The Villages at Southern Hills

In the surveyor’s words

From the most serious findings on record at The Villages at Southern Hills, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF755Aug 26, 2022

  Based on record review, observation, and interview, the facility failed to ensure a [MEDICATION(S)] injection (an anticoagulant medication) was available for one (#158) of 12 residents observed during medication pass. The DON identified five residents who were prescribed [MEDICATION(S)]. Findings: A facility policy titled, Disposal of Medications, Syringes and Needles, dated December 2012, read in parts, .Discontinued medications and/or medications left in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition . […]

• No harm, potential for more than minimal, patternF761Aug 26, 2022

  Based on record review, observation, and interview, the facility failed to ensure medications and treatments were properly stored/secured for one (100 hall) of six medication carts observed and two of two treatment carts observed. The DON identified the facility had seven medication carts and two treatment carts. Findings: A facility policy titled, Medication Administration General Guidelines, dated September 2018, read in parts, .During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the personnel administering medications when unlocked . On 08/23/22 at 10:30 a.m., a medication cart was observed to be unlocked/unsecured on the 100 hall. […]

• No harm, potential for more than minimal, patternF880Jul 21, 2021

  Based on observation, interview, and record review, it was determined the facility failed to: a. ensure staff wore face masks according to the Centers for Medicare & Medicaid Services (CMS) guidelines to prevent the development and transmission of COVID-19; and b. ensure COVID-19 screening was completed upon entry and exit to the facility per policy. The administrator identified 107 residents who resided in the facility. Findings: CDC (Centers for Disease Control) guidance, updated on 04/06/21, titled Improve the Fit and Filtration of Your Mask to Reduce the Spread of COVID-19, .Correct and consistent mask use is a critical step everyone can take to reduce their risk of getting and spreading COVID-19 .Masks should a) Completely cover the nose and mouth. […]

• No harm, potential for more than minimal, isolatedF684Nov 8, 2023

  Surveyor: [NAME], [NAME] Based on observation, record review, and interview, the facility failed to ensure a resident with MASD received necessary treatment and services that were consistent with the standards of practice for one (#256) of two residents reviewed for skin conditions. The DON identified 20 residents with MASD resided in the facility. Findings: The Non-Pressure Wounds: Moisture Associated Dermatitis Clinical Operations policy, dated July 2018, read in parts, .Review and investigate the type and frequency in which the areas managed for prevention and treatments .Briefs used and frequency of changing briefs .Review orders and treatments and gather supplies .Report abnormalities to supervisor . […]