John Knox Village Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident #1) was fully informed of his/her care prior to receiving the care out of three sampled residents. The facility census was 117 residents. On 4/30/25 the Administrator was notified of the past non-compliance which occurred on 4/28/25. Facility staff were educated on resident rights and resident's right to informed care. The deficiency was corrected on 4/29/25. Review of the facility's policy titled Resident Rights dated 1/3/23 showed: -Residents had the right to receive service with reasonable accommodation of their individual needs and preferences except when their health and safety, or that of another resident's, would be endangered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control standards of practices including hand hygiene were incorporated during wound care for one sampled resident (Resident #77); and failed to ensure Enhanced Barrier Precautions (EBP-strategy to decrease transmission of infections and/or cross-contamination during high-contact care activities for residents in nursing homes that include wearing gowns, gloves and at times a face mask) were used for one sampled resident (Resident #19) with a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) out of 23 sampled residents. The facility census was 112 residents. Review of the facility's Hand Hygiene policy review dated 2/19/2024 showed: -Proper hand hygiene is used for the prevention of transmission of infectious diseases. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN, Form CMS-10055) was provided for two of two residents (Residents #75 and #89) who resided at the facility, to inform them that skilled services may not be paid by Medicare, Part A; the amount of their potential financial liability if they decided to continue to receive services; and applicable claim appeal rights. The facility census was 112 residents. Review of the facility's SNF Liability Notice Policy, dated 1/1/18 and revised 1/9/25, showed: -If the facility believes during a resident's stay that Medicare will not pay for skilled nursing or rehabilitative services the facility will notify the resident/legal representative in writing and explain: --Why specific services may not be covered. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise a resident's person-centered care plan when it failed to address a pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one sampled resident (Resident #18) out of 23 sampled residents. The facility census was 112 residents. Review of the facility's policy, Care Plan-Baseline and Comprehensive revised 1/3/23, showed: -The comprehensive assessment and resulting care plan were completed through work of an interdisciplinary care plan team. -The Minimum Data Set (MDS- A federally mandated assessment instrument completed by facility staff for care planning) nurse (Registered Nurse (RN)/Licensed Practical Nurse (LPN)) facilitated the care plan decision making. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment such as Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle) masks were cleaned and stored in a sanitary condition for one sampled resident (Resident #18); and failed to ensure respiratory face masks and tubing were kept covered when not in use for one sampled resident (Resident #412) out of 23 sampled residents. The facility census was 112 residents. A CPAP equipment storage policy was requested by the facility and not provided. Review of the facility's policy titled Oxygen Administration reviewed on 7/24/24 showed: -The oxygen cannula/mask should be stored in a plastic bag when not in use. -Oxygen supplies were replaced weekly (every seven days). [...]

Inspectors wroteBased on interview and record review, the facility staff failed to follow the facility guidelines for using mechanical lifts by transferring one sampled resident, (Resident #1) out of three sampled residents, using an incorrect sling for this resident on a Hoyer lift, (a medical device used to assist lifting and transferring individuals with limited mobility), which caused him/her to slip from the sling onto the floor without injury. The facility census was 116 residents. The Administrator was notified on 7/16/24 of Past Non-Compliance which occurred on 7/2/24. An all nursing staff in-service was completed on resident transfers by 7/9/24. The deficiency was corrected 7/9/24. Review of the undated facility General Guidelines for Using Mechanical Lifts showed: -Two people were always to be used when using a Hoyer lift. -Staff were to make sure to use the correct size sling. [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the Dry Storage (DS) room, walk-in refrigerator, and walk-in freezer floors clean; to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to change the deep fryer oil in a timely manner; to properly measure and document hot food temperatures at the ovens and/or stoves to ensure they were suitably cooked, and cook longer if needed, to lessen the chance of bacterial contamination; to maintain plastic plate covers and utensils in good condition to avoid food safety hazards (cross-contamination); and to separate damaged foodstuffs, in accordance with professional standards for food service safety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents oxygen and equipment were stored in a sanitary manor for three sampled residents (Resident #2, #34, and #65); and to ensure physician orders for oxygen supplementation were clarified and carried out as intended for one sampled resident (Resident #61) out of 21 sampled residents. The facility census was 105 residents. Review of the facility's policy, Oxygen Administration and Proper Storage dated 1/31/23 showed: -This procedure was performed by a Registered Nurse (RN) or Licensed Practical Nurse (LPN). -An order for the administration of oxygen must have been obtained from a physician. -Oxygen supplies were to have been replaced weekly (every seven days). -Label and date supplies. -Respiratory equipment was to have been checked each shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents prescribed narcotic (a drug or other substance that affects mood or behavior) medications were documented as counted and the narcotic count was verified to be accurate at the beginning and end of each shift by two nursing staff. The facility census was 105 residents. Review of the facility's policy, Controlled Substance (medications that have to potential for abuse) Count, dated 4/8/23 showed: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. -This procedure was to have been performed by Registered Nurse (RN), Licensed Practical Nurse (LPN), and Certified Medication Technician (CMT). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a secure, sanitary, temperature appropriate environment. The facility census was 105 residents. Review of the facility's policy, Storage of Medications, dated 11/1/2014 showed: -The purpose was to ensure that the community stored all drugs and biologicals under proper conditions of security, segregation and environmental control at all times. -Medications were to have been stored primarily in a locked mobile medication cart which was accessible only to licensed nursing personnel. -Storage of other medication would be in a locked area. -The medication cart was to have been kept locked at all times when not in use or in direct view of the nurse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases by not changing their gloves at appropriate times, by not washing their hands between glove changes, by not cleaning scissors after each use and by failing to wash or sanitize their hands between each resident during wound care for four sampled residents (Resident #96, #80, #33, and #89) out of 21 sampled residents; and to provide Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for two sampled residents (Resident #39 and #96) out of five residents sampled for TB. The facility census was 105 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders for a sit to stand (a device designed to help people stand and transfer when the person can bear some body weight but lacks strength and/or muscle control to independently rise to a standing position) transfer with two staff were followed and clarified with the physician and to ensure the resident orders and Resident Profile sheet were updated when the resident's transfer status changed following an injury during a sit-to-stand transfer for one sampled resident (Resident #61) out of 21 sampled residents. The facility census was 105 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the dry storage and walk-in refrigerator & freezer floors clean; failed to retain thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils; failed to safeguard against foreign material or mold possibly getting into food and/or beverages; failed to keep trash and garbage receptacles lidded; failed to change deep fryer oil in a timely manner; failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; failed to follow correct hair hygiene practices; and failed to ensure the proper refrigeration of foodstuff. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 135 residents with a licensed capacity for 375. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for five sampled residents (Residents #3, #4, #6, #7 and #8) out of five residents sampled for quarterly MDS review. The facility census was 135 residents. Record review of the facility's Resident Assessment (RAI) Process policy dated 7/2/20 showed: -The RAI process was mandated process that required resident assessments. -The resident assessments should be completed upon admission, quarterly, annually and with a significant change of the resident's status. -The MDS nurses (titles are Resident Assessment Coordinators (RAC)) were responsible for submitting the MDSs to the state database. 1. Record review of Resident #3's MDSs showed: -The last MDS completed was a quarterly MDS dated [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Certified Nursing Assistants (CNA's)/Certified Medication Technicians (CMTs) directly responsible for resident care per shift in locations throughout the facility for view by residents and the public, and failed to develop a policy to address the Federal requirement for posting of staffing. The facility census was 135 residents. 1. Record review and observation of the staff posting for 8/26/21, 8/27/21, and 8/30/21 showed: -The posting detailed the licensed nurses on duty but did not show if the nurses were RNs or LPNs and did not show the total numbers of hours worked for the RNs and the LPNs on duty. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and biologicals (therapeutic substance, such as a vaccine or drug) were secure and inaccessible to unauthorized staff and residents by leaving medication carts and treatment carts unlocked; to ensure the medication cart was clean and sanitary, and to ensure there were no loose pills or other objects in the medication carts. The facility census was 135 residents. Record review of facilities Medication Administration policy dated 5/11/2010 revised 7/11/2018 showed the medication carts are to be kept closed and locked when out of sight of the medication nurse or medication aid. Record review of the facility's policy, Use of the Medication Cart, revision date 1/1/2006 showed: -The medication cart was to be locked at all times when not in use. [...]

Inspectors wroteBased on interview and record review the facility failed to complete and update as needed and at least annually a facility-wide assessment that included the necessary staff competencies needed to meet the needs of the residents, and failed to develop a Facility Assessment policy. A total of 27 residents were selected for review. The facility census was 135 residents. 1. Record review of the undated Facility Needs Assessment showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for one sampled resident (Resident #5) out of one resident sampled for annual MDS review. The facility census was 135 residents. Record review of the facility's Resident Assessment (RAI) Process policy dated 7/2/20 showed: -The RAI process was mandated process that required resident assessments. -The resident assessments should be completed upon admission, quarterly, annually and with a significant change of the resident's status. 1. Record review of Resident #5's MDSs showed: -An annual MDS was completed 7/21/20. -The last MDS completed was a quarterly MDS dated [DATE]. -An annual MDS dated [DATE] that was not completed. During an interview on 8/27/21 at 11:53 A.M., the Clinical Compliance Manager said: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or provide a written baseline care plan to the resident or family within 48 hours of admission for four out of 27 sampled residents (Residents #51, #88, #333 and #447). The facility census was 135 residents. Record review of the facility's Care Plan-Baseline and Comprehensive policy reviewed 2/7/19 showed: -The facility would begin developing a baseline care plan which would be completed within 48 hours of admission. -The resident and representative would be provided with a copy of the care plan or summary of the care plan. 1. Record review of Resident #51's entry tracking form showed he/she admitted to the facility on [DATE]. Record review of the resident's admission note dated 6/11/21 showed the resident: -Used oxygen via nasal cannula (a tubing device used to deliver oxygen). [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide Gastrostomy tube (G-tube - surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube) cleansing and care for one sampled resident (Resident #23) out of 27 residents. The facility census was 135 residents. Record review of the facilities Gastrostomy Tube Care policy, dated 2/12/2019, showed: -Nursing procedures were performed according to acceptable nursing practice guidelines. -The purpose of the policy was to prevent infection and provide proper skin care with daily G-tube and stoma care. -Prevent tube complications such as bleeding, gastric leakage, tube clogging or inappropriate migration. -Guidelines for assessment included: --Signs of misplacement or displacement. --Signs and symptoms of inward and outward migration. [...]