Senior Village Nursing & Rehabilitation Center

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician documented a Gradual Dose Reduction (GDR) was attempted or a clinical rationale for not reducing psychotropic medication recommended for GDR for 1 (#2) out of 5 (#1, #2, #4, #7, and #99) residents sampled for unnecessary medication review.

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the State's Long-Term Care Ombudsman of emergency transfers in writing for 1 (#7) out of 4 (#7, #62, #89, #105) residents reviewed for accidents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1, and Resident #43) residents out of 41 sampled residents.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive careplan for 2 (Resident #4 and Resident #62) of 41 sampled residents as evidenced by failing to: 1. ensure physician orders were implemented for wound care for Resident #4 and 2. develop a careplan for bed rails for Resident #62Findings:Review of Resident #4's electronic health record revealed an admission date of 06/24/2021 with diagnoses that included but were not limited to, age-related osteoporosis, cognitive communication deficit, and hereditary and idiopathic neuropathy. Review of Resident #4's TAR (Treatment Administration Record) for September 2025, October 2025, and November 2025 revealed an order dated 09/07/2025 for Cleanse excoriated area to left buttock with normal saline, and apply zinc oxide bid (twice a day) until resolved. [...]

Inspectors wroteBased on record review and interviews the facility failed to develop a person-centered comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 (Resident #16) out of 41 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure accurate administration of all drugs by failing to administer the correct dose of Zinc for 1 (Resident #79) out of 4 residents observed form medication administration.

Inspectors wroteBased on record review and interviews, the facility failed to follow physician's orders for 1 (Resident #3) of 3 (Residents #1, #2, #3) sampled residents. The deficient practice had the potential to affect a census of 126.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that an injury of unknown origin was reported immediately, but not later than two (2) hours to State Survey Agency after discovering or learning of the injury for 1 (Resident #1) of 3 (Residents #1, #2, #3) sampled residents. The deficient practice had the potential to affect a total census of 126 residents.

Inspectors wroteBased on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were transmitted within 14 days after completion for 8 (# 8, #10, #23, #45, #67, #105, #112, and #122) out of 9 ( (# 8, #9, #10, #23, #45, #67, #105, #112, and #122) residents reviewed for resident assessments submission activities.

Inspectors wroteBased on policy review, observation, record review and interview, the facility failed to store food in accordance with professional standards for food service safety by the dietary staff failing to ensure that all foods on the steam table maintained adequate holding temperature prior to being served. This deficient practice had the potential to affect 111 residents that received food from the kitchen. Total facility census was 118.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a clean and sanitary environment by failing to ensure the Resident's personal equipment in the resident's room were free of dust and lint for 1 (#231) of 48 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment was completed accurately for 1 (#9) out of 48 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to develop and implement a person-centered care plan that addressed catheter care for 1 (#63) out of a total sample of 48 residents.

Inspectors wroteBased on record review and interview, the facility failed to maintain acceptable parameters of nutritional status, by failing to address a recommendation from the RD (Registered Dietician) for 1 (resident #127) out of 7 residents (#47, #58, #100, #102, #109, #124, #127) investigated for nutrition out of a total sample of 48 residents.

Inspectors wroteBased on policy review, observation and interview, the facility failed to ensure the resident's food was palatable and attractive by the dietary staff failing to prepare foods according to the recipe. This deficient practice had the potential to affect 111 residents that received food from the kitchen. Total facility census was 118.

Inspectors wroteBased on observations and interview, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition by having an air conditioner that was leaking a liquid substance for 1 (Resident #48) out of a finalized sample of 48 residents.

Inspectors wroteBased on records reviewed and interviews, the facility failed to ensure their grievance policy and procedure was followed. The facility failed to initiate grievances that were voiced for 1 (#3) out of 4 (#1-#4) residents investigated for grievances out of a sample of 6 (#1-#4, R1 and R2) residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an alleged violation of physical abuse involving staff to resident was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#4) of 1 resident investigated for abuse out of a total of 6 (#1-#4, R1 and R2) sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were completed accurately for 2 (#2 and #4) out of 6 (#1-#4, R1 and R2) sampled residents.

Inspectors wroteBased on record review and interview the facility failed to ensure that services were provided as outlined in the comprehensive plan of care by failing to accurately document intake and output for 2 residents (#42 and #95) out of 2 sampled residents. The total sample was 49 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure that dishware had been thoroughly cleaned as evidenced by multiple bins that were being used to hold beverages for the residents, and a bin that had just been cleaned, were noted with a black substance inside the bins. This deficiency had the potential to affect 107 residents who consumed beverages prepared in the kitchen, of a total census of 114 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident medical records accurately reflected the resident's and/or RP's (Responsible Party) wishes for Advanced Directives for 3 (#91, #100, #108) of 4 (#91, #100, #108, and #273) residents investigated, out of a total sample of 49 residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents' equipment was kept clean and in good repair for 3 (#27, #92 and #115) out of 5 (#16, #27, #86, #92 and #115) residents investigated for environment as evidenced by: 1. Resident #27's left hand roll observed unclean with brown stains noted to the strap secured on top of the resident's hand. 2. The sink in Residents' #92 and #115 bathroom observed with a moderate amount of green and white buildup and water splattered stains to both knobs. The spout of the sink's faucet was covered in a thick white buildup. This deficient practice had the potential to affect the 114 residents who resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure each residents Minimum Data Set (MDS) assessment was transmitted within 7 days of completion for 1 (#112) out of 1 resident reviewed for Resident Assessment.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a resident admitted to a facility without pressure ulcers received care to prevent the development of an avoidable pressure ulcer for 1 (#27) out 5 (#3, #27, #33, #53 and #54) residents investigated for pressure ulcers out of a total sample of 49 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to each resident as evidenced by: 1. Staff failing to provide ADLs (Activities of Daily Living) in a timely manner for resident (#86) who was dependent on staff for ADLs for 1 out of 49 sampled residents and 2. Staff failing to pass ice on Hall C during the 6 a.m. to 2 p.m. shift on 08/07/2023 and 08/08/2023.

Inspectors wroteBased on observation and interview, the facility failed to ensure cold foods were stored at the appropriate temperature as evidenced by supplement shakes and milk being served to the residents that were held at temperatures above 41 degrees. This deficient practice had the potential to affect the 107 residents who consumed cold food served from the kitchen, out of the entire census of 114 residents.

Inspectors wroteBased on observations and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infections as evidenced by failing to ensure hand hygiene was performed between distributing each resident's meal tray for 3 (#40, #41, #116) residents out of a final sample of 49 residents