Green Village Skilled Nursing & Rehabilitation Ltd

In the surveyor’s words

From the most serious findings on record at Green Village Skilled Nursing & Rehabilitation Ltd, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Apr 28, 2025

  Based on observation, interview and policy review, the facility failed to have test strips at the three-sink manual dishwash area to test for proper sanitation levels. This had the potential to affect all 59 of 59 residents receiving dietary services. Findings include: On [DATE] at 8:30 A.M. an initial tour of the kitchen revealed Hydrion test strips to test for proper sanitation levels at the three-sink manual dishwash station expired ,d+[DATE]. An interview at the time of the observation with Dietary Manager (DM) #448 verified the expired test strips. DM #448 also stated they were unaware of an expiration date for test strips existed. […]

• No harm, potential for more than minimal, patternF880Apr 28, 2025

  Based on observation, record review, and interview, the facility failed to ensure insulin pens were only used for one resident and failed to follow infection control precautions for Resident #32 and #73. This affected Resident #5, Resident #32, and Resident #73 with the potential to affect five residents (#42, #70, #71, #72, and #73) who resided on the 100 hall. The facility census was 59. Findings include: 1. Observation of an insulin administration for Resident #5 on 04/21/25 at 4:28 P.M. revealed Registered Nurse (RN) #434 programmed a dose of 21 units of Humalog insulin from a Humalog Kwikpen device (a multi-use insulin injection syringe). Observation of the syringe revealed it was a previously-opened device labeled as belonging to Resident #46. […]

• No harm, potential for more than minimal, isolatedF656Apr 28, 2025

  Based on medical record review, interview, and review of facility policy, the facility failed to ensure Resident #2 and Resident #18's comprehensive care plans included all goals and interventions needed to meet the residents' total care needs. This affected two residents (Resident #2 and Resident #18) of 27 residents reviewed for comprehensive care plans. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diverticulitis, type two diabetes mellitus with metabolic diabetic polyneuropathy, chronic pain syndrome, atrial fibrillation, gout, major depressive disorder, unspecified psychosis, mild cognitive impairment, and need for assistance with personal care. […]

• No harm, potential for more than minimal, isolatedF657Apr 28, 2025

  Based on review of the medical record, interview, and review of facility policy, the facility failed to ensure the care plan for Resident #4 was updated with new fall interventions after a fall with injury. This affected one resident (Resident #4) of two residents reviewed for accidents. The facility census was 59. Findings include: Review of the medical record for Resident #4 revealed an admitted [DATE] with diagnoses including syncope and collapse, lower back pain, unspecified head injury, dizziness and giddiness, muscle weakness, unsteadiness on the feet, difficulty walking, and unspecified disorders of bone density and structure. […]

• No harm, potential for more than minimal, isolatedF677Apr 28, 2025

  Based on review of the medical record, interview, and review of facility policy, the facility failed to ensure Resident #2 received assistance with baths and showers per preferences or the care plan. This affected one resident (Resident #2) of six residents reviewed for activities of daily living (ADL). The facility census was 59. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), diverticulitis, type two diabetes mellitus with metabolic diabetic polyneuropathy, chronic pain syndrome, atrial fibrillation, gout, major depressive disorder, unspecified psychosis, mild cognitive impairment, and need for assistance with personal care. […]