Village Shalom Inc

Inspectors wroteThe facility identified a census of 64 residents. The facility had one main kitchen, three kitchenettes, and dining areas. Based on observation and interview the facility failed to ensure that opened packages of frozen foods were stored in a sealed bag with a label and an open date. The facility failed to ensure staff wore a hairnet when in the kitchen food preparation and serving areas. The facility failed to ensure staff delivered plates of food in a sanitary manner. The facility failed to ensure staff performed hand hygiene after serving residents their plates and or drinks. This placed residents at risk of food-borne illnesses.

Inspectors wroteThe facility had a census of 65 residents. The sample included 16 residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure pressurized supplemental oxygen tanks in a safe, locked area, and out of reach of the 11 cognitively impaired independently mobile residents. The facility additionally failed to provide Resident (R) 19 with consistent supervision during her meals and ensure her call light remained within reach. This deficient practice placed the residents at risk for preventable accidents and injuries.

Inspectors wroteThe facility identified a census of 65 residents. The facility identified eleven residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to perform hand hygiene before performing glucose checks, and before performing intravenous (IV - administered directly into the bloodstream via a vein) administration. The facility further failed to sanitize the Hoyer (total body mechanical lift) lift between residents. This defiant practice placed residents at risk of infections.

Inspectors wroteThe facility identified a census of 65 residents. The sample included 16 residents, with one reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure a dignified care environment for Residents (R) 31. This deficient practice placed R31 at risk for impaired dignity and unmet care needs.

Inspectors wroteThe facility identified a census of 65 residents. The sample included 16 residents, with three residents reviewed for Beneficiary Notification. Based on record review and interview the facility failed to ensure a Center for Medicare/Medicaid Services (CMS) form 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and the CMS form-10123 Notice of Medicare Non-Coverage (NOMNC) form was provided to Resident (R) 165. This placed R165 at risk of uninformed treatment decisions and unexpected costs.

Inspectors wroteThe facility identified a census of 65 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 50 and R1, who had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. [...]

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with three reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to provide Resident (R) 19 with consistent assistance and supervision during mealtime. This deficient practice placed R19 at risk for potential risk related to impaired nutrition and weight loss.

Inspectors wroteThe facility identified a census of 65 residents. The sample included 12 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to follow a physician's order for daily weights to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) for Resident (R) 50. This deficient practice placed R50 at risk for delay in treatment related to fluid overload and untreated illness.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with three reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 19's pressure-reducing interventions were implemented correctly when R19's low air-loss mattress pumps were not set within her current weight range. This deficient practice placed R19 at risk for complications related to skin breakdown and pressure ulcers.

Inspectors wroteThe facility identified a census of 65 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to address the Consultant Pharmacist (CP) recommendations for Resident (R) 50's Midodrine (hypotension (low blood pressure) medication). [...]

Inspectors wroteThe facility identified a census of 65 residents. The sample included 16 residents, with six residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician's order for Resident (R) 50's hypotension (low blood pressure) medication) was administered. This deficient practice placed R50 at risk for unnecessary medications and adverse side effects.

Inspectors wroteThe facility identified a census of 65 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 50 was free from a significant medication error by not following the physician-ordered parameter for the administration of Midodrine (hypotensive medication used to treat low blood pressure). This deficient practice placed R50 at risk for increased complications, untreated complications, and falls with possible injuries.

Inspectors wroteThe facility identified a census of 65 residents. The sample included 16 residents, with four medication rooms and six medication carts. Based on observation, record review, and interviews, the facility failed to appropriately store medications and biologicals when staff failed to ensure the medication carts were locked when the cart was not within the nurses' view. This placed the residents at risk for adverse outcomes or ineffective medication regimens.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with three reviewed for specialized diets. Based on observation, record review, and interviews, the facility failed to follow Resident (R) 19's physician's order to provide Ensure supplementation 30 minutes after her meals. This deficient practice placed R19 at risk for potential risk related to impaired nutrition and weight loss. Findings Included: The Medical Diagnosis section within R19's Electronic Medical Record (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (difficulty sleeping), anxiety (cognitive or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and speech/language deficits. [...]

Inspectors wroteThe facility identified a census of 65 residents. Based on record review and interviews, the facility failed to ensure that direct care staff had received the required in-service education for nurse aide training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with six reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to implement preventative measure to prevent facility acquired pressure ulcers for three sampled residents. [...]

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with five reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide supervision for one sampled resident, Resident (R) 31, who fell in the facility courtyard and fractured (broken) her right arm and right middle finger. The facility further failed to ensure a safe environment for R50, who fell in his room and fractured his nasal bone, fractured his lumbar transverse process (the bony projection on either side of your spine), sustained a laceration (cut) to his left eye, and bruising to his right side. These failures placed the residents at risk for further falls and related injury.

Inspectors wroteThe facility had a census of 66 residents. Based on interview and record review, the facility failed to submit accurate staffing information through Payroll Based Journaling (PBJ) to the Centers for Medicare and Medicaid Services (CMS). This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on interview and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) possessed the qualifying education, training, experience as well as certification required to fulfill the role, placing the residents at risk of unidentified and untreated infections.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to act upon the concerns of the resident council group concerning issues of care and life in the facility. This placed the residents at risk of decreased quality of care and services.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R)13's medications which lacked indications for use and the inappropriate indication for the use of an antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) for R13, R2, R53, and R23. The facility further failed to ensure the CP identified and reported the lack of a stop date for R13 and R57s' as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed the residents at risk for unnecessary medications and related side effects. Findings Included: [...]

Inspectors wrote- R57's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental, uncertainty and irrational fear), and dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion). R57's Quarterly Change Minimum Data Set (MDS), dated [DATE], documented the resident had severely impaired cognition. R57 required extensive assistance with bed mobility, transfer, dressing, toilet use, and locomotion on and off the unit and hygiene. The MDS lacked documentation R57 received an antianxiety medication during the look back days. The Cognitive Loss Care Area Assessment (CAA), dated 05/09/23, documented R57 had memory problems due to dementia and the disease process, and impaired decision-making skills. [...]

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents with five residents reviewed for pneumococcal (a disease that refers to a range of illness that affects various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to obtain pneumococcal history and administer the vaccine for four out of five reviewed for pneumococcal immunization status.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents with one reviewed for dignity. Based on observation, record review, and interview, The facility failed to promote dignity for Resident (R) 39 during medication administration, and R22 during noon meal service. This placed the resident's at risk for undignified care and services.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to report to the State Agency (SA) an unwitnessed fall that resulted in a fracture for Resident (R)50, who was unable to state what happened. This placed the resident at risk for unidentified and ongoing abuse or neglect. Findings Included: - R50's Electronic Medical Record (EMR) documented diagnoses of repeated falls, confusional arousal (when a sleeping person appears to wake up, but their behavior is unusual or strange), muscle spasms, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). [...]

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents with six residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing, for Resident (R)61. This placed the resident at risk for poor personal hygiene and infection.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents with one reviewed for non-pressure skin injuries. Based on observation, record review, and interview, the facility failed to follow up on Resident (R) 23's impaired skin with interventions to prevent further injuries and failed to document the treatment that was administered for a skin tear of unknown origin on the resident's left lower leg. This placed the resident at risk for further skin injuries and related complications. Findings Included: - R23's Electronic Medical Record (EMR) documented diagnoses of reduced mobility, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), polyneuropathy (simultaneous malfunction of peripheral nerves throughout the body), and hypertension (high blood pressure). [...]

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide an environment free of accident hazards to prevent an avoidable accident, when staff on the memory care unit left chemicals in an unlocked cabinet. This placed the five cognitively impaired independently mobile residents at risk for harm.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to include the resident and the resident representative in the development and planning of the resident's care plan for Resident (R) 26 and R27. This deficient practice placed the residents at risk for not having their needs met.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to accommodate the needs of Resident (R) 2 who had to reach up to the dining table to eat. This placed R2 at risk for discomfort during meals.

Inspectors wroteThe facility had a census of 47 residents. The sample included 12 residents with one reviewed for dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interview, the facility failed to provide a Registered Dietician (RD) assessment in a timely manner after the admission of Resident (R) 93, placing R93 at risk to have unmet special nutritional needs.