Village at the Greene

In the surveyor’s words

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

• Immediate jeopardy, patternF689Dec 13, 2022

  Based on medical record review, review of fall investigations, observations, staff interviews, and review of facility policy on falls, the facility failed to adequately assess the root cause of falls, identify trends and patterns of falls, implement appropriate fall prevention interventions, assess the effectiveness of interventions, ensure previously implemented interventions were in place, and failed to update care plans timely for fall interventions for Residents #11, #29, #38, #61, and #81. This resulted in Immediate Jeopardy when Resident #29 sustained a fall on 01/29/22 that caused a head laceration, which was repaired with skin glue. On 07/03/22, Resident #11 fell and fractured her clavicle. On 08/21/22, Resident #38 fractured her hip during a fall. […]

• Immediate jeopardy, isolatedF686Dec 13, 2022

  Based on observation, interview, record review, review of the National Pressure Ulcer Advisory Panel (NPUAP) information, and policy review, the facility failed to assess and identify pressure ulcers and failed to implement interventions and treatments to prevent the development and promote healing of pressure ulcers. The facility failed to identify multiple unstageable (blackened in color with necrotic tissue) deep tissue injuries (DTI), failed to contact the physician to implement treatments, resulting in worsening tissue damage and failed to follow infection control protocols during pressure ulcer dressing changes. […]

• Immediate jeopardy, isolatedF690Dec 13, 2022

  Based on medical record review, review of the hospital record, staff and family interview, observation, review of the skills checklist for catheter care, and policy review, the facility failed to ensure Resident #10 was timely sent to the hospital when the resident exhibited signs and symptom of sepsis. This resulted in Immediate Jeopardy and serious life-threatening harm and/or injuries when Resident #10 had symptoms of lethargy, foul-smelling urine, and had no urinary output for 48 hours. […]

• Actual harm, isolatedF689Jan 6, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, resident and family interview, review of video camera footage, review of facility investigation and incident report, and policy review the facility failed to ensure a resident was properly transferred and provided a mechanical lift (Hoyer) during transfer. This resulted in actual harm when Resident #27 who was a high fall risk, dependent for transfers, and required the utilization of a mechanical lift (Hoyer) for all transfers suffered a right distal femur fracture from a fall that occurred during a transfer. This affected one (#27) of three residents reviewed for falls. […]

• Actual harm, isolatedF684Dec 13, 2022

  Based on medical record review, resident interview, family interview, and staff interview, the facility failed to prevent a resident from developing Moisture Associated Skin Damage (MASD). This resulted in actual harm when it was discovered Resident #08 was left on a wet mattress, resulting in significant MASD needing antibiotic treatment. This affected one (Resident #08) of one reviewed for MASD prevention. Findings include: Review of the medical record for Resident #08 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, congestive heart failure, and peripheral vascular disease. Resident #08 was cognitively impaired. […]