placed residents at risk of a delay in care and services, increased falls, and a decreased quality of life. Record review of Resident #124's face sheet dated 01/09/26 revealed she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #124 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 1 of 6 residents (Resident #13) reviewed for privacy. The facility failed to ensure CNA B closed Resident #13's window blind while providing Foley catheter care for the resident. This failure could have placed residents at risk of loss of self-esteem, self-worth, and dignity. Record review of Resident #13's face sheet dated 12/04/25 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. He had diagnoses that included benign prostatic hyperplasia (enlarged prostate gland), heart failure (when the heart could not pump enough blood to meet the body's needs), and atrial fibrillation (when the upper heart chamber beat rapidly instead of pumping). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring and administering of all drugs to meet the needs of the residents for 1 (Resident# 2) of 3 residents observed during medication pass. MA A administered expired medication to Resident # 2. This failure could place residents at risk of receiving less therapeutic benefits from medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 (Resident #1) of 3 resident reviewed for medication administration. The facility failed to ensure MA G did not administer Resident # 1's morning medication late. This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication. Record review of Resident #1's face sheet dated 10/23/25 revealed she was a [AGE] year-old female admitted to the facility initial on 07/02/24 and readmitted on [DATE]. Resident #1 had diagnoses which included: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for 1(station A) of 3 medication aide cart, reviewed for medications storage.- The facility failed to ensure MA G did not leave Station A's MA medication cart unattended. This failure could affect residents, placing them at risk for taking medication which could affect the resident's health, requiring medical intervention and drug diversion.

Inspectors wroteBased on observation, record review and interviews, the facility staff failed to ensure that a resident received treatment and care in accordance with professional standards of practice, to promote healing and prevent infection for 1 of 5 residents (CR# 1) reviewed for pressure ulcers. The facility failed to prevent progression of CR # 1's Stage 4 Sacral Pressure Ulcer (a severe pressure injury that extends through all layers of skin,) that was not getting better and enlarged from 2.20 cm in length, 1.10 cm in width, 0.10 cm in depth and 2.42 cm in area on 8/19/2025 to 5.40 cm in length, 6.00 cm in width, 2.30 cm in depth, and 32.40 cm ( 2nd degree) in Area on 9/10/2025, had odor an exhibited signs of infection. The facility failed to administer CR # 1's antibiotics, Cefdinir, for the sacral ulcers and as ordered by the wound care Nurse Practitioner on 9/3/2025. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident individuality and protected and promoted the rights of the resident personal privacy for each resident's individuality for 2 of 4 residents (Resident #1 and Resident #2) reviewed for dignity in that: The facility failed to provide Resident #1 and Resident #2 with privacy covers for their urinary catheter bags. The failure could place residents with catheters at risk of emotional distress, embarrassment, lower self-esteem and decreased privacy.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents are offered a therapeutic diet when there is a nutritional problem, and the healthcare provider orders a therapeutic diet for 1 of 1 resident (Resident #3) reviewed for food and nutrition. The facility failed to ensure a diet order for Resident #3 was ordered and implemented timely. This failure could lead to electrolyte imbalances and other imbalances related to fluid in the body.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (CR #1) of 5 residents reviewed for pharmacy services. -The facility failed to ensure CR#1's morphine (opioid pain-relieving medication that usually provides significant pain relief for short term or chronic pain) and Norco (combination of acetaminophen and hydrocodone to relieve moderate to severe pain) medications were not administered too close together to prevent accidental overdose on 01/01/25. An Immediate Jeopardy (IJ) was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 9:26 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that its residents were free of any significant medication errors resident for 1 (CR #1) of 5 residents reviewed for pharmacy services. -The facility failed to ensure CR#1's morphine (opioid pain-relieving medication that usually provides significant pain relief for short term or chronic pain) and Norco (combination of acetaminophen and hydrocodone to relieve moderate to severe pain) medications were not administered too close together to prevent accidental overdose on 01/01/25. An Immediate Jeopardy (IJ) was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 9:26 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #59) of 40 residents reviewed for quality of care. The facility failed to conduct skin assessments /assess skin on Resident #59's contracted right arm and forearm resulting in redness at site of contracture and forearm with brown exudate (moisture associated skin damage) and pungent odor. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. Seven dented cans were on the rack located in the dry storage room. This deficient practice could place residents who received meals from the main kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's right to formulate advance directives for 1 (Resident #165) of 40 residents reviewed for advance directives. Between [DATE] and [DATE] Resident #165 did not have an active physician's order for a code status with either Full Code Status, DNR or any other order to support her advanced directive. The facility failed to ensure that Resident #165 admitted on [DATE] had a code status entered in the resident's records at the facility. This deficient practice could place the residents at risk of not having their end of life wishes honored, such as receiving unwanted resuscitative measures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 40 (Resident #93) residents reviewed for quality of care. The facility failed to ensure Resident #93's oxygen tubing was labeled and dated. This failure places the resident at an increased risk of infection leading to a decline in health.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 23 residents (Resident #100) reviewed for significant medication errors. The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered on 10/05/2024 and 10/11/2024 to Resident #100 as ordered on 08/05/2024 by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 4 halls (200 Hall) and 1 of 4 treatment carts (treatment cart 200 hall) reviewed for medication storage. The facility failed to ensure RN C locked the 200-hall treatment Cart before leaving it unattended on 10/17/2024. This failure could place residents at risk for possible drug diversions or accidental ingestion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 8 residents (Resident #31) reviewed for infection control. The facility failed to ensure LVN A followed proper infection control and handwashing during wound care for Resident #31on 10/16/2024. The facility failed to ensure CNA A followed proper infection control and hand washing procedure before incontinent care for Resident #31 on 10/16/2024. These failures could lead to cross-contamination and the development of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12%, based on 4 errors out of 32 opportunities, which involved 2 (Residents #89 and #49) of 5 residents and 2 (LVN B and MA G) of 4 staff reviewed for medication errors in that: -LVN B failed to administer Resident #89's medications individually via gastrostomy tube (a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration, or medicine) and failed to administer a water flush between each medication according to the physician orders. -MA G administered Sodium Bicarbonate 325 mg to Resident #49 instead of Sodium Bicarbonate 650 mg as ordered by the Physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (Parkside station Nurse cart and Courtyard station Nurse cart) reviewed for medication storage. - The facility failed to ensure the Parkside station's Nursing cart did not contain two opened and undated insulin pens. -The facility failed to ensure the Courtyard station's Nursing cart did not contain one undated insulin pen. These failures could place residents at risk of adverse medication reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for each resident. The facility failed to ensure 7 of 56 resident rooms (rooms 409, 410, 411, 412, 413, 414, and 418) were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 3 (Courtyard station's Nursing Cart) medication carts reviewed for pharmacy services. The facility failed to ensure the Courtyard station's Nursing cart did not contain two expired insulin vials. This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.