English Village Skilled Nursing and Therapy

In the surveyor’s words

From the most serious findings on record at English Village Skilled Nursing and Therapy, in the surveyor’s own words.

• Actual harm, isolatedF697Jul 20, 2023

  Based on record review and interview, the facility failed to have an effective method for ordering and obtaining medications in a timely manner, to provide adequate pain management for a resident, which resulted in a hospital visit for one (#1) of three sampled residents reviewed for pain. The Resident Census and Conditions of Residents, dated 07/20/23, documented 64 residents resided in the facility and 36 residents were on a pain management program. Findings: A facility policy, Nursing Protocols - Pain, revised 09/10/07, documented in part, .Believe the resident's report of pain. […]

• No harm, potential for more than minimal, patternF640Dec 18, 2023

  Based on record review and interview, the facility failed to electronically submit MDS assessments to CMS within the required timeframe after completion for four (#1, 5, 18, and #23) of four residents reviewed for resident assessments. The DON reported 62 residents resided in the facility. Findings: 1. Resident #1's quarterly assessment, dated 10/22/23, was documented as transmitted. The final validation report documented the assessment was submitted to CMS on 12/08/23. 2. Resident #5's annual assessment, dated 10/20/23, was documented as transmitted. The final validation report documented the assessment was submitted to CMS on 12/08/23. 3. Resident #18's quarterly assessment, dated 10/20/23, was documented as transmitted. […]

• No harm, potential for more than minimal, patternF689Nov 5, 2021

  Based on interview and record review, the facility failed to provide adequate supervision to prevent elopement for one (#60) of three residents reviewed for elopement. The Administrator reported 60 residents resided in the facility. Findings: Resident #60 was readmitted to the facility on [DATE] with diagnoses which included depression and [CONDITION(S)]. A Wandering Risk Scale Assessment, dated 12/27/20, documented no history of wandering and the resident had not wandered from the facility. A Smoking Safety Screen Assessment, dated 12/27/20, documented the resident was safe to smoke with supervision. The assessment documented the resident required supervision due to smoking all cigarettes then becoming angry with staff when the cigarettes were gone. […]

• No harm, potential for more than minimal, patternF812Nov 5, 2021

  Based on observation and interview, the facility failed to store and serve food and ice to maintain food service safety. The Administrator reported 60 residents resided in the facility and 58 residents received food and ice from the kitchen. Findings: On [DATE] at 10:50 a.m., a tour of the facility kitchen was conducted. Approximately 20 containers of Med Pass 2.0 was observed to be expired on [DATE] and [DATE]. Approximately eight containers of Ready Care Dairy Drink was observed to be expired on [DATE]. The expired items were reviewed with Assistant Cook #1 and she agreed the items were expired and should have been disposed of. On [DATE] at 11:05 a.m., two ice machines were observed to have a layer of dust on the outside of both machines. […]

• No harm, potential for more than minimal, patternF880Nov 5, 2021

  Based on observation, interview, and record review, the facility failed to dispose of retractable needles in a puncture resistant container for one (#6) of two sampled residents observed for insulin administration. The administrator reported a census of 60 residents. Findings: A facility infection control and isolation policy, revised date 06/23/17, read in part, .Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate impervious, puncture resistant containers, which are located as close as practical to the area in which the items were used . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Inject 50 units subcutaneously two times a day related to type 2 Diabetes Mellitus with [CONDITION(S)]. […]