Town and Country Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Town and Country Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 31, 2024

  48366 Based on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 24 Residents (Residents #15, #47, #50, and #82) reviewed for safety, monitoring, and supervision. 1. The facility failed to monitor and supervise Resident #50's multiple incidents of drinking beer and receiving quetiapine (used to treat the symptoms of mental illness that caused disturbed or unusual thinking), Zolpidem (used to treat difficulty falling asleep or staying asleep; a class of medications called sedative-hypnotics) and hydrocodone (a narcotic analgesic agent for the treatment of moderate to moderately severe pain) with subsequent falls, possession of cigarettes and a personal lighter while… […]

• Immediate jeopardy, isolatedF755Jul 26, 2024

  Based on observation, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmacy services in that: The facility failed to follow physician orders for the fentanyl patch resulting in Resident #1 becoming unresponsive and suffering respiratory failure. An Immediate Jeopardy was identified on 7/25/24 at 3:15 PM. […]

• Immediate jeopardy, isolatedF761Mar 31, 2024

  Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 24 residents reviewed for medication storage. 1. The facility failed to store Resident #52's medications which were kept at her bedside which resulted in an incident on 11/22/2023, when she was hospitalized and diagnosed with overdose related to self-medication with Diphenhydramine (an antihistamines; used for relief from symptoms related to hay fever, upper respiratory allergy, or cold symptoms) and hydrocodone (a narcotic analgesic agent for the treatment of moderate to moderately severe pain). An Immediate Jeopardy (IJ) was identified on 03/29/2024. […]

• No harm, potential for more than minimal, widespreadF812Mar 31, 2024

  Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. Sanitizing buckets were not stored away from food products on 03/24/24. 2. Personal beverages were in a part of the kitchen work area on 03/24/24. 3. The juice machine was not clean on 03/24/24. 4. A couple of milk jugs were opened and not dated on 03/24/24. 5. There was a prepared salad in the refrigerator that was not discarded on the discard date of 03/20/2024. 6. There was a package of cheese stored in the freezer that was open and exposed to the inner freezer environment on 03/24/24. 7. […]

• No harm, potential for more than minimal, patternF759May 23, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5% for 28 medication administration opportunities with 3 errors resulting in a 10% medication error rate, for 2 of 4 (Residents #1 and #37) reviewed for medication administration. 1. The facility failed to ensure Resident #1 received medications Amiodarone (used to regulate rapid and/or irregular heart rhythms) and Apixaban (used to prevent blood clots) as ordered by the physician. 2. The facility failed to ensure Resident #37 received medication Xifaxan (used to treat the brain function decline that can occur secondary to liver damage) as ordered by the physician. These failures could result in residents not receiving the intended therapeutic benefits of medications. […]