Kruse Village Senior Living Community

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for one of one kitchen. The facility failed to ensure Dietary Aide C used proper hand hygiene between tasks on 05/05/2026. This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on interview, and record review the facility failed ensure the comprehensive care plan, consistent with resident rights, included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of five residents (Resident #41) reviewed for care plans completion. The facility failed to ensure Resident #41's care plan was completed to reflect Resident #41 had a pacemaker. This failure could place residents at risk of not receiving appropriate interventions to meet their medical needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #41) reviewed for quality of care. The facility failed to ensure that nursing staff ensured the pacemaker was being transmitted on Resident #41. This failure could place residents at risk for not being provided the care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheter care (Resident #5). The facility failed to ensure Resident #5's catheter was secured to his body with a catheter secure device per the care plan and physician's orders. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (Medication Cart #1) reviewed for medication storage. The facility failed to ensure Medication Cart #1 was locked and medications were secured. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the counter medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were given the appropriate services to maintain activities of daily living (ADLs) for three of six (Resident #1, Resident #2, and Resident #3) residents. 1. Resident #1 had a soiled and stained top. 2. Resident #2 had soiled pants and unwanted facial hairs. 3. Resident # 3 had crumbs on the top of her blanket, unwanted facial hair, and had a brown substance under her fingernails. These deficient practices could place residents at risk of embarrassment and placing them at risk for social isolation, loss of dignity and self-worth.

Inspectors wroteBased on interview, observation, and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for residents residing on four of four halls. The facility failed to provide activities on the weekends for the months of February and March of 2025. This failure placed residents at risk for boredom, depression, increased behaviors, and diminished quality of life.

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 drug and biological) to meet the needs of each resident for 2 of 4 residents (Resident #14 and Resident #29) reviewed for medications and pharmacy services, in that: 1. The facility failed to ensure Resident #14's physician ordered medication Calcium and Gabapentin were available for administration. 2. The facility failed to ensure Resident #29's physician ordered medication Saccharomyces Baulardii (probiotic) was available for administration. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs.

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 11.54% based on 3 out of 26 opportunities, which involved 2 of 4 residents (Resident #14 and Resident #29) and 1 of 1 MA's (MA E) observed during medication administration reviewed for medication error. 1. The facility failed to ensure Resident #14's physician ordered medication Calcium and Gabapentin was available for administration. 2. The facility failed to ensure Resident #29's physician orders medication Saccharomyces Baulardii (probiotic) was available for administration. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in one of one kitchen reviewed for kitchen and food sanitation. The facility failed to ensure [NAME] J wore gloves and used proper hand hygiene while preparing purée food for residents on 03/10/2025. The facility failed to ensure Culinary Aide I wore gloves while preparing a cake on 03/11/2025. These failures could have placed residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, 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 infections for one of five residents (Resident #15) reviewed for infection control practices. The facility failed to ensure LVN D followed standard precautions during wound care on 03/10/2025 for Resident #15's Stage III pressure ulcer to her sacrum, when she failed to set up a clean wound dressing field without cross contamination and failed to use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #160) of 6 residents reviewed for resident rights. The facility failed to cover Resident #160's catheter bag during therapy in the rehabilitation unit. This failure placed residents at risk of loss of dignity, embarrassment, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of three residents (Resident #15) reviewed for pressure ulcers. The facility failed to ensure LVN D followed standard precautions during wound care on 03/10/2025 for Resident #15's Stage III pressure ulcer to her sacrum, when she failed to set up a clean wound dressing field without cross contamination and failed to use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for two ( Resident #7 and Resident #160) of seven residents reviewed for catheters. The facility failed to prevent Resident #7's and Resident #160's catheter bag/tubing from touching the floor on 03/09/2025. These failures could place residents at risk for cross contamination and urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, and homelike environment for 5 of 6 Resident' beds (Residents # 1, #2, #3, #4, and #5) observed for bed linens and failed to have clean towels and top sheets available in one of one rehabilitation units. The facility failed to ensure Residents #1, #2, #3, #4, and #5's beds had a top sheet. The facility failed to ensure there were clean towels and top sheets available in the Rehabilitation unit. These failures could place residents at risk of living in an un-homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs 3 of 7 residents (Residents #39, #44, and #47) reviewed for unnecessary medications. The facility did not have appropriate indications for medications based on Resident #39's diagnoses. The facility did not have parameters to hold blood pressure medication for Resident #39. The facility did not hold blood pressure medications for Residents #44 and #47 when the residents' blood pressure or pulse was outside parameters set by their physician. These failures could place residents at risk of complications related to receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 10 dietary staff (Dietary Aide B) reviewed for food and nutrition services. The facility failed to ensure Dietary Aide B had a current Food Handler's Certificate while working in the facility's kitchen. This failure could place residents who consumed food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide liquids consistent to meet the residents' needs, for one (Resident #43) of 16 residents reviewed for food and nutrition services. The facility did not serve Resident #43 nectar thickened coffee or juice during his breakfast meal on 01/29/24. This failure could place residents who have dysphagia at risk for aspiration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided the therapeutic diets as prescribed by the attending physician for 2 of 16 residents (Residents #18 and #40) reviewed for therapeutic dietsfood and nutrition services. The facility failed to ensure Residents #18 and #40 did not received their health shake with the lunch meal on 01/29/24 as ordered by physician. This failure could place residents with diet needs at risk for a decrease in calories and potential weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being, for one1 of 5 residents (Resident #1) reviewed for treatment and services. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #1's continuous intermittent aggressive behaviors toward male residents. This failure placed residents at risk for their medical, physical, and psychological needs not being met.