White Horse Village.

“Training records lacked training dates and length of training. Staff training sign-in sheets for medication administration and other topics did not document when training occurred or how long it lasted.”

“Poisonous materials were unlocked, unattended, and accessible to residents. Derma Cerin skin protectant moisturizing cream was accessible in a room, and Ecolab lime-away, Ecolab High Performance Ultra Concentrated Neutral food cleaner, and Ecolab Dip it XP were accessible in the Secure Dementia Care Unit kitchen. Not all residents were assessed as capable of recognizing and using poisons safely.”

“Six containers of undated and unsealed ice cream were found in the personal care unit freezer. This was a repeat violation.”

“Weekly menus were not posted one week in advance in a conspicuous and public place. The menu for the week of the inspection was posted, but the menu for the following week was not.”

“Medications were not stored properly under proper conditions. An expired medication was found in the top drawer of the brown medication cart. A blister pack for a resident was punctured at multiple pill slots with pills remaining and taped over. Loose broken white pills and a whole round pill were observed in the SDCU medication cart.”

“An OTC medication in the medication cart was not labeled with the resident's name.”

“A resident's glucometer was not calibrated to the correct time and read 2:37 PM when the actual time was 1:38 PM, affecting medication administration accuracy.”

“Direct care staff persons A and B did not receive required annual training in medication self-administration and instructions on meeting resident needs as described in pre-screening, DME, and RASP documents.”

“Colgate toothpaste with a manufacturer's label warning to keep out of reach of children was unlocked, unattended, and accessible to a resident in a bedroom. Not all residents of the home have been assessed as capable of recognizing and using poisonous materials safely.”

“At 10:21 a.m., several small cups with medications for various residents were inside the medication cart awaiting the noon medication pass, representing improper medication administration practices.”

“At 10:21 a.m., several small cups with medications for various residents were in the medication cart awaiting the noon pass, not stored under proper conditions of sanitation. Additionally, a blister pack of medication for a resident with an opening on the back was taped.”

“Staff person A, an LPN, discontinued a resident's prescribed medication without receiving a written order from an authorized prescriber. The home had not received written notice of the change and does not have registered nurses authorized to receive verbal orders.”

“Staff person forcefully pushed resident's feet into wheelchair pedals multiple times. Although the incident was reported to staff immediately, the allegation of abuse was not reported to the local area agency on aging as required.”

“Following an allegation of abuse involving a staff person who forcefully pushed a resident's feet into wheelchair pedals, the home did not develop and implement a plan of supervision or suspend the staff person until 12/6/23, rather than immediately.”

“Staff person A forcefully pushed resident's feet into wheelchair pedals multiple times after the resident's foot came off the rests and the resident tried to get up. The resident was visibly upset, made facial expressions indicating discomfort, and said 'ow' during the incident. This is a repeat violation from 8/24/22.”

“During a concert in the Clubhouse outside the Secured Dementia Care Unit, only one direct care staff person was supervising SDCU residents and was solely responsible for escorting residents back to the unit after the concert ended.”

“Resident assessment does not include assessments for Behavioral/Cognitive Needs. The resident began using a wheelchair on or before the assessment date, but the resident's need for ambulation was not re-assessed. This is a repeat violation from 8/24/22.”