Village Care Center Inc

Inspectors wroteBased on interview and record review, the facility failed to protect one resident's right to be free from mental and physical abuse when during care, as three staff were providing cares, RN A forcefully pushed the residents wheelchair forward and pulled it back and told the resident something to the effect of Ride'em cowgirl, verbally threatened to shame/humiliate the resident publicly for his/her behavior of taking off his/her clothes in public, when the resident resisted cares and made a biting motion, RN A told the resident babies bite. The resident was reported to be visibly upset and crying and when an aide offered to stay with the resident so the resident could calm down, RN A said no and that the resident needed to go to the dining room so others could see how he/she was acting and they would know what RN A has to deal with. The facility census was 28. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 35. 1. The facility did not provide a policy for the Dietary Manager qualifications. During an interview on 3/27/25 at 9:42 A.M., Dietary Manager said: -He/She has worked at the facility for ten years; -He/She has been the Dietary Manager for a year; -He/She did not have any dietary manager certifications; -He/She did not know what certifications were required for a dietary manager; -He/She was not currently enrolled in classes for dietary manager certifications; -He/She needed to make a plan with the dietician about enrolling in dietary certification classes. -The facility dietician was contracted to come in once a month. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a record of the dishwasher temperature and chemical tests, failed to cease using dishwasher when temperatures did not meet requirements, failed to keep a daily record of refrigerator temperatures, failed to wash hands in between tasks and in between glove changes, failed to label and date all foods upon receiving and upon opening, failed to ensure kitchen was clean and in good repair, and failed to ensure dishwasher temperature reached minimum temperatures. The facility census was 35. 1. Review of the facility's Food Handling policy, dated 7/2014, showed: -Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff obtained physicians' orders and assess residents for safe administration of medication to be kept at the bedside for two of 12 sampled residents (Resident #19 and #25). The facility census was 35. Review of the facility's policy for Resident Self-Administration of Medication, dated 12/2016, showed: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe to do so; -In addition to general evaluation of decision-making capacity, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they utilized the correct Skilled Nursing Facility Advance Beneficiary Notice of non-coverage (SNFABN) form (a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility), for two of the 12 sampled residents, (Resident #20 and #25). The facility census was 35. The facility did not provide a policy for ABN's. 1. Review of Resident #20's medical records showed: - Notice of Medicare Non-coverage (NOMNC) CMS - 10123 showed the last date of coverage was [DATE]. The resident signed it on [DATE]; - The facility used an outdated ABN form CMS - R-131 (expired [DATE]) and was signed by the resident on [DATE]. 2. Review of Resident #25's medical records showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADL) received the necessary serviced to maintain good personal hygiene when staff did not provide complete perineal care which affected two of the 12 sampled residents, (Resident #18 and #21). Additionally, the staff failed to provide A.M. care to Resident #18. The facility census was 35. Review of the facility's policy titled, Supporting Activities of Daily Living, revised March 2018 showed: - Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of the 12 sampled residents, (Resident #18 and #21) during the use of a mechanical lift. The facility census was 35. Review of the facility's policy titled, Using a Mechanical Lifting Machine, revised July 2017, showed: - The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device; - It is not a substitute for manufacturer's training or instructions; - At least two nursing assistants are needed to safely move a resident with a mechanical lift. Review of the undated manufacturer's guidelines for the Direct Supply lift showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to keep oxygen tubing off the floor for three residents (Resident #22, #25, and #134), failed to date oxygen tubing for one resident (Resident #134), and failed to fill humidifier bottle with distilled water for one resident (Resident #134), resulting in possible exposure to bacteria and discomfort during oxygen usage. This affected three of 12 sampled residents. The facility census was 35. Review of the facility's Oxygen Administration policy, dated 10/2010, showed: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as the oxygen flows through; -Periodically recheck water level in humidifying jar; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, failed to ensure the bed's dimensions were appropriate for the resident's size, (for resident #134). Additionally the facility failed to obtain physicians orders and care plan the use of bed rails for three residents (Resident #23, #19 and #134). This included three of 12 residents sampled (Residents #23, #19, and #134). The facility census was 35. Review of facility policy, Proper Use of Side Rails, revised 12/2016, showed: -The purpose of these guidelines is to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medial symptoms; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse aides met the minimum qualifications which included satisfactory participation in a State-approved nurse aide training and competency evaluation program within four months of hire. The facility census was 35. Review of the facility's policy titled, Nurse Aide (NA) Qualifications and Training Requirements, revised May, 2019 showed: - Nurse Aides must undergo a state-approved training program; - In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities; - Our facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than five percent. Facility staff made three medication errors out of 25 opportunities for error, which resulted in a medication error rate of 12%, which affected two of the 12 sampled residents, (Resident # 19 and #27). The facility census was 35. Review of the facility's policy titled, Medication and Treatment Orders, revised July 2016, showed: - Orders for medications and treatments will be consistent with principles of safe and effective order writing; - Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state; - Drug and biological orders must be recorded on the Physician Order Sheet (POS) in the resident's chart; [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff wore the proper personal protective equipment (PPE, specialized clothing or gear worn to minimize exposure to workplace hazards that can cause serious injuries or illnesses) which affected one of the 12 sampled residents, (Resident #18), failed to wear gloves when obtaining Resident #19's blood sugar, and failed to clean the port of the insulin pen prior to attaching the needle for Resident #1, #5, and #21. The facility census was 35. Review of the facility's policy titled, Infection Prevention and Control Manual, showed: - Enhanced Barrier Precautions, (EBP), are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes; [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure they maintained a safe, clean, comfortable environment for the residents when staff did not keep all areas of the facility clean and safe and when they did not maintain the only drinking fountain. The facility census was 28. The facility did not provide an environmental policy. 1. Observations beginning on 4/23/24 at 9:24 A.M. showed: -room [ROOM NUMBER] door had scuff marks, the frame had chipped paint with exposed wood; -The exit door's frame was chipped, exposing wooden frame underneath; -The fan heater below the handrail, had a bent metal frame, causing a sharp protrusion of metal at knee/calf height; -Sliding bathroom door of room [ROOM NUMBER] had molding loose on one side, with a 2 inch screw exposed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a complete, accurate and individualized care plan, to address the specific needs for three of the 12 sampled residents (Residents #1, #13 and #22). The facility census was 28. Review of the facility's 2018 policy on Resident's Plan of Care., showed: -Every resident will have a formal plan of care within 48 hours of admission. The care plan team is responsible for periodic review and updating of care plans. -Care plans should be updated when there is a significant change in the resident's condition, with a readmission from the hospital, and at least quarterly. Review of Resident #22's admission MDS (Minimum Data Set) A federally mandated comprehensive assessment completed by facility staff. Completed on 3/26/24., showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure systems and interventions were put in place for one resident to ensure the resident's safety, (Resident #22), This resident had a urinary infection, severely impaired cognition, medication use daily for anxiety as well as narcotic use and had sustained three falls with in a week's time resulting in a hematoma (a collection for blood outside of the broken blood vessel, causing swelling and bruising) to the back of the head, without additional interventions put into place. This effected one resident (Resident #22), of 12 sampled residents. The facility census was 28. Review of the facility policy on Fall Clinical Protocol, dated March of 2018., showed: - The nursing staff will help identify individuals with a history of falls and risk factors for falling. [...]

Inspectors wroteBased on record review and interviews, the facility failed to purchase a surety bond with a sufficient amount to ensure the security of all the residents' personal funds held by the facility in the Residents' Trust Fund (RTF) account. The facility census was 27. The facility did not provide a policy regarding personal funds. Review of the facility surety bond, dated 11/24/16, showed a bond amount of $20,000. Review of the RTF account worksheet completed on 3/10/22, for the previous twelve months of reconciled bank statements and petty cash amounts showed the facility was required to maintain a surety bond in the amount of $22,500. During an interview on 3/11/22, at 8:01 A.M., the Business Office Manager (BOM) said: - He/she does not know how much the bond is but, he/she can look it up. - He/she did not know the bond was not high enough. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standards of practice by not following and/or obtaining physicians' orders for two of 12 sampled residents (Residents #14 and #26) when staff initiate oxygen (O2) therapy for the residents without a physician order; failed to obtain a physician's order for two residents (Residents #17 and #26) prior to starting hospice services; Failed to administer Flonase nasal spray (used to treat seasonal allergies) correctly for Resident #19, failed to obtain an order for Vick's [NAME] severe nasal spray for Resident #26; and failed to allow fingertips to dry before obtaining blood sugars for Residents #8, #19, and #25. The facility census was 27. Review of the undated facility policy for Physician Drug Orders showed in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assure staff provided proper respiratory care when staff failed to date oxygen tubing and nebulizer tubing for four of 12 sampled residents (Resident #13, #20, and #26). The facility census was 27. Review of the facility's undated oxygen and nebulizer protocol policy, showed: - Oxygen and nebulizers will be changed out every two weeks on Friday night shift. - When changing out the oxygen tubing and nebulizer sets, it should be dated when changed out (using a piece of tape to write date on); - Nebulizer must be rinsed out with warm water and let air dry, after each use. - Oxygen filters need to be cleaned every Friday on the night shift. 1. Review of Resident #26's care plan, dated 2/9/22, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication rate of less than 5%. Facility staff made nine medication errors out of 28 opportunities for error, a medication error rate of 32.14%, which affected four of 12 sampled residents (Resident #8, #17, #22 and #26). The facility census was 27. Review of the facility's undated policy for administration of drugs, showed, in part: - Drugs to be administered are checked against the physician's orders; - Observe the five rights in giving medications: the right resident; the right time; the right medicine; the right dose;and the right method of administration; - Do not return to stock, supplies, excess medicine, or medicine refused by a resident. If a resident refuses the dose, it must be destroyed according to policy; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff discarded expired medications and biologicals stored in the facility emergency kit and in the medication room which affected one of 12 sampled residents (Resident #2); failed to date an opened bottle of lorazepam (used to treat anxiety) for Resident #26; failed to date an opened vial of tuberculin (TB) purified protein derivative (PPD, skin test used to help diagnose tuberculosis infection); failed to date an opened vial of influenza vaccine; failed to ensure staff did not leave medications at bedside for Resident #13 and #22; and failed to ensure there were no loose pills on the floor. The facility census was 27. Review of the facility's undated policy for administration of drugs, showed: - Observe the five rights in giving medications: the right resident; the right time; the right medicine; [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety, and failed to ensure they stored food properly. The facility census was 27. Review of the facility's undated policy, Procedure for Storing Leftovers, said: - All leftovers should be put into approved container, covered, labeled, and date; - Indicate expiration date for all items. Let cool to appropriate temperature before placing in the refrigerator. - Keep refrigerated items at 40 degrees Fahrenheit or below; cover all foods, and store meats on the bottom shelf. - Employ safe food handling and infection control practices at all times to avoid cross contamination. 1. Observation on 3/8/22 beginning at 9:11 A.M. showed the following: - Two frozen meat packages not labeled or dated; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use proper hand hygiene when administering medications and did not follow the facility's policy, which affected one of 12 sampled residents (Resident #21). Staff failed to clean the glucometer (machine that checks the level of glucose in the blood) appropriately which affected Residents #8, #22, and #25 and failed to clean the insulin port before attaching the needle, which affected Residents #8, #22, and #25. Staff failed to wash their hands between dirty and clean tasks for Residents #6, #10, #13, and #21. The facility census was 27. Review of the facility's infection prevention and control policy, updated 3/16/20, showed, in part: [...]

Inspectors wroteBased on interview and record review, the facility failed to clarify the status of two of 12 sampled residents (Residents #20 and #26) advanced directive and code status. The facility census was 27. Review of the facility policy dated [DATE] Advanced Directive Policy showed in part: - Statement: To ensure everyone has the information necessary to make an informed decision concerning their medical care, the right to accept or refuse medical or surgical treatment, and the right to formulate advanced directives. - Should the resident or family member indicate that an advanced directive exists about his or her care treatment, the facility will require that a copy of such directives be included in the medical record. - Social Services representative is to document in the medical record wether or not the individual has executed an advanced directive. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform one of 12 sampled residents (Resident #26) and the resident's family/legal representative of the facility's bed-hold policy at the time of transfer/discharge to the hospital. The facility census was 27. Review of the facility's bed hold policy dated 1/26/15, showed: - The facility will notify all residents and/or their representative of the bed hold guidelines upon admission in writing. - At the time of transfer to the hospital, at the time of non-covered therapeutic leave and notified verbally of one of these changes by the facility or resident and/or representative will start the bed hold guidelines. 1. Review of Resident #26's significant change in condition Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 2/24/22, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they developed and implemented a comprehensive person-centered plan of care which included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for two of 12 sampled residents (Resident #13 and #26). The facility census was 27. Review of the facility policy, dated February, 2018, Resident Plan of Care showed in part: - Policy Statement: To ensure staff follows a plan of care on each resident admitted . - The care planning team is responsible for maintaining care plans on a current status. The care planning team is responsible for periodic review and updating care plans: a. When there has been a significant change in the resident's condition; b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected two of 12 sampled residents (Resident #6 and #13) and failed to ensure showers and shaving were completed for Resident #13. The facility census was 27. Review of the facility's perineal care skills check, dated 5/2/17, showed, in part: - It is the policy of the facility to conduct perineal care in order to accomplish the following objectives: to prevent infections, prevent inflammation and/or facilitate healing of reddened perineal area and to enhance the resident's comfort; - Wash the front of the resident first; begin by washing off the lower abdomen, then the tops of the hip and thigh regions; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring two of 12 sampled residents (Resident #6 and #10) during a gait belt (safety device and mobility aid used to provide assistance during transfers, ambulation or repositioning) transfer and during the use of a mechanical lift transfer for Resident #21. The facility census was 27. Review of the facility's policy for gait belts, revised 3/20/14, showed, in part; - The purpose is to provide resident safety and protection during the transfer and upon ambulation; to prevent dislocations of the shoulder; and aid in controlling balance; - Apply the gait belt around the resident, over clothing and never next to bare skin; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow the facility's skills check for insulin administration when staff failed to prime the insulin pens with two units prior to administering insulin to two of 12 sampled residents, (Resident #8 and #22). The facility census was 27. Review of the facility's skills check for accucheck and insulin administration, dated 4/15/19, showed, in part: - Prime insulin pen; dial up two units and dispense. 1. Review of Resident #8's physician order sheet (POS) dated March 2022, showed: - An order for Levemir insulin, 40 units twice daily for diabetes mellitus; - An order for Novolog insulin per sliding scale before meals for diabetes mellitus, blood sugar 201 - 250, give 17 units. Review of Resident #25's POS, dated March 2022, showed: - An order for Levemir insulin, 58 units at bedtime for diabetes mellitus; [...]