John Knox Village Care Center

In the surveyor’s words

From the most serious findings on record at John Knox Village Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 9, 2021

  Based on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accident hazards, when the facility failed to keep chemicals locked and out of reach of residents, and failed to provide supervision for one sampled resident (Resident #1) out of five sampled residents. On 12/5/21 the resident accessed the facility shower room and obtained an unopened bottle of cleaning solution from the unlocked unsecured cabinet. He/she took the bottle to his/her room and drank 3/4 of the cleaning solution. The facility census was 135 residents. The Administrator was notified on 12/8/21 at 3:30 P.M. of an Immediate Jeopardy (IJ) which began on 12/5/21. The IJ was removed on 12/9/21, as confirmed by surveyor onsite verification. […]

• Actual harm, isolatedF600Jan 11, 2021

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when Certified Nurse Aide (CNA) B pushed the resident into a chair, holding him/her down by the shoulders, resulting in the resident becoming agitated, bruising on his/her neck, and blood on his/her lip, out of three sampled residents. The facility census was 151 residents. The facility staff was notified on 1/8/21 of Past Non-Compliance which occurred on 1/6/21. Upon discovery, staff suspended the employee on 1/6/21, conducted an investigation, and notified appropriate parties. On 1/7/21, the Administrator identified through the facility investigation CNA B physically abused the resident, CNA B was terminated. […]

• No harm, potential for more than minimal, widespreadF812Jul 5, 2023

  Based on observation and interview, the facility failed to keep the Dry Storage (DS) room, walk-in refrigerator, and walk-in freezer floors clean; to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; to maintain sanitary utensils and food preparation equipment; to change the deep fryer oil in a timely manner; to properly measure and document hot food temperatures at the ovens and/or stoves to ensure they were suitably cooked, and cook longer if needed, to lessen the chance of bacterial contamination; to maintain plastic plate covers and utensils in good condition to avoid food safety hazards (cross-contamination); and to separate damaged foodstuffs, in accordance with professional standards for food service safety. […]

• No harm, potential for more than minimal, widespreadF812Aug 30, 2021

  Based on observation, interview, and record review, the facility failed to keep the dry storage and walk-in refrigerator & freezer floors clean; failed to retain thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary utensils; failed to safeguard against foreign material or mold possibly getting into food and/or beverages; failed to keep trash and garbage receptacles lidded; failed to change deep fryer oil in a timely manner; failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; failed to follow correct hair hygiene practices; and failed to ensure the proper refrigeration of foodstuff. These deficient practices potentially affected all residents who ate food from the kitchen. […]

• No harm, potential for more than minimal, patternF880Jan 14, 2025

  Based on observation, interview, and record review, the facility failed to ensure infection control standards of practices including hand hygiene were incorporated during wound care for one sampled resident (Resident #77); and failed to ensure Enhanced Barrier Precautions (EBP-strategy to decrease transmission of infections and/or cross-contamination during high-contact care activities for residents in nursing homes that include wearing gowns, gloves and at times a face mask) were used for one sampled resident (Resident #19) with a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) out of 23 sampled residents. The facility census was 112 residents. […]