Antonine Village

Based on record review, interview, and policy review, the facility failed to ensure a written statement signed by a physician or other licensed healthcare professional acting within their scope of practice was obtained and maintained indicating whether the resident could self-administer medications. This affected three (#132, #118, and #146) of three residents reviewed for medication self-administration. The facility census was 65.

Findings include:

Record review on 01/28/26 revealed the Resident #132 admitted on 01/12/24 with diagnoses including chronic respiratory failure with hypoxia, dementia, anxiety, major depression, and diabetes. The medical record failed to include documentation of a written statement signed by a physician or other licensed healthcare professional indicating whether the resident was capable of self-administering medications.

Record review on 01/28/26 revealed Resident #118 admitted on 08/16/24 with diagnoses including stroke, obesity, vitamin D deficiency, hypertension, benign heart murmur, and anxiety. The medical record failed to include documentation of a written statement signed by a physician or other licensed healthcare professional indicating whether the resident was capable of self-administering medications.

Record review on 01/28/26 revealed Resident #146 admitted on 02/16/20 with diagnoses including Alzheimer's, hyperlipidemia, hypertension, anxiety, and major depression. The medical record failed to include documentation of a written statement signed by a physician or other licensed healthcare professional indicating whether the resident was capable of self-administering medications.

Interview on 01/28/26 at 3:47 P.M. with Business Office Manager (BOM)#488 confirmed the facility did not have signed statements indicating whether Residents #132, #118, and #146 were capable of self-administering medications and acknowledged that such documentation is required. BOM #488 stated medication self administration form is only completed for residents who are able to self administer their own medications. Facility does not complete a form for residents who are unable to self administer medication.

Review of the facility policy titled Self Administration of Medication revealed residents in the facility who wish to self-administer medications may do so if it is determined by a physician that they are able to do so as part of an overall evaluation. The policy further indicated staff and the practitioner will assess each resident's mental and physical abilities to determine whether the resident is capable of self-administering medications.

Based on record review and staff interview, the facility failed to ensure Resident Fund authorizations were witnessed by a non employee This affected four (#102, #109, #128,and #168) of four residents reviewed for personal funds. The facility census is 65.

Finding include:

Review of the resident fund accounts for Resident #102, #109, #128, and #168 revealed that Director of Nursing (DON) and Employee #408 signed for the witness sections of the Resident Fund authorization.

Interview with the Employee #488 on 1/28/26 at 4:00 P.M. confirmed the signatures of the DON and Employee #408 signed the Resident Fund authorization.

Based on record review and interview, the facility failed to ensure employees had a written acknowledgment of the transfer and discharge resident provisions maintained in their employee personnel files, as required, for six (#402, #437, #456, #443, #451, and the Administrator) of six employee files reviewed. This has the potential to affect all residents. The facility census was 65.

Findings include:

Record review completed on 01/28/26 revealed the personnel file for Licensed Practical Nurse (LPN) #402 failed to include a written acknowledgment indicating the employee received and understood the facility's transfer and discharge resident provisions.

Record review comleted on 01/28/26 revealed the personnel file for Nursing Supervisor #437 failed to include a written acknowledgment indicating the employee received and understood the facility's transfer and discharge resident provisions.

Record review compelted on 01/28/26 revealed the personnel file for Nurse Aide #456 failed to include a written acknowledgment indicating the employee received and understood the facility's transfer and discharge resident provisions.

Record review completed on 01/28/26 revealed the personnel file for LPN #443 failed to include a written acknowledgment indicating the employee received and understood the facility's transfer and discharge resident provisions.

Record review comeplted on 01/28/26 revealed the personnel file for State Tested Nurse Aide (STNA) #451 failed to include a written acknowledgment indicating the employee received and understood the facility's transfer and discharge resident provisions.

Record review completed on 01/28/26 revealed the personnel file for the Administrator failed to include a written acknowledgment indicating the Administrator received and understood the facility's transfer and discharge resident provisions.

Interview on 01/28/26 at 3:45 P.M. with Business Office Manager #488 confirmed the facility did not ensure written acknowledgments of the transfer and discharge resident provisions were maintained in employee personnel files. Employees are instructed to read the provisions, but no written documentation is kept in their employee record.

Based on observation, record review, and staff interview, the facility failed to ensure that medications were stored securely. This had the potential to affect the 30 residents who resided on the assisted living first floor. The total facility census was 64.

Findings Include:

Observation and interview with Licensed Practical Nurse #38 on 02/19/25 at 7:45 A.M. in the opened medication room on the first floor revealed there were 30 medication cups with pills in them, and three medication cups with an unidentified cream in them sitting on top of the medication cart. LPN #38 was asked about the medication cups and stated those were the morning medications for the residents on the first floor. She stated the cups had the resident name on them and proceeded to point to a handwritten first names on the cups. The nurse then turned to the cupboard and opened the door and boxes of resident medications in a sealed, dated, and timed dose packs were observed. The LPN stated the medications are delivered from the pharmacy like this for the residents but she places them in cups for the residents, so the residents do not drop the medication out of the packs.

Observation and interview on 02/19/25 at 7:50 A.M. with Executive Director (ED) of the medication room on the first floor revealed there continued to be medications in cups on top of the medication cart. The ED verified the medications are set up in cups to dispense the medications to all the residents to save time.

Interview with the Director of Nursing on 02/19/25 at 1:36 P.M. confirmed medications are not to be prepared prior to administration to the resident.

Based on record review and staff interview, the facility failed to have Resident Fund authorization witnessed by a non employee. This affected one, Resident #20, of five reviewed for resident funds. The facility census was 64.

Findings Include:

Review of Resident #20's medical record revealed the resident was admitted 02/06/24 with a diagnoses of dementia and bipolar disorder.

Review of Resident # 20's Authorization of the Facility to Manage Resident Funds form revealed the witness who signed the form was the Director of Nursing on 02/06/24.

Interview with Executive Director on 02/19/25 at 11:00 A.M. verified the witness signature on the Authorization of the Facility to Manage Resident Funds was completed by a facility staff.

Based on record review and staff interview, the facility failed to ensure a disaster drill was conducted twice a year. This had the potential to affect all residents in the facility. The facility census was 64.

Findings Include:

Review of the facility disaster drills for the previous 12 months revealed the facility had conducted a tornado drill on 06/24/24.

Interview with Director of Nursing on 02/19/25 at approximately 3:00 P.M. confirmed the facility had conducted one disaster drill in the previous 12 months.

This violation is a recite to the annual survey completed on 12/20/23.

Based on observation, record review, and staff interview, the facility failed to provide adequate and appropriate treatment for one, Resident # 38, while being transferred from her bed to a chair in a Hoyer lift (mechanical lift). This had the potential to affect the seven residents on the secured unit who required a mechanical lifts for transfer. The total facility census was 64.

Findings Include:

Review of Resident #38's medical record reveled the resident was admitted on 08/15/24 with diagnoses of hypertension, dementia, osteoporosis, compression fracture of the spine, and frequent falls.

Observation on 02/19/25 at 9:48 A.M. Resident #38 was observed being transferred to her chair with the use of a Hoyer lift by Certified Nursing Assistant (CNA) #62. No other staff were in the room or assisting with the transfer.

Interview with CNA #62 on 02/19/25 at 9:50 A.M. confirmed she was the only staff who was transferring Resident #38 and CNA #62 verified there should always be two staff members present to operate the Hoyer lift. She stated she usually gets someone to assist with transfers.

Interview with Director of Nursing on 02/19/25 at approximately 2:30 P.M. it was verified the Hoyer lift should be operated with two staff.