The Villas at the Park

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a resident received appropriate interventions to prevent contractures for a resident who was admitted to the care facility without contractures (permanent shortening of tissue, such as muscle, tendon or skin leading to the inability to straighten joints fully and to permanent deformity and disability) for one of two residents (R20) reviewed for range of motion. This resulted in actual harm when R20 developed severe contractures of bilateral upper and lower extremities.

Inspectors wroteDuring observation and interview, the facility failed to implement interventions to ensure resident's personal care information was kept secured and out of public view when stored on 1 of 3 mobile medication carts. This had the potential to affect 14 residents (R3, R4, R9, R14, R27, R28, R30, R32, R35, R40, R43, R47, R48, and a discharged resident) on the long-term care unit whose personal information was left unattended on a medication cart in the hallway corridor.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a resident (R20) was assessed and care planned for a dignified toileting experience for a continent resident who was told to wet himself for toileting.

Inspectors wroteBased on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 2 of 5 residents (R7, R12) reviewed for use of psychotropic medications.

Inspectors wroteBased in interview and document review, the facility failed to ensure a resident had an appropriate diagnosis and indication for use for a prescribed antipsychotic medication for one of five residents (R12) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a bed bound resident was care planned for, and received, adequate activities for social and mental stimulation for one of two residents (R20) reviewed for activities.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that residents requiring assistance with eating were provided services by qualified staff for 1 of 1 residents (R47) reviewed requiring a mechanically altered diet.

Inspectors wroteBased on interview and document review, the facility failed to ensure binding arbitration agreements of 1 of 3 residents (R23) were clearly communicated in a form and manner that they understood prior to signing the forms.

Inspectors wroteThe State Operations Manual (SOM) defined the various presure ulcers as follows: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. It may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) are not present. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self administration assessment (SAM) and a physician's order was completed to allow a resident to safely administer their own medication for 1 of 1 resident (R18) observed with medication at the bedside.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure freedom of movement was not restricted when multiple pillows were placed by nursing staff adjacent to the resident's body, blocking the egress section of a perimeter mattress, underneath the fitted sheet which could not be removed easily by the resident for 1 of 1 resident (R104) reviewed for potential restraints.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure orders for compression were implemented for 2 of 2 residents (R40, R45) reviewed for edema.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an occupational therapy (OT) ordered hand splint program was implemented for 1 of 2 residents (R14) reviewed for positioning and mobility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement fall interventions for 1 of 2 residents (R40) reviewed with a history of falls.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff utilized enhanced barrier precautions (EBP) during wound care and failed to ensure current standards of infection control practice for catheter care was followed for 1 of 2 residents (R30) observed for wound care and catheter care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to conduct regular inspections of hospital bed rails as part of a regular maintenance program.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders and manufacturer guidelines for 3 of 6 residents (R25, R38, R45) observed to received medication. A total of four (4) errors out of 31 opportunities were identified resulting in a 12.9% (percent) facility' error rate.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a community-use glucometer was properly cleaned and disinfected between patient' uses for 1 of 1 resident (R45) observed to have their blood glucose checked. This had potential to affect 4 of 4 residents (R45, R41, R246, R35) who were diabetic on the same unit. In addition, the facility failed to ensure appropriate hand hygiene was completed with personal cares for 1 of 2 residents (R246) whose cares were observed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R3) were comprehensively assess for safety and ability who were observed to self-administer medications.

Inspectors wroteBased on observation, interview and document review the facility failed to provide hygienic nail care to 2 of 3 residents (R35 and R19) reviewed for dependent activities of daily living (ALD's). R19's annual Minimum Data Set (MDS) assessment dated [DATE], included R19 was severely cognitively impaired, had diagnoses of dementia and aphasia (difficulty speaking), and no behavioral concerns. R19's Cognitive Loss/Dementia Care Area assessment dated [DATE], included he required assistance with ADLs. R19's ADL Functional/Rehabilitation Potential was not assessed or triggered. R19's ADL care plan dated 4/20/20, indicated he often used his hands to eat and required set-up and encouragement for personal hygiene, but lacked nail care assistance needs. His behavioral focus dated 4/1/22, included R19 had behaviors of putting fecal matter on his plates/trays at mealtimes. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to schedule a follow-up gastrointestinal procedure for 1 of 1 residents (R3) reviewed who had difficulty swallowing. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 was cognitively intact, required set-up assistance for eating and oral hygiene, had complaints of difficulty or pain with swallowing, and had diagnoses of diabetes, seizure disorder, and traumatic brain injury. R3's care plan dated 10/10/23, indicated she had difficulty swallowing and must sit up when drinking or eating anything, no matter how small the amount per speech therapy recommendations. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed implement care planned fall interventions, perform a comprehensive post-fall root cause analysis, and initiate and implement subsequent fall interventions for 1 of 4 residents (R4) reviewed for falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure stock medications (i.e., medication used for multiple patients) were tracked and re-ordered timely to prevent disruption in supply and potential complication for 1 of 1 resident (R38) observed to need medications which weren't available.

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate side effect monitoring was completed, in accordance with the care plan and standard of care, related to psychotropic (i.e., antipsychotic) medication use for 2 of 5 residents (R29, R4); and failed to ensure as-needed (i.e., PRN) antipsychotic medication use was limited or re-evaluated after 14 days for 1 of 5 residents (R19) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a fast-acting insulin Flexpen and newly attached needle was primed and administered in accordance with manufacturer instructions to facilitate complete dosing of the medication for 1 of 1 resident (R45) observed to receive insulin. This had potential to modify the dose of insulin being delivered and constituted a significant medication error.

Inspectors wroteBased on interview and document review, the facility failed to ensure orders to obtain and process urinary analysis' and cultures (UA/UC) were acted upon, collected, and transported to the offsite laboratory for processing in a timely manner to reduce the risk of complication (i.e., worsening infection) for 2 of 2 residents (R11, R3) reviewed who had signs of potential urinary-based infections.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dental needs were comprehensively assessed and, if needed, coordinated with a dental provider for further care to reduce the risk of complication (i.e., cavities, oral pain) for 2 of 2 residents (R29, R24) reviewed for dental care and services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a therapeutic diet of thickened liquids was followed and implemented for 1 of 1 resident (R21) reviewed for therapeutic diets.

Inspectors wroteDuring observation, interview and document review, the facility failed to assure that the kitchen dishwasher was maintained per the manufacturer's instructions, causing buildup of thick white residue on the outside of the machine. The had the potential to affect all 44 residents within the facility reviewed for essential equipment being maintained in a safe and operating condition.