Locust Grove Village

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week.

Inspectors wroteBased on interviews and record review, the facility failed to provide the services of a full-time certified dietary manager for the 36 residents who resided in the facility and received their meals from the kitchen.

Inspectors wroteBased on observation, record review and interviews, the facility failed to follow sanitary dietary standards related to food storage and service.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store medications and biologicals within professional standards of practice when the facility failed to date check vials of of intramuscular (IM-injected directly into a muscle) lorazepam (a class of medications that calm and relax people), high dose influenza (highly contagious viral infection) vaccine, and influenza vaccine, that were past the date to be used.

Inspectors wroteBased on interviews, observation, and record review the facility failed to ensure the as needed (PRN) Benadryl being used for its psychotropic (alters mood or thought) properties had a 14-day stop date or a specified duration with supporting physician documentation for Resident (R) 6's PRN Benadryl.

Inspectors wroteBased on interviews, observation, and record review the facility failed to ensure Resident (R) 6 had a current physician order with an appropriate indication for the ongoing use of an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) which included the size of catheter needed.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for Resident(R)6's as needed psychotropic (alters mood or thought) medication.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure collaboration with the hospice provider for Resident (R) 6.

Inspectors wroteBased on record reviews, and interviews, the facility failed to offer and provide or obtain a signed declination for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) for Resident (R)11, R4 and R25.

Inspectors wroteThe facility identified a census of 34 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to prevent an episode of staff-to-resident physical abuse. On 06/28/25 at approximately 06:40 PM, Certified Nurse Aide (CNA) M took cognitively impaired Resident (R)1 to the bathroom. CNA M called for assistance, and CNA N came to R1's room. CNA M told CNA N that R1 bit her, so CNA N took over care. CNA N noticed R1 was dabbing her face with toilet paper, and the toilet paper had blood on it. CNA N asked R1 what happened, and R1 said, Honey, can you believe it? Her fist hit my jaw. CNA N observed a purple bruise on R1's right jaw and blood in the resident's mouth. CNA N informed LN G and CNA M of R1's statement. CNA M denied hitting R1. [...]

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, interview, and record review the facility failed to employ a full time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 36 residents of the facility at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 36 residents. Based on observation, interview, and record review the facility failed to store biologicals as required when staff failed to discard or destroy expired medications and vaccines. This deficient practice placed residents of the facility at risk of receiving ineffective medications.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents. Based on observation, interview, and record review the facility failed to provide food prepared by methods that conserve nutritive value, flavor, and appearance when dietary staff failed to measure and provide the proper amounts of food for the four residents with a pureed diet. This placed the four residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to ensure a bed rail that met safety requirements and addressed risks for entrapment for Resident (R)4. This placed her at risk for accident or injury due to unidentified risks associated with side rail use.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a 14-day stop date or specified duration, for Resident (R)10's as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R10 at risk for unintended effects related to psychotropic drug medications.

Inspectors wroteThe facility had a census of 36 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with rationale for Resident (R)10's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R10 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to discard expired medications in the emergency drug treatment kit/box located in the medication room. This placed residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with five reviewed for falls. Based on observation, interview and record review the facility failed to provide adequate supervision for Resident (R) 29 who fell when she was left unattended in the shower room and R35 who fell while unsupervised in an unlocked treatment room. This deficient practice placed R29 and R35 at risk for injuries from falls.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing, facility medical director, and physician, the lack of a 14 day stop date for Resident (R)11 and R13's as needed (PRN) psychotropic (a medication that affects mood and/or thought) or rationale for continued use. This placed the residents at risk for inappropriate use of a psychotropic medication with side effects.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interview and record review, the facility failed to ensure a 14- day stop date for Resident (R)11 and R13 who received as needed (PRN) psychotropic (medication that affects mood and/or thoughts) that lacked a 14 day stop date or rationale for continued use. This placed the affected residents at risk for unintended affects related to psychotropic drug medications.