Country Village Center, Genesis Healthcare

Based on interview and record review, it was determined that the facility failed to inform a resident and/or the resident's representative of the risks and benefits of psychotropic medications for 1 of 5 resident reviewed for unnecessary medications in a final sample of 18 residents. (Resident identifier is #3.)Findings include:Review on 9/10/25 of Resident #3's active physician's orders revealed the following psychotropic medications and start date:Buspirone 5 mg (milligram) give 1 tablet by mouth three times a day for anxiety with a start date of 6/24/25.Lamotrigine 100 mg give 1 tablet by mouth one time day for bipolar disorder with a start date of 6/25/25.Ziprasidone 60 mg give 1 capsule by mouth twice a day with meal or snack for bipolar disorder with a start date of 6/24/25. Review on 9/11/25 of Resident #3's medical record revealed no documentation that Resident #3 or Resident #3's representative was informed of the risk and benefits of the above psychotropic medications. Interview on 9/11/25 at approximately 11:25 a.m. with Staff D (Director of Nursing) confirmed the above…

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, it was determined that the facility failed to properly dispose of medications for 1 of 4 residents observed for medication administration. (Resident identifier is #23.)Findings include:Observation on 9/10/25 between 8:25 a.m. to 8:35 a.m. with Staff F (Licensed Practical Nurse (LPN)) during Resident #23's medication administration revealed that Staff F poured two tablets of multivitamin in a medicine cup and discarded one tablet of multivitamin in the sharps container. Further observation revealed that an open bottle of Over The Counter (OTC) Aspirin Enteric-Coated (EC) 81 mg (milligram) had no visible expiration date on the bottle. Staff G (LPN) came over to ask a question to Staff F and Staff G took the above mentioned open bottle of Aspirin EC 81 mg then discarded the bottle in the open waste bin that had no label and was attached to the medication cart.Interview on 9/10/25 between 8:25 a.m. to 8:35 a.m. with Staff F confirmed the above observation. Review on 9/10/25 of the facility policy titled, Disposal of Medication Waste,…

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, it was determined that the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 1 of 1 resident reviewed for urinary catheter in a final sample of 18 residents. (Residents identifier are #78.)Findings include: Review on 9/10/25 of the facility's policy titled, Enhanced Barrier Precautions, revision date of 12/16/24, revealed .Implementation of EBP .Patient Status .Has a wound or indwelling medical device .Use EBP Yes, if they do not meet criteria for Contact Precautions .Observation on 9/9/25 at approximately 11:00 a.m. with Resident #78 revealed that Resident #78 has an indwelling urinary catheter. Further observation revealed no EBP signage posted and no Personal Protective Equipment (PPE) cart or supplies in Resident #78's room or outside of Resident #78's room. Interview on 9/9/25 at 11:36 a.m. with Staff I (Licensed Nursing Assistant) revealed that he/she was not aware if Resident #78 was on EBP. Interview on 9/9/25 at 11:48 a.m. with Staff H (Licensed Practical Nurse) confirmed that…

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, it was determined that the facility failed to ensure that residents were offered the COVID-19 vaccine or provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine for 2 of 5 residents reviewed for immunizations and to implement policies and procedures on COVID-19 immunization for 1 of 1 staff reviewed for COVID-19 immunizations. (Resident Identifiers are #20 and #39 and Staff identifier is Staff A).Findings include:Review on 6/4/25 of the current CDC immunization guidelines retrieved from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html revealed People ages 65 years and older .are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart.Review on 9/11/25 of facility policy titled COVID-19 Vaccination revised on 2/7/24 revealed . Centers will provide the opportunity to receive COVID-19 vaccination following Centers for Disease Control and Prevention (CDC) recommendations…

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 policy review, it was determined that the facility failed to store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchen and 2 of 3 kitchenettes observed. Findings include: Observation on 9/4/24 at approximately 9:55 a.m. with Staff B (Dietary Manager) of the main kitchen milk cooler revealed the following: 1 open container and 1 unopened container of Grave prune juice, both with a manufacturer's use by date of 8/10/24; 10 single serve containers of Dannon Light and Fit yogurts with a manufacturer's use by date of 4/2/24. Observation on 9/4/24 at approximately 10:00 a.m. with Staff B of the Cohass Unit kitchenette refrigerator revealed the following: 1 open container of Hormel thick and easy hydrolyte water with hint of lemon with a hand written open date of 6/19/24. Further observation of the Hormel container revealed manufacturer's instructions that read Discard if not used with in 10 days of opening.; 1 open container of Chick-fil-A sauce with a manufacturer's use by date of 12/18/23.…

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 it was determined that the facility failed to follow CDC guidelines for hand hygiene and the use of appropriate Personal Protective Equipment (PPE) to prevent the spread of infection for 32 residents on Transmission Based Precautions (TBP) and 3 residents on Enhanced Barrier Precautions (EBP). Findings include: Isolation Gowns Interview on 9/4/24 at 9:46 a.m. with Staff A (Administrator) revealed that the facility currently had 32 residents on Droplet Precautions for COVID-19 and they resided on all 3 units. Review on 9/4/24 of the facility Resident Matrix, dated 9/4/24, revealed that there were 32 residents on TBP and 3 additional residents who had indwelling devices; who were observed to be on EBP. Observation on 9/4/24 at approximately 1:15 p.m. of the facility isolation gowns being used on all 3 units for TBP and EBP rooms revealed that gowns being used in the facility were thin and of a light material. There were no other gowns observed on the units. Review on 9/4/24 at approximately 1:15 p.m. of the plastic packaging for the…

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 record review and interview, it was determined that the facility failed to follow professional standards for clarifying medication orders for as-needed pain medication for 1 of 1 resident reviewed for pain management in a final sample of 19 residents (Resident Identifier is #37). Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336-Physicians' Orders. The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 9/19/23 of Resident #37's physician's orders revealed the following orders: Acetaminophen Tablet 325 milligram (mg) give two tablets by mouth every 4 hours as needed for mild/mod[erate] pain, dated 9/1/23. Oxycodone-Acetaminophen Oral Tablet 5-325 mg (milligrams) Give 1…

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 policy review, it was determined that the facility failed to ensure that a biological was labeled with an opened date and failed to ensure that controlled drugs were in a double locked secure compartment in 1 out of 1 medication room observed (Resident Identifier is #11). Findings include: Observation on 9/18/23 at approximately 10:15 a.m. with Staff A (Registered Nurse) of the only medication room revealed 1 opened multi-dose vial of Aplisol (Tuberculin Purified Protein Derivative, diluted) not labeled with an open expiration date. Interview on 9/18/23 at approximately 10:15 a.m. with Staff A confirmed the above findings. Review on 9/18/23 of the manufacturer's instructions for APLISOL revealed .Storage Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . Review on 9/18/23 of the Storage and Expiration Dating of Medications, Biologicals policy, dated 8/7/23 revealed . 5.3 If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured ), the…

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 policy review it was determined that the facility failed to store food in accordance to professional standards in the main kitchen. Findings include: Review on 9/21/23 of the Food Code U.S. Public Health Service 2022 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2022 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines . Chapter 3 Food .3-305.11 Food Storage .FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . Observation on 9/18/23 at approximately 9:45 a.m. with Staff D (Cook) of the dry food storage area and walk-in refrigerator revealed the following: One (1) box of bananas in the dry food storage area containing 8 bananas that were wilted and brown, peels split open in some areas covered with fruit flies, stored with fresh bananas. One (1) box of celery in the walk-in refrigerator containing 3 wilted celery stocks with brown discolored…

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.