Village Care and Rehabilitation Center, the

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on observation, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with Life Safety Code Section 9.6 and NFPA 72.This was evidenced by the following:1. The Main Fire Alarm Control Panel displays a "Trouble" condition.NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.NFPA 72, 14.2.1.1.2 Inspection, testing, and maintenance programs shall verify the correct operation of the system.NFPA 72, 14.2.1.2.2 System defects and malfunctions shall be corrected.Failure to maintain the fire alarm system can harm all occupants, staff, and visitors if a fire is not located immediately.This deficiency was discussed during the exit conference. It was also discussed that the facilty is in the process to replace their fire alarm system and have submitted plans to the state. Annual fire alarm inspection report indicates that the FACP is operational at the time of this survey. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducted on January 8, 2025, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies."This structure is a one (1) story, Type V (111) wood frame construction with no basement. The facility was constructed in 1992. The facility is licensed for 60 beds, and the census on the survey date was 56.The facility is fully sprinkled and protected by National Fire Protection Association (NFPA) 13 automatic wet-pipe and anti-freeze fire sprinkler systems. The anti-freeze fire sprinkler system protects the drive-thru canopy. The survey results were discussed with the Maintenance Director and the Facility Administrator during the exit conference.

A recertification survey with complaint #CO38606 was conducted 12/16/24 to 12/19/24. Three deficiencies were cited. An Emergency Preparedness survey was conducted from 12/16/24 to 12/19/24. No deficiencies were cited. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of disease and infection.Specifically, the facility failed to ensure glucometers were sanitized appropriately.Findings include:I. Professional referenceThe Centers for Disease Control and Prevention (CDC). Considerations for Blood Glucose Monitoring and Insulin Administration (2024), was retrieved on 12/18/24 from https://www.cdc.gov/injection-safety/hcp/infection-control/ index.html#:~:text=Unsafe%20practices%20during%20assisted%20monitoring,for%20more%20than%20one%20person. It read in pertinent part,"Clean and disinfect blood glucose meters after every use, per the manufacturer' s instructions... Based on observations, record review and interviews, the facility failed to implement an activities program that met the interests of and supported the physical, mental, and psychosocial well-being of each resident for one (#32) of two residents reviewed for activities out of 29 sample residents.Specifically, the facility failed to invite Resident #32 to group activities and meet the socialization needs for the resident. Findings include:I. Resident #32A. Resident status Resident #32, age 77, was admitted on 10/3/24. According to the December 2024 computerized physician orders (CPO), diagnoses included pneumonia (lung infection), pulmonary emboli (blood clots in the lungs) and type 2 diabetes (high blood sugar). The 11/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive i.. Based on record review and interviews, the facility failed to ensure two (#42 and #45) of two residents out of 29 sample residents were free of significant medication errors. Specifically, the facility failed to:-Ensure Resident #45 was administered his schizoaffective disorder medication per the physician orders; and,-Ensure Resident #42 was administered his diabetes medication per the physician orders.Findings include:I. Professional reference According to the Trihexyphenidyl dosing instructions, retrieved on 12/30/24 from https://www.goodrx.com/trihexyphenidyl/what-is#dosage, "Trihexyphenidyl is an anticholinergic medication that blocks acetylcholine, a chemical that affects movement. It is used to help with tremors in adults with Parkinson' s dis..