Senior Village Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Senior Village Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 21, 2023

  Based on interview and record review, the facility failed to identify and provide the needed care and services in accordance with professional standards of practice to meet the highest practicable physical well-being of residents for 1 (#2) out of 5 (#1, #2, #3, #4 and #5) sample residents: 1. staff failing to assess Resident #2's glucose when the resident had symptoms of hyperglycemia; and by 2. staff failing to follow up with the physician after notifying the physician of a change in the resident's #2's condition: This failure resulted in a harm on 04/27/2023 at 4:10 p.m., for Resident #2, who was admitted with Type 2 Diabetes Mellitus with Hyperglycemia 9 days prior, when he had a change of condition/decrease, in level of consciousness. […]

• No harm, potential for more than minimal, widespreadF851Sep 10, 2024

  Based on record review and interviews, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Finding: Review of the PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 3 2024 (April 1- June 30) revealed triggers for Excessively Low Weekend Staffing. Review of the facility's Staff Reporting Forms provided from April to June 2024, revealed in part: Weekdays (Monday-Friday) were noted to have between 3 -6 RN's (Registered Nurses), and 7-9 LPN's (Licensed Practical Nurses), whereas the weekends (Saturday-Sunday) had 1 RN and 4 LPN's for the Day shifts. On 09/10/2024 at 10:00 a.m., an interview was conducted with S3DON (Director of Nursing), with S10ADM (Administrator) present. […]

• No harm, potential for more than minimal, patternF656Jun 18, 2025

  Based on record review and interviews, the facility failed to follow physician's orders for 1 (Resident #3) of 3 (Residents #1, #2, #3) sampled residents. The deficient practice had the potential to affect a census of 126. Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses included but not limited to Unspecified Severe Protein-Calorie Malnutrition, Anorexia, Aphasia and Cognitive Communication Deficit. Review of Resident #3's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/20/2025 revealed he had a BIMS (Brief Interview for Mental Status) of 03, indicating he was severely, cognitively impaired. […]

• No harm, potential for more than minimal, patternF640Sep 10, 2024

  Based on record reviews and interviews, the facility failed to ensure the resident's Minimum Data Set (MDS) assessments were transmitted within 14 days after completion for 8 (# 8, #10, #23, #45, #67, #105, #112, and #122) out of 9 ( (# 8, #9, #10, #23, #45, #67, #105, #112, and #122) residents reviewed for resident assessments submission activities. Findings: Resident # 45 Review of Resident #45's Quarterly MDS, with ARD (Assessment Reference Date) of 07/25/2024, revealed it was completed on 08/08/2024, and transmitted on 09/09/2024. Resident # 10 Review of Resident #10's Quarterly MDS, with ARD of 08/06/2024, revealed it was completed on 08/20/2024, and transmitted on 09/06/2024. […]

• No harm, potential for more than minimal, patternF812Sep 10, 2024

  Based on policy review, observation, record review and interview, the facility failed to store food in accordance with professional standards for food service safety by the dietary staff failing to ensure that all foods on the steam table maintained adequate holding temperature prior to being served. This deficient practice had the potential to affect 111 residents that received food from the kitchen. Total facility census was 118. Findings: A review of the facility's Monitoring Temperatures of Cooked Foods policy was conducted on 09/09/2024 at 1:30 p.m. The policy read in part . […]