Redbud Village

In the surveyor’s words

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

• Actual harm, isolatedF602Mar 23, 2026

  The facility identified a census of 33 residents, with 15 residents reviewed for misappropriation of property through diversion. Based on record review, observation, and interview, the facility failed to prevent misappropriation of medications for 15 cognitively impaired residents including some controlled substances, which resulted in missed medications for the affected residents. Findings included: The Facility Incident Report, dated 02/13/26, documented on 02/08/26 at 06:30 AM, Laundry Staff U went into the soiled utility room to pick up dirty laundry. When Laundry Staff U was transferring the dirty laundry to the laundry bin, she came across a black trash bag that made a noise when she picked it up. Laundry Staff U opened the bag and saw a bunch of pills. […]

• Actual harm, isolatedF689Jan 26, 2026

  The facility identified a census of 33 residents, with three residents reviewed for falls and supervision. Based on record review and interview, the facility failed to provide the care planned supervision for cognitively impaired Resident (R) 1 (who had a history of falls, dizziness, and weakness) to prevent a fall with major injury. On 01/08/26 at 08:57 PM, Licensed Nurse (LN) G assisted R1 to the north patio smoking area, placed a smoking apron on R1, and lit R1's cigarette. LN G left R1 outside on the patio and went back inside the facility, which left R1 without direct supervision. While inside, LN G stepped away for a moment and heard R1 yell for help at 09:05 PM. LN G went outside and discovered R1 on the ground on his left side. […]

• No harm, potential for more than minimal, patternF880Mar 12, 2025

  The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to disinfect a glucometer (blood sugar reading machine) between resident use and sort soiled laundry in a sanitary manner. This placed the residents at risk for infectious disease processes. Findings included: - On 03/11/25 at 07:31 AM, Licensed Nurse (LN) G obtained a blood sugar reading for Resident (R) 6 by using a multiuse glucometer. LN G then placed the glucometer on top of the treatment cart. LN G then left the glucometer on the top of the cart and went on to perform other nursing tasks. On 03/11/25 at 07:52 AM, LN G returned to the treatment cart and retrieved the glucometer to obtain another resident's blood sugar level. […]

• No harm, potential for more than minimal, isolatedF658Mar 12, 2025

  The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to meet professional standards of quality when administering insulin (a hormone that lowers the level of glucose in the blood) with an insulin pen (an injection device used to deliver preloaded insulin). This placed the seven residents who received insulin at risk of receiving an inaccurate dose. Findings included: - On 03/11/25 at 08:00 AM, Licensed Nurse (LN) G administered Lantus and Aspart (manufacturer named) insulin subcutaneously (beneath the skin) without priming the insulin pen to Resident (R) 11. […]

• No harm, potential for more than minimal, isolatedF883Mar 12, 2025

  The facility had a census of 31 residents. The sample included 12 residents, with five residents reviewed for immunizations. Residents (R) 11 and R13 lacked the pneumococcal vaccination (helps protect against serious illnesses like pneumonia). Based on record review, and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) to administer a pneumococcal vaccine following written consent. This deficient practice placed the R11 and R13 at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease. Findings included: - A review of immunization records revealed R11 and R13 lacked the CDC recommended pneumococcal immunizations. […]