H & J Vonderlieth LVG CTR, The

In the surveyor’s words

From the most serious findings on record at H & J Vonderlieth LVG CTR, The, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Dec 11, 2025

  Based on observation, interview, and record review the facility failed to ensure injectable medications for two residents (R1 and R38) were labeled and dated when opened, and failed to ensure a multidose tuberculin vial was discarded after the expiration date when opened. These failures have the potential to affect all 55 residents residing in the facility.Findings include: The Storage of Medication Policy dated [DATE] documents Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Expiration Dating G. […]

• No harm, potential for more than minimal, patternF880Dec 11, 2025

  Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds and surgical wounds for six of six residents (R2, R8, R9, R18, R26, and R31) reviewed for EBP in the sample of 45. Findings include: The Enhanced Barrier Precaution Protocol dated 4/8/24 documents Enhanced Barrier Precautions (EBP) expands the use of Personal Protective Equipment (PPE) beyond situations in which exposer to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug-Resistant Organisms (MDROs) to staff hands and clothing. […]

• No harm, potential for more than minimal, isolatedF605Dec 11, 2025

  Based on observation, interview, and record review the facility failed to ensure a resident who has a diagnosis of dementia was kept free from chemical restraints for one resident (R2) of six residents reviewed for antipsychotic medications in a sample of 45. Findings Include:The facility's Abuse policy dated 8/25/25 documents All residents have the right to be free of from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. This includes but is not limited to freedom from corporal punishment, and involuntary seclusion and physical or chemical restraints not required to treat the resident's symptoms. […]

• No harm, potential for more than minimal, isolatedF759Dec 11, 2025

  Based on observation, record review and interview, the facility failed to give medications as ordered by the physician for three of 15 residents (R22, R23 and R44) reviewed for medication pass in the sample of 45. This failure resulted in three errors out of twenty-six opportunities totaling an 11.5% medication error rate.Findings include:The facility's Medication Administration policy, dated 1/11/2010, documents Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. […]

• No harm, potential for more than minimal, isolatedF758Aug 3, 2023

  Based on observation, interview and record review the facility failed to document appropriate indications to warrant the use of an antipsychotic medication (R46) and attempt a gradual dose reduction (R19) for 2 of 5 residents reviewed for unnecessary medication in a sample of 23. Findings include: A Psychotropic Medication policy dated 11/28/17 gives as its intent, Residents are free from unnecessary psychotropic medication use. This policy states that antipsychotic medication may be indicated for use if behavioral symptoms present a danger to the resident or others; expressions or indications of distress that are significant distress to the resident; if not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are… […]