Village at the Greene

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to ensure a resident was not inappropriately discharged when the facility issued a resident a 30- day discharge notice without proper cause. This affected one (#52) out of three residents reviewed for discharge notices. The facility census was 47.

Inspectors wroteBased on medical record reviews, staff interviews, and review of the facility policies, the facility failed to complete discharge summary/recapitulation of stays and failed to obtain physician discharge orders prior to discharge. This affected two (#48 and #52) out of three residents reviewed for discharges. The facility census was 47.

Inspectors wroteBased on medical record review, observations, resident and staff interviews and policy review, the facility failed to obtain a physician order prior to administering a c-pap machine and oxygen. This affected one (#09) out of three residents reviewed for following physician orders. The facility census was 47.

Inspectors wroteBased on medical record review, resident and staff interviews, and policy review, the facility failed to provide therapy services to ensure a resident maintained highest practicable level of physical and functional mobility. This affected one (#10) out of three residents reviewed for cares and services. The facility census was 47.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to provide care and services for residents who required staff assistance with Activities of Daily Living (ADLs). This affected five (#09, #22, #43, #53, and #73) of five residents reviewed for ADLs. The facility census was 76.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure gloves were changed between contaminated surfaces and food. This had the potential to affect 12 residents (#11, #18, #25, #28, #32, #34, #39, #40, #41, #54, #59, and #73) who were served from this kitchenette on the Pine Club unit. The census was 76.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure significant change assessments were completed in a timely manner. This affected three (#43, #45, and #51) of three residents reviewed for hospice services. The facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected three (#22, #37, and #51) of 22 residents reviewed for assessment accuracy. The facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure nephrostomy tube care was completed as ordered. This affected one (#234) resident out of the one resident reviewed for urinary catheters. The facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure weights were obtained in a timely manner. This affected three (#49, #51, and #64) of four residents reviewed for nutrition. The facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and review of facility skills documentation form, the facility failed to ensure tracheostomy care/oral care was completed as ordered. This affected one (#13) of one resident reviewed for tracheostomy care. The facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure dialysis communication forms were completed and sent to the dialysis center prior to dialysis. This affected one (#47) resident who attended hemodialysis. The facility census was 76.

Inspectors wroteBased on medical record reviews, observations, staff interviews, and policy review, the facility failed to ensure resident's medications were administered as ordered resulting in three medication errors out of 29 opportunities or a 10.34 percent (%) medication error rate. This affected two (#33 and #62) residents out of the four residents reviewed for medication administration. The facility census was 76.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to prevent a significant medication errors when staff did not prime an insulin pen prior to administration. This affected one (Resident #33) of four residents observed for medication administration. The facility census was 76.

Inspectors wroteBased on medical record reviews, observations, staff interviews, review of insulin pen checklist, and policy review, the facility failed to ensure over the counter medication bottle and insulin pen were dated after opened and failed to ensure medications were not left at the bedside. This affected two (#33 and 51) residents out of the four residents reviewed for medications. The facility census was 76.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to follow infection control procedures during tracheostomy care. This affected one (#13) resident of one resident observed for tracheostomy care.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, resident and family interview, review of video camera footage, review of facility investigation and incident report, and policy review the facility failed to ensure a resident was properly transferred and provided a mechanical lift (Hoyer) during transfer. This resulted in actual harm when Resident #27 who was a high fall risk, dependent for transfers, and required the utilization of a mechanical lift (Hoyer) for all transfers suffered a right distal femur fracture from a fall that occurred during a transfer. This affected one (#27) of three residents reviewed for falls. The census was 83.

Inspectors wroteBased on medical record review, staff interview, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73.

Inspectors wroteBased on medical record review, staff interview, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73.

Inspectors wroteBased on medical record review, staff interview, review of facility self-reported incidents, and policy review the facility failed to ensure the abuse policy was implemented. This affected one (#57) of three residents reviewed for abuse. The census was 73.

Inspectors wroteBased on observation, medical record review, staff and family interview the facility failed to ensure bathing was provided for residents at least twice a week. This affected two (#27 and #17) of three residents reviewed for bathing. The census was 74.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to provide care and services to prevent a resident fall. This affected one (#32) resident of the three residents reviewed for falls. The facility census was 78.

Inspectors wroteBased on medical record review, staff interview, and review of the Medication Administration checklist, the facility failed to ensure medications were administered as ordered. This affected two (#18 and #32) residents out of the five residents reviewed for medication administration. The facility census was 78.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility staff failed to follow infection control procedures during medication administration. This affected one (#18) resident out of the three residents reviewed for medication administration. The facility census was 78.

Inspectors wroteBased on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff provided a resident assistance with feeding. This affected one (#56) of the three residents reviewed for assistance with meals. The facility census was 74.

Inspectors wroteBased on record review, staff and physician interviews, and facility policy review, the facility failed to notify the physician of a change in the resident's condition. This affected one (Resident #200) of three residents reviewed for a change of condition. The facility census was 79.

Inspectors wroteBased on observation, interview, record review, review of the National Pressure Ulcer Advisory Panel (NPUAP) information, and policy review, the facility failed to assess and identify pressure ulcers and failed to implement interventions and treatments to prevent the development and promote healing of pressure ulcers. The facility failed to identify multiple unstageable (blackened in color with necrotic tissue) deep tissue injuries (DTI), failed to contact the physician to implement treatments, resulting in worsening tissue damage and failed to follow infection control protocols during pressure ulcer dressing changes. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when one resident (#286) was hospitalized with septic shock as she had a large Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. [...]

Inspectors wrote5. Observation on 11/07/22 from 1:09 P.M. through 1:29 P.M. in the Cypress, [NAME] View, Pine Glen and Juniper unit kitchenettes, revealed steam table wells at wheelchair height directly open to a walk-through corridor. There were no sneeze guards or barriers from the steam table edge of eight inches, to the corridor counter edge, where residents were passing by the steam table. Foods were being served from the steam table. Observation on 11/07/22 at 1:40 P.M. of Cypress, [NAME] View, Pine Glen and Juniper unit kitchenettes, after meal service was completed, revealed no barrier between the kitchenettes and adjacent resident dining area. Three steam table controls were exposed and two carafes of hot coffee were unattended. During interview on 11/07/22 at 1:55 P.M., Maintenance Director #220 stated the steam table controls should be covered with a counter cover made with a lock. [...]

Inspectors wroteBased on medical record review, review of the hospital record, staff and family interview, observation, review of the skills checklist for catheter care, and policy review, the facility failed to ensure Resident #10 was timely sent to the hospital when the resident exhibited signs and symptom of sepsis. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when Resident #10 had symptoms of lethargy, foul-smelling urine, and had no urinary output for 48 hours. [...]

Inspectors wroteBased on medical record review, resident interview, family interview, and staff interview, the facility failed to prevent a resident from developing Moisture Associated Skin Damage (MASD). This resulted in actual harm when it was discovered Resident #08 was left on a wet mattress, resulting in significant MASD needing antibiotic treatment. This affected one (Resident #08) of one reviewed for MASD prevention.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement an action plan when they identified pressure ulcers and falls as an area of quality concern, resulting in a substandard quality of care deficiency. Failure to implement an action plan directly affected six (Residents #11, #29, #38, #46, #61, and #81) out of seven falls reviewed who had falls with injuries when the facility had not identified patterns, trends, root cause analysis or implement appropriate interventions. (See findings under F689). Four (Residents #08, #05, #02, and #20) out of six residents reviewed for pressure ulcers were identified when the facility didn't ensure proper care, treatment, assessments and care plan interventions were in place. (See findings under F686). [...]

Inspectors wroteBased on record review, review of the medical director reports, staff interview, and policy review, the facility failed to implement an effective Quality Assurance (QA) program to ensure accidents, pressure ulcers, and catheters were comprehensively reviewed and timely initiate corrective actions to prevent the incidents. This affected 11 (Residents #11, #29, #38, #46, #61, #81, #08, #05, #02, #20 and #10) out of 30 reviewed. This had the potential to affect all 89 residents in the facility. The facility census was 89.

Inspectors wroteBased on record review and staff interview, the facility failed to notify family/residents of hospital transfer/discharge in writing and send a copy to the Ombudsman. This affected seven (Residents #39, #05, #63, #65, #10, #286 and #58) of seven residents reviewed for hospitalizations. The facility census was 89.

Inspectors wroteBased on record review and staff interview, the facility failed to provide family/residents of bed hold notice upon discharge to the hospital. This affected seven (Residents #39, #5, #63, #65, #10, #286 and #58) of seven residents reviewed for hospitalizations. The facility census was 89.

Inspectors wroteBased on medical record review, observations, resident interviews, staff interviews, and policy review, the facility failed to provide assistance with activities of daily living (ADL) for bathing for residents who required assistance. This affected four (Residents #08, #26, #56, and #64) of four residents reviewed for ADL care. The facility census was 89.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff to provide personal care and ensure accident prevention. This affected four (Residents #8, #64, #56 and #5), of six residents reviewed for personal hygiene care and two (Residents #29 and #11) of 11 residents reviewed for accident prevention. The total facility census was 89.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was properly stored in the kitchenette refrigerators to prevent contamination and food borne illness . This had the potential to affect all 85 residents who received food from the kitchenettes. The total facility census was 89.

Inspectors wroteBased on record review, family and staff interview, the facility failed to conduct care conferences as required and invite residents or resident representatives. This affected three (Residents #10, #63, and #26) of four residents reviewed for care planning. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, Power of Attorney (POA) interview and policy review, the facility failed to ensure notification was made to the POA for removal of a urinary catheter and when a tube feeding was restarted continuously. This affected one (Resident #63) of one reviewed for notification of change. The census was 89.

Inspectors wroteBased on observation, resident interview, family interview and staff interviews, the facility failed to accurately document a resident's hearing status on the Minimum Data Set (MDS) assessment. This affected one (Resident #08) of 30 MDS assessments reviewed. The facility census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission was accurate. This affected one (Resident #39) of two residents reviewed for PASARR. The facility census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure there was a baseline care plan for a resident who utilized a tracheostomy and ventilator. This affected one (Resident #05) of 30 residents reviewed for baseline care plans. The census was 89.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure comprehensive care plans were completed. This affected three (Residents #05, #56 and #10) of 30 resident care plans reviewed. The facility census was 89.

Inspectors wroteBased on medical record review, staff and family interview, and policy review, the facility failed to ensure proper discharge planning was completed. This affected one (Resident #42) of one resident reviewed for discharge. The census was 89.

Inspectors wroteBased on medical record review, staff and family interview, and policy review, the facility failed to ensure a discharge summary was prepared and provided to a resident or resident representative. This affected one (Resident #42) of one resident reviewed for discharge. The census was 89.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities were provided for residents. This affected two (Residents #29 and #39) of four residents reviewed for activities. The census was 89.

Inspectors wroteBased on record review, observation, interview and policy review, the facility failed to ensure residents received proper foot care. This affected one (Resident #26) of one resident reviewed for foot care. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, and observation, the facility failed to ensure tube feeding were given per physician orders. This affected two (#5 and #63) out of three reviewed for tube feeding. The facility identified there were seven tube feeding residents. The census was 89.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure staff properly performed Peripherally Inserted Central Catheter (PICC) line care for one (Resident #286) out of one resident reviewed with a PICC line and urinary catheter care for one (Resident #39) out of three reviewed for urinary catheter use to prevent potential infection of the resident. The facility identified one resident with a PICC line and six residents with indwelling urinary catheters. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, review of the consent forms, and policy review, the facility failed to maintain an effective immunization program for pneumococcal (pneumonia) and influenza (flu). This affected three (Residents #32, #34, and #48) out of five residents reviewed for immunizations. The facility census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment. This affected one (Resident #2) of two residents reviewed for resident assessments. The census was 97.

Inspectors wroteBased on closed medical record review and staff interview, the facility failed to complete a discharge Minimum Data Set (MDS) assessment. This affected one (Resident #1) of two residents reviewed for resident assessments. The census was 97.

Inspectors wroteBased on resident record review, observation, staff interview, and facility policy review; the facility failed to develop a comprehensive care plan for the use of antianxiety and antibiotic medication. Additionally, the facility failed to develop a comprehensive care plan to address the use of a urinary catheter. This affected two Resident's (#8 and #59) of 23 residents reviewed for the development and implementation of comprehensive care plans. The census was 97.

Inspectors wroteBased on medical record review and staff interview the facility failed to revise a resident's care plan. This affected one (Resident #50) of two residents reviewed for fall. The census was 97.

Inspectors wroteBased on medical record review, observation, staff and resident interview and facility policy review, the facility failed to ensure a dependent resident received hygiene assistance on a regular basis. This affected one (Resident #43) of two reviewed during the annual survey. The census was 97.

Inspectors wroteBased on medical record review, observation, and staff interviews, the facility failed to ensure a resident's splint device was in place per therapy recommendations. This affected one (Resident #82) of one resident reviewed for limited range of motion. The facility census was 97.

Inspectors wroteBased on resident record review, observation, resident representative interview, and staff interview; the facility failed to have fall interventions in place as ordered by the physician. This affected one (Resident #27) of two residents reviewed for falls. The census was 97.

Inspectors wroteBased on medical record review, observation, staff and resident interview and facility policy review the facility failed to ensure physician catheter orders were entered, a baseline care plan was initiated for an indwelling catheter, and catheter care was provided. This affected one (Resident #192) of two residents reviewed for indwelling catheter. The facility identified six residents who had indwelling catheters. The census was 97.

Inspectors wroteBased on observation and staff interview, the facility failed to properly sanitize the blood glucose monitoring system between resident use. This affected one (Resident #73) of two residents observed during medication administration. The facility identified three residents who use the glucometer from the medication cart on the Willow/Juniper halls. The census was 97.