Town of Vici Nursing Home

In the surveyor’s words

From the most serious findings on record at Town of Vici Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 25, 2024

  Based on record review and interview, the facility failed to ensure staff used a mechanical lift for one (#3) of four sampled residents reviewed for the use of mechanical lifts. On 06/09/24 CNA #4 attempted a one person transfer with Resident #3 without using the mechanical lift and was lowered to the floor. Resident #3 required the assistance of two staff with the use of a maxi lift for transfers per the care plan. An X-ray was completed two days later when the resident continued to complain of pain and had swelling and warmth to their leg. The X-ray documented Resident #3 had an oblique fracture of the left distal femur. The census was 43. […]

• No harm, potential for more than minimal, patternF580Apr 9, 2025

  Based on record review and interview, the facility failed to ensure the physician was notified of insulin being held for 1 (#19) of 5 sampled residents reviewed for notification. LPN #3 identified eight residents received insulin. Findings: A quarterly resident assessment, dated 11/22/24, showed Resident #19 had diagnosis which included diabetes mellitus and BIMS score of 14 (cognition intact). Resident #19's physicians order, dated 01/17/25, showed Lantus insulin (medication to control blood sugar) 50 U, subcutaneous daily. Hold for FSBS below 120. A MAR, dated March 2025, showed the Lantus insulin had not been administered on 03/03/25, 03/09/25, 03/11/25, 03/14/25, 03/21/25, 03/28/25 and on 03/29/25 due to the resident not eating breakfast. […]

• No harm, potential for more than minimal, patternF755Apr 9, 2025

  Based on record review and interview, the facility failed to ensure: a. BP monitoring for a PRN antihypertensive medication for 1 (#3); and b. medications were available for 1 (#11) of 5 sampled residents reviewed for medications. The administrator identified 37 residents resided in the facility. LPN #3 identified three residents had orders for clonidine. Findings: 1. Resident #3's quarterly resident assessment, dated 11/18/24, showed a diagnosis of hypertension and a BIMS score of five (severe cognitive impairment). A physician's order, dated 12/23/24, showed to administer clonidine (antihypertensive agent) tablet 0.1 mg three times a day as needed for SBP (the maximum blood pressure during contraction of the heart) greater than 160. […]

• No harm, potential for more than minimal, patternF636Dec 6, 2023

  Based on record review and interview, the facility failed to ensure comprehensive MDS assessments were completed timely for three (#27, 38, and #140) of 12 sampled residents reviewed for assessments. The administrator identified 36 residents resided in the facility. Findings: A [MDS] and Care Plan policy, undated, read in part, .(MDS) will be completed upon each new admission within 14 days of admission. A MDS will also be completed upon .Annual Assessment . An Admission Summary report, documented Resident #38 was admitted [DATE] and Resident #140 was admitted [DATE]. The facility's EHR documented Resident #27's quarterly assessment was completed 08/07/23. The resident's comprehensive assessment was due in November. […]

• No harm, potential for more than minimal, patternF638Dec 6, 2023

  Based on record review and interview, the facility failed to ensure quarterly MDS assessments were completed timely for four (#15, 32, 19, and #2) of 12 sampled residents reviewed for assessments. The administrator identified 36 residents resided in the facility. Findings: A [MDS] and Care Plan policy, undated, read in part, .Quarterly reviews and updates will be completed as mandated . The facility's EHR documented Resident #15's last completed assessment was 07/28/23. It documented a quarterly assessment, dated 10/27/23, had not been completed. The facility's EHR documented Resident #32's last completed assessment was 07/09/23. […]