Medilodge of Green View

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living among all residents. Findings Include:On 07/30/2025 at 10:27 AM, it was noted that the drain line on the ice machine in the main dining room off the kitchen had black slime growing on end of the pipe. Maintenance Director F observed the drain pipe, and stated he cleans the ice machine and the drain tray weekly, but not the drain line that hangs above the floor drain.On 7/29/25 at 10:31 AM, the register cover in room [ROOM NUMBER] was observed dirty with brown splatters on the wall and had been re-enforced to hold the front and the top of the unit together. On 7/29/25 at 12:42 PM, during an interview with Guardian/Conservator G she was asked about the heater/register in room [ROOM NUMBER] and stated that it looks terrible, but functions fine. She stated the register was beat up and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the physician documented the clinical rationale and duration of use in the medical record for a PRN (as needed) psychotropic medication for one Resident (#6) of five residents reviewed for unnecessary medications. Findings include: Resident #6 (R6) was admitted to the facility 6/23/25. A Minimum Data Set (MDS) assessment dated [DATE] documented R6 had severe cognitive impairment and received psychotropic medications. There were no behaviors coded in the MDS.The Electronic Medical Record (EMR) of R6 contained a physician's order dated 7/9/25 for alprazolam (an antianxiety medication) 0.25 mg (milligrams) every 24 hours PRN for anxiety. A medication history review revealed the PRN alprazolam was initially ordered on 6/24/25.A pharmacist medication regimen review (MRR) for R6 dated 6/24/25 read, in part: .Note to attending physician/prescriber.This resident has an order for PRN alprazolam. Please evaluate current diagnosis, behaviors and usage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure one Resident (#2) of one resident reviewed for PASARR (Preadmission screening/Annual Resident Review) had a Level one (1) OBRA (Omnibus Budget Reconciliation Act) screening sent to the Community Mental Health Services Program (CMHSP) for a level two (2) OBRA evaluation. Findings include:The Electronic Medical Record (EMR) of Resident #2 (R2) revealed an admission date of 6/19/25. R2's diagnoses included but were not limited to: Bipolar Disorder and Major Depressive Disorder. A Level 1 screening dated 6/11/25 documented R2 had a diagnosis of mental illness and had received treatment for mental illness, including psychotropic medications within the last 14 days. The EMR did not contain a Level 2 OBRA evaluation, and no documentation was in the EMR indicating a Level 1 had been referred to the CMHSP for evaluation.The MDS Nurse (Registered Nurse (RN) C) was interviewed on 7/30/25 at 1:41 PM. RN C confirmed she was the staff member responsible for completing the PASARR. RN C said there was not a Level 2 for R2 because a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were safely administered in an environment of a residents choosing for one Resident (R191) of twelve residents reviewed for Residents' Rights. Findings include: During medication administration observation on 8/7/24 at 7:24 a.m., Registered Nurse (RN) E provided Resident #191 (R191) her prescribed medications while R191 was eating breakfast in the dining room with other residents. RN E placed the medications directly on the table next to R191 and exited the dining room without observing R191 take the medications. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:30 a.m. The DON agreed medications should not be provided in the dining room unless a resident prefers to take his or her medications in the dining room. The DON said the resident preference for administration locale would be in the care plan if a resident wants medications administered in a public area such as the dining room. R191 was interviewed on 8/7/24 at 11:51 a.m. When asked about receiving medication while in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assistance was provided with donning a back brace for one Resident (R20) of four residents reviewed for range-of-motion and mobility. Findings include: Resident #20 (R20) On 8/5/24 at approximately 9:15 a.m., a Thoracolumbosacral orthosis (TLSO - a type of back brace) was observed on a chair in R20's room. R20 was sitting in a wheelchair talking on the phone and was not visibly wearing a different brace or device to stabilize or support the spine. On 8/5/24 at 12:47 p.m., the TLSO remained in the chair in R20's room. When asked about the TLSO, R20 said, I broke my back and I'm supposed to wear that when I'm out of bed, but I can't put it on by myself. R20 indicated she was admitted to the facility for skilled rehabilitation services after experiencing a fall at home that resulted in a spinal fracture. R20 was asked if the staff assisted with donning the brace. R20 said the therapist was assisting with the brace but skilled therapy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to: 1. Document the rationale for declining gradual dose reductions for an antipsychotic medication for one Resident (R1) of five residents reviewed for unnecessary medications, and 2. Document the rationale and duration of PRN use of a psychotropic medication for one Resident (R6) of five residents reviewed for unnecessary medications. Findings include: Resident #1 (R1) A review of the physician's orders for R1 included an order for Abilify (an antipsychotic medication) 10 milligrams (mg) daily. A review of R1's medical record did not reveal any attempts at Gradual Dose Reduction (GDR) of the Abilify since R1 was admitted to the facility on [DATE]. A form Antipsychotic Gradual Dose Reduction Form dated 11/23/23 was in R1's record. The form documented the Antipsychotic medication to be addressed was Abilify for Bipolar disorder and hallucinations. A box was checked that read: a gradual dose reduction is contraindicated for the following reason: . but no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were appropriately administered for two Residents (R4 and R17) of four residents reviewed for infection control practices during medication administration. Findings include: During medication administration observation on 8/6/24 at 7:41 a.m., Registered Nurse (RN) A was preparing medications for Resident #4 (R4) at the medication cart. RN A picked up a plastic water cup by the lip of the cup with ungloved hands to set the cup on the med cart. RN A poured water into the cup they had just touched with bare fingers and gathered the medications and cup of water and entered R4's room. RN A placed the cup of water, a medication cup containing R4's medications, and an insulin syringe on R4's bedside table without a barrier. RN A handed R4 the medication cup containing the medication. When R4 attempted to place the medications from the cup into his mouth, three medications fell from the cup onto R4's bed. RN A picked up the medications with bare, ungloved fingers and placed the three medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to implement a comprehensive, facility-wide Infection Control Program as evidenced by failure to: 1. Don, doff, and disinfect PPE (personal protective equipment) for residents with confirmed or suspected of COVID-19 infection. 2. Assess for COVID-19 symptoms and implement transmission-base precautions timely. 3. Complete infection control analysis, correlation, and trending of resident and staff infections. 4. Maintain timely and accurate infection control line listings and surveillance mapping. 5. Properly retrieve meal room trays from COVID-19 positive rooms. 6. Ensure disinfectant chemicals used to clean and disinfect transmission based precaution (TBP) rooms met the minimum concentration specified by the vendor of the chemical. This deficient practice has the potential to result in the transmission of pathogens between residents rooms and the spread of infectious organisms to all 32 vulnerable residents. Findings include: On 9/19/23 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent, for two Residents (#2 & #7) of five residents reviewed for medication administration. This deficient practice resulted in lack of assessments to determine efficacy of respiratory medications and the potential for undesirable therapeutic effects from inaccurate insulin administration. Findings include: Resident #2 (R2) Medication administration for R2 on 9/20/23 at 12:10 PM, was observed performed by Registered Nurse (RN) H. This included the administration of Albuterol Sulfate Inhalation Nebulizer Solution 2.5 mg (milligrams) / 3 ml (milliliters), 3 ml inhale orally via nebulizer (machine that turns liquid medication into a fine mist and inhaled though the mouth into the lungs). RN H did not have a stethoscope with her. RN H failed to listen to R2's lung sounds, check heart rate and respiration rate, and obtain a pulse ox (oxygen saturation level in the blood) prior to treatment. On 9/20/23 at 12:30 PM, an interview was conducted with RN H who was asked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.