Penick Village

In the surveyor’s words

From the most serious findings on record at Penick Village, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 23, 2023

  Based on observations, record review, resident, staff, and Physician Assistant (PA) interviews the facility failed to safely transfer a resident (Resident #3) from her bathroom to the recliner using the mechanical lift that resulted in the dislocation of the left shoulder which required treatment at a hospital. The facility also failed to safely transfer a resident (Resident #2) from her motorized wheelchair to the bed using the mechanical lift that resulted in a fracture to the right hip which required treatment at a hospital. This was for 2 of 6 residents reviewed for supervision to prevent accidents. Findings included: 1. […]

• Actual harm, isolatedF689Aug 10, 2022

  Based on observation, staff interviews, Physician Assistant (PA) interview and Responsible Party (RP) interview and record review the facility failed to identify the root cause and implement effective interventions to prevent multiple falls (Resident #32). In addition, the facility failed to identify the root cause for multiple falls (Resident #18) and failed to safely utilize a total body (hydraulic lift utilizing a body sling) lift while attempting to transfer a resident resulting in a fall without injuries (Resident #29). This was for 3 of 3 residents reviewed for accidents. The findings included: 1. Resident #32 was admitted on [DATE] with cumulative diagnoses of Dementia, [CONDITION(S)], a history of a femur fracture and a history of falls. […]

• Actual harm, isolatedF692Aug 10, 2022

  Based on record review, observation and interview with the Registered Dietician (RD), Dietary Manager (DM), Physician Assistant (PA), resident and staff, the facility failed to address and to intervene when a resident was identified to have a weight loss (Residents #13,& #3) which resulted in continued weight loss and failed to provide a nutritional supplement on admission for a resident with history of weight loss and continued to lose weight (Resident #14). This was for 3 of 4 sampled residents reviewed for nutrition (Residents # 13, #3, #14). Findings included: 1. […]

• No harm, potential for more than minimal, widespreadF880Jul 28, 2021

  Based on observations, record reviews, and staff interviews, the facility failed to implement the Centers for Medicare and Medicaid Services (CMS) guidelines by not screening vaccinated staff or visitors prior to entering the facility. The findings included: On 7/28/21 at 2:34 PM the Administrator stated the corporate office made the decision to stop screening vaccinated employees in a memo titled; updated mask guideline: COVID-19, dated 5/19/2021. The memo read, in part: the Governor and federal government had loosened guidelines. These guidelines allowed discretion for organizations to be more specific regarding the use of masks and the screening of employees. […]

• No harm, potential for more than minimal, patternF686Jul 28, 2021

  Based on record review, observations, staff interviews and wound care provider interview, the facility failed to complete and document wound care as ordered (Residents #6, #7 and #24), failed to ensure a pressure relieving device was in place (Resident #7) and also failed to accurately transcribe physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 3 of 4 residents reviewed for pressure ulcers. The findings included: 1) Resident #24 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #24's most recent quarterly Minimum Data Set (MDS) date 6/11/2021 indicated the resident was severely cognitively impaired and had no behaviors during the assessment period. […]