Premier at Perry Village for Nursing and Rehab, LL

In the surveyor’s words

From the most serious findings on record at Premier at Perry Village for Nursing and Rehab, LL, in the surveyor’s own words.

• Actual harm, isolatedF689May 8, 2024

  Based on facility job description, clinical record review, review of facility investigation and documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to provide adequate supervision and assistive devices to prevent accidents, which resulted in harm, as evidenced by a scalp laceration and a leg injury for one of two residents reviewed (Resident 1). Findings include: Review of the facility's job description for a Transportation Driver, revealed [in part] must have knowledge of equipment used in long term care; and transports residents safely. Review of Employee 1's personnel file revealed that they were hired to be the Transportation Driver on January 30, 2024. […]

• No harm, potential for more than minimal, patternF690Jan 10, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of two residents reviewed for use of a catheter (Resident 42). Findings Include: Review of Resident 42's clinical record revealed diagnoses that included paraplegia (impairment in motor or sensory function of the lower extremities) and neuromuscular dysfunction of the bladder (urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination). […]

• No harm, potential for more than minimal, patternF692Jan 10, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessed nutritional interventions were provided to maintain acceptable nutritional parameters for one of 19 residents reviewed (Resident 20). Findings: Review of Resident 20's clinical record revealed diagnoses that included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior) and acute kidney failure (when your kidneys become unable to filter waste products from your blood). Review of Resident 20's clinical record revealed a progress note entered by dietary on February 12, 2023, that indicated Resident 20 had a 17.3% weight loss within 180 days. […]

• No harm, potential for more than minimal, patternF758Jan 10, 2024

  Based on Food and Drug Administration (FDA) information review, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of five residents reviewed (Resident 35). Findings include: Review of the FDA drug safety information revealed a black box warning for quetiapine (Seroquel) (antipsychotic medication) for increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. […]

• No harm, potential for more than minimal, patternF790Jan 10, 2024

  Based on observation, staff and resident interviews, grievance review, and record review, it was determined that the facility failed to offer and/or provide dental services for one of 19 resident records reviewed (Resident 16). Findings: Review of Resident 16's clinical record revealed diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by nerves) and hypertension (high blood pressure). During an interview with Resident 16 on January 7, 2024, at 12:36 PM, Resident 16 revealed they lost their lower partial denture about six weeks ago, and it was reported to the facility. Resident 16 revealed they were not in pain, but it is hard to chew. […]