Park Village Assisted Living

Based on observation and interview the facility failed to ensure medications requiring refrigeration were stored safely. This affected three residents (#01, #36, #44) requiring refrigerated medications of 55 residents residing in the facility.

Findings Include:

Observation on 02/02/26 at 1:15 P.M. of the medication refrigerator in the medication storage room revealed the freezer tray with an approximately 2 inch ice build up all the way around the inside and outside of the tray. There was a yellowish honey like consistency, sticky substance noted through out the refrigerator on bags of medications and on the shelves in which bags of medication were placed. There was no temperature logs noted near the refrigerator. There was a thermometer on the second shelf in the back of the refrigerator.

Further observation of the medication refrigerator revealed the presence of several medications including: eight 3 milliliter (ml) Lantus 100 units/ml insulin syringes for Resident #01, eight 3 ml of Insulin Lispro 100 units/ml syringes for Resident #36, four 1 (ml) of Repatha 140 mg/ml syringes for Resident #44, a stock vial of 1 ml of tubersol 5 T units/0.1 ml, a stock supply of five Afluria 2025-2026 0.5 ml Influenza vaccines syringes, and a stock supply of thirty six acetaminophen 650mg suppositories.

Interview on 02/02/26 at 1:20 P.M. with licensed practical nurse (LPN) #61 revealed she did not know where the refrigerator temperature logs were and she thought maybe night shift checked them.

Interview on 02/02/26 at 1:22 P.M. with the Vice President of Nursing (VPN) #121 revealed verification that there was a sticky yellowish substance on several medications bags and the shelves of the refrigerator as well as ice build up on freezer compartment. VPN #121 confirmed several resident medications present as well as stock medications including the influenza vaccines, the TB serum, and acetaminophen suppositories.

Based on observation and staff interview the facility failed to remove expired stock medications from the medications carts for hall A, B, C, and the medication cart for hall D. This had the potential to affect 55 residents. The facility census was 55.

Findings Include:

Observation on 02/02/26 at 12:31 P.M. of medication cart used for residents residing in halls A, B, and C revealed the following expired over-the-counter stock medications (medications that can be given to any resident from a general supply not specific to each residents): Rugby brand Calcium 600 milligrams (mg) with 5 (micrograms) mcg of Vitamin D3 opened on 12/11/25 with a do not use after date 12/14/25, a bottle of Magnesium Oxide 400 mg opened on 06/08/24 with a do not use after date 12/31/25, a bottle of 21st Century brand cranberry extract 200 mg capsules opened on 02/11/25 with a do not use after date 12/31/25, a bottle of cetirizine 10 mg opened on 07/31/25 with a do not use after date of 04/22/25, a bottle of Major brand Magnesium 500 mg opened on 07/03/25 with a do not use after date of 12/02/25, a bottle of Rugby brand Calcium 600 mg with 10 mcg Vitamin D3, a bottle of Centrum Silver Women's 50+ opened on 03/19/24 with an expiration of 04/2025 on bottle, a bottle of Alcon brand systane eye drops issued on 04/15/24 with expiration date of September 2025, and a bottle of Vitamin D3 50,000 International Units (IU) opened on 03/2/24 with an unknown expiration date visible.

Observation on 02/02/26 at 12:46 P.M. of the medication cart used for residents on memory care unit, hall D, revealed the following expired over-the-counter stock medications: a bottle of Rolaids Ultra Strength tablets with expiration date of 12/2025, a bottle of aspirin 325 mg with a do not use after date of 06/06/25, and a bottle of Vitamin C 500 mg with a do not use after date of 08/09/25.

Interview on 02/02/26 between 12:31 P.M. and 12:46 P.M. with licensed practical nurse (LPN) #61 revealed the listed medications were opened and either expired or past the do not use after date printed by the pharmacy on the medication labels. LPN #61 removed all expired or out dated medications from both medications carts and placed in medication storage room where they were placed in a bottle medication destruction solution and discarded. LPN #61 revealed that the night shift nurse is to check the medication stock and that pharmacy does come to facility at least monthly and checks carts and is does not know why there are so many out dated medications in both carts.

Review of the Pharmaceutical Services Policy, undated, revealed medications no longer in use (discontinued) and those having an expiration date which has passed, are to be destroyed.

Based on observation and staff interview, the facility failed to store and prepare food in a sanitary manner. This had the potential to affect all the individuals in the facility. The facility census was 55.

Findings Include:

Tour of the kitchen on 02/02/26 at 9:48 A.M. revealed the following observations:

There were two full packages of Nickels split top buns expired 01/25/26.

There were two separate bags of hot dog buns with one bun each expired 01/24/26 and 01/31/26.

There was a bag of pizza burgers in the reach in freezer. The bag had a hole torn open in the middle instead of reaching from the top of the bag leaving seven pizza burgers exposed to the freezer air.

There was a scoop in the sugar container.

The ansel system above the grill had dust on it going up the pipes.

The shelf above the the grill was dusty and greasy. There were large containers of spices staff would pull down off of it while cooking.

The reach in refrigerator, reach in freezer, three compartment sink and dishwasher were all soiled. The handles and doors of the refrigerator and freezer had food on them. The doors were smeared. The front of the dishwasher was dirty with dried streaks down the front. The three compartment sink stainless steel was dirty with a white powdery substance on it.

There was a a gallon jug of 2% milk half empty with a best by date of 02/01/26.

Interview on 02/02/26 at 10:10 A.M. with Cook #101 verified the expired bread, exposed pizza burgers, soiled stainless steel, dirty ansel system, and shelf.

Observation of the Memory Care Kitchen on 02/03/26 at 10:32 A.M. revealed a full package of Nickels split top buns expired 01/25/26.

Interview on 02/03/26 at 10:33 A.M. with Personal Assistant #95 verified the buns were past the use by date.

Based on review of fire drill reports, policy review, and interview, the facility failed to evacuate residents as required. This affected all the residents in the facility. The facility census was 55.

Findings Include:

Review of the monthly fire drill records revealed residents capable of self-evacuation were not evacuated to safe areas or to the exterior of the facility in at least two fire drills a year on each shift. The fire drills from April 2025 through January 2026 revealed zero to twelve residents were evacuated during the ten fire drills.

Review of the facility's Fire and Disaster Policy (dated 09/20/23) included residents capable of self-evacuation must actually be evacuated to a safe area or exterior in at least two fire drills a year on each shift.

Interview on 02/02/26 at 4:36 P.M. with the Administrator verified the resident's capable of self evacuation were not evacuated for any of the fire drills. The Administrator included he thought only two residents needed to evacuate.

Based on interviews, medical record review, and policy review the facility failed to have a process to provide residents, newly admitted to the facility, with education and training for fire, tornado, and other disasters. This affected one resident (#4) of one resident reviewed for admission to the facility and had the potential to affect all new residents admitted to the facility. The facility census was 55.

Findings Include:

Review of the medical record for Resident #4 revealed admission to the facility on 01/26/26 with diagnoses including hypothyroidism, unspecified psychosis, insomnia, anxiety disorder, high blood pressure, depression, respiratory failure with hypoxia, congestive heart failure, anemia (low blood count).

Further review of the medical record revealed Resident #4 required assistance from staff with bathing, housekeeping, and social activities and utilizes walker for ambulation (walking around).

Review of the medical record for Resident #4 revealed no evidence of education or training on fire safety, tornado emergency or other emergency situations.

Review of the facility admission packet provided by the facility to all new admissions included a document provided to residents titled Park Village Emergency Plan informing residents if an emergency would arise that the facility would notify them of further actions to take at that time. There was no specific mention of actions to take during any specific type of emergency including fire, tornado or other emergency disaster event.

Interview on 02/03/26 at 11:45 A.M. with licensed practical nurse (LPN) #61 revealed she educates residents on admission to the facility schedule, meal times, activities calendar and the aides coordinate with residents regarding showering assistance schedule and laundry and cleaning days. LPN #61 did not reference instructing residents on actions to take in event of an emergency.

Interview on 02/03/26 at 12:00 P.M. with Resident #4 revealed she did not recall being provided education and training on fire or tornado or other emergency since her arrival at the facility. Resident #4 further revealed she has not participated in any fire or tornado drills since arriving at facility.

Interview on 02/03/26 at 12:24 P.M. with the Vice President of Nursing (VPN) #121 revealed residents are advised to stay in rooms until further instructions are provided by staff. VPN #121 further revealed that residents receive education and training on disaster response when the facility does monthly fire drills and annual tornado drills. Review of monthly fire drills April 2025 through January 2026 did not show evidence of residents who received education or training.

Interview on 02/03/26 at 12:55 P.M. with the facility Administrator revealed staff are to inform residents on admission if a fire or tornado/weather emergency occur to stay in their rooms and staff will come to them with further instructions on what to do. The Administrator further revealed the facility does not want residents panicking and roaming the hallways in an emergency and that staff would individually evacuate residents as needed.

Based on observation and interview, the facility failed to install a carbon monoxide detection in the area of a fuel-burning appliance. This had the potential to affect all 55 residents in the facility.

Findings Include:

Tour of the facility 02/02/26 at 12:26 P.M. with Maintenance Staff #107 revealed through the entry foyer down the hall toward the lounge area and nurse station there was a library on the left side of the hall with the door open. A gas fireplace was burning. Observation of the library revealed there was not a carbon monoxide detection system in the library.

Interview on 02/02/26 at 12:26 P.M. with Maintenance Staff #107 verified the library had a gas fireplace without a carbon monoxide detector.