Van Healthcare

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property, and exploitation for 1 of 5 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's checkbook on 06/09/2026. The noncompliance was identified as PNC. The noncompliance began on 06/25/2026 and ended on 06/27/2026. The facility had corrected the noncompliance before the investigation began on 07/09/2026. This failure could place residents at risk for misappropriation of their personal property.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement comprehensive care plans with measurable objectives and timeframes to address resident's medical, nursing, and required enhanced barrier precautions needs for 2 of 4 residents reviewed. The facility failed to ensure that Resident #7's and Resident #32's care plans reflected focus instructions on Enhanced Barrier Precautions for high contact care related to history of MDRO and / indwelling device. The facility fails to ensure that Resident #7's care plans reflected focused interventions for indwelling catheter care in accordance with facility policy and physician orders. This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 2 medication carts ((Cart A/B halls and Cart C/D halls) reviewed for pharmacy services. The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented the performance of change of shift narcotic counts on multiple shifts and days for Medication Cart A/B halls and Cart C/D halls. This failure could place residents at risk for loss of medications and possible drug diversion.

Inspectors wroteBased on observations, interviews, 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 2 of 4 residents (Residents #7 and #32) reviewed who required Enhanced Barrier Precautions. The facility failed to ensure Enhanced Barrier Precautions signage was posted on the entry doors for Resident's #7 and Resident #32. This failure had the potential to expose residents, staff, and visitors to the transmission of infectious organisms.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with a diagnosis of mental illness were provided an accurate Preadmission Screening and Resident Review (PASARR) Level 1 Screening for 1 of 3 residents reviewed for PASARR (Resident #8). The facility failed to ensure that Resident #8 had an accurate PASARR Level 1 Screening indicating a diagnosis of mental illness after newly evident diagnosis dated 05/31/2019. This failure could place residents at risk of not receiving needed assessments (PASARR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post their most recent survey of the facility in an area of the facility accessible to residents, and family members and legal representatives of residents, in 1 of 1 survey binder. The facility failed ensure the most recent standard survey dated 10/23/2024 was readily available within the survey binder. This failure could place residents at risk for not having access to current information regarding the facility's compliance with federal and state regulations, limiting their ability to make informed decisions and exercise their rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 3 of 4 residents reviewed for pharmacy services (Residents #16, #24, #26). The facility failed to ensure medications were available in the form ordered by the physician for Residents #16 and #24. The facility failed to ensure a physician's order to discontinue an oral diabetic medication and replace it with another medication was carried out resulting in the discontinued medication being given for 3 (three) months after it was discontinued, and the replacement medication not being initiated for Resident #16. The facility failed to ensure LVN D administered insulin to Resident #26 in a safe, therapeutic manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 5 Residents (Residents #3, #7, #21) reviewed for medical records accuracy. The facility failed to ensure Resident #3's physician orders included orders for dialysis and the care of the dialysis access device. The facility failed to ensure Resident #7's physician orders included clear and precise instructions for the administration of an antidepressant medication. The facility failed to insure Resident #21's physician orders included the amount of an ordered liquid nutritional supplement to be given. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased observation, interview and record review, the facility failed to 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 1 of 1 resident (Resident #29) reviewed for infection control. The facility failed to keep the urine drainage bag off the floor. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for adequate supervision. The facility failed to ensure hospice staff were informed of Resident #1's need for a cup with a lid and supervision when provided coffee. The facility failed to ensure facility staff were aware of Resident #1's need for a cup with a lid when provided coffee. The facility failed to have a method or form of communication to ensure all staff were aware of Resident #1's need for a cup with a lid and supervision when provided coffee. The facility failed to ensure Resident #1's meal ticket was updated to indicate the need for a cup with a lid for hot liquids. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to the keys for 1 of 2 rooms (medication room and DON office) used for storage of medications and other biological chemicals. The facility failed to ensure the DON's office located on Hall D was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for medication misuse, medication diversion, and injury related to ingestion or use of biological chemicals.