Farmington Village Nrsg

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess a resident for elopement risk, ensure adequate supervision, and develop and implement interventions to prevent a resident from eloping on multiple occasions for one of twenty-four residents (R65) reviewed for elopement in the sample of 64. These failures resulted in R65 exiting the building unsupervised on multiple occasions, creating a likelihood of serious injury, harm, or death and put R65 at risk for suffering falls with major injury, weather exposure, and getting lost without the ability to summon help. The Immediate Jeopardy began on 11/12/25 when R65 was inaccurately assessed as being at zero risk for elopement despite documented elopement-risk behaviors. V1/Administrator and V2/Director of Nursing were notified of the Immediate Jeopardy on 4/24/26 at 12:00 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to place use by dates on perishable foods. This failure has the potential to affect all 83 residents who reside in the facility.

Inspectors wroteBased on record review and interview, the facility failed to perform Antibiotic Stewardship duties and fully utilize the Facility adopted McGeer's criteria for antibiotic use and education. This failure has the potential to affect all 83 residents that currently reside in the facility. Findings Include: The Facility's Antibiotic Stewardship Program policy dated 4/29/2025 documents The purpose of antimicrobial stewardship is to promote the appropriate use of antimicrobials by selecting the appropriate agent, dose, duration, and route of administration to improve patient outcomes, while minimizing toxicity and the emergence of antimicrobial resistance. The Facility's Antibiotic Stewardship Program policy dated 4/29/2025 documents Education: The facility will provide resources to clinician, nursing staff, residents, and families about resistance and appropriate antibiotic use. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop, implement and maintain an effective training program for all staff and determine the amount of time and the types of training necessary to meet the residents' needs. This failure has the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff received mandatory training and education related to effective communication. This failure has the potential to affect all 83 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff received mandatory training and education related to rights of the residents and responsibilities of the facility to care for its residents. This failure has the potential to affect all 83 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff received mandatory training and education on abuse, neglect and exploitation including activities which constitute abuse, neglect and exploitation, procedures for reporting incidents, dementia management and abuse prevention. This failure has the potential to affect all 83 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff received mandatory training and education on the elements and goals of its Quality Assurance Performance Improvement program. This failure has the potential to affect all 83 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff received mandatory training and education for the Infection Prevention and Control program which includes the written standards, policies and procedures for the program. This failure has the potential to affect all 83 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) were provided and completed a minimum of 12 hours of in-service training per year. This failure has the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff received mandatory training and education related to Behavioral Health. This failure has the potential to affect all 83 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store medications for two (R28, R71) of nineteen residents reviewed for medication administration. The facility also failed to assure a medication cart was locked when not attended, this failure has the potential to affect all 31 (R1, R5, R7, R9, R11, R12, R14, R23, R24, R26, R28, R31, R34, R35, R36, R41, R44, R48, R51, R52, R54, R58, R63, R64, R66, R69, R71, R80, R81, R83, R85) residents that reside on the 200 hall.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were updated and accurately reflected residents' current code status and advanced directive wishes consistent with signed Practitioner Order for Life-Sustaining Treatment (POLST) forms for two (R3 and R65) of 24 residents reviewed for advanced directives in the sample of 64.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure psychotropic medications had proper indications for use and failed to use nonpharmacologic interventions other than psychotropic medication for three residents (R1, R2, R56) of five residents reviewed for unnecessary medications in a total sample of 64. Findings Include: The Facility's undated Psychotropic Medications policy documents This facility shall ensure that residents do not receive psychotropic drugs unless such therapy is necessary to treat a specific condition is diagnosed by the attending physician or psychiatric consult. Chemical Restraints shall not be used to discipline a resident or for staff convenience, but only in accordance with the physician's orders when other interventions have proven unsuccessful, as documented in the medical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who depend on staff's assistance for Restorative Care services received care as ordered for four of four residents (R6, R8, R16, R18 R43) reviewed for Restorative Care, in a sample of 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and changed gloves when providing urinary catheter care and maintained a urinary catheter bag off the floor for one (R32) of three residents reviewed for urinary catheters in the sample of 64 residents.

Inspectors wroteBased on interview and record review, the facility failed to offer bedtime snacks to three of three diabetic residents (R4, R6, R43) reviewed for bedtime snacks in the sample of 64.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate medical record for three of three residents (R6, R8, R43) reviewed for accuracy of medical records, in a sample of 64.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure opened items in the kitchen were dated when opened and dry food items were stored in an airtight container. These failures have the potential to affect all 83 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient seating was available to accommodate residents who chose to eat in the dining room. This failure affected R1, R4, R6, R9, R10, R15, R19, R24, R30, R62, R68, R74, R230 and R305 reviewed for resident rights.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to thoroughly cleanse around a wound leaving fecal matter at the exterior boarder of a wound for one of one resident (R72) reviewed for pressure ulcers in the sample of 37. Finding Include: The facility's Dressing Non-Sterile (Aseptic) policy, dated January 2017, documents, The purpose of this procedure is to provide guidelines for the application of non-sterile dressings. Clean or irrigate area/wound with solution specified in treatment order (normal saline, wound cleanser, etc.) Pat peri wound and wound dry using dry gauze. R72's Wound Order documents, Cleanse area to sacrum with (wound cleanser), pack wound with wound cleanser soaked in gauze, cover with ABD (abdominal pad) and secure with tape once daily and as needed for soiling. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions while providing cares to a resident with a central line for one of one resident (R6) reviewed for Enhanced Barrier Precautions in the sample of 37.

Inspectors wroteBased on record review and interview the facility failed to notify, in writing, and maintain a copy in the Medical Record for notification of Resident/Resident Representatives upon Transfer/Discharge that were reviewed for Bed Hold Transfers. This failure has the potential to affect all 75 Residents residing in the Facility.

Inspectors wroteBased on record review and interview the facility failed to notify, in writing, and maintain a copy in the Medical Record for notification of Resident/Resident Representatives upon Transfer/Discharge that were reviewed for Bed Hold Transfers. This failure has the potential to affect all 75 Residents residing in the Facility.

Inspectors wroteBased on interview and review the facility failed have a valid PASRR (Pre-admission Screening and Resident Review) for one resident (R49) of three reviewed for PASSR in a total sample of twenty-three. Findings Include: The Facility's undated PASRR (Pre-admission Screening and Resident Review) Guideline documents the objective of the PASSR guideline is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASRR will be evaluated annually and upon any significant change for those individuals identified, R49's Pre-admission Screening and Resident Review/ Level 1 Screen dated [DATE] documents Convalescence Category with no required services. R49's PASSR dated [DATE] also documented Approval Period: 60 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan to include a biliary drain and a skin condition for two (R33, R42) of 18 residents reviewed for care plans in a sample of 23.

Inspectors wroteBased on observation, record review and interview, the facility failed to revise a plan of care for 1 of 4 (R26) residents reviewed for indwelling catheters in a total sample of 23. Findings Include: Facility Care Plans policy, updated October 2022, documents An individualized Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and/or psychological needs is developed for each resident. On 4/2/2/24 at 9:38 AM R26 was in his room and did not have an indwelling catheter. R26's Physician Orders dated March 2024 did not have an order for an indwelling catheter. R26's current Care Plan dated 03/05/24 lists an indwelling catheter as an area of care. On 04/03/24 at 2:34 PM, V4, Care Plan Coordinator, confirmed R26 does not have an indwelling catheter but his Care Plan states he does.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have orders and follow up on a dermatology order for one (R42) of one resident reviewed for skin conditions in a sample of 23.