Village Care Center

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 32 sampled residents (Resident (R) 2, R3, R41, and R84. Observation on 09/23/2025 during dinner service in the second-floor dining room revealed R3 did not receive his food at the same time as those that sat at his table did. Additionally, State Registered Nurse Aide (SRNA )7 was observed standing beside R2 feeding and coaxing her to eat, and SRNA5 was observed sitting between two residents, R41 and R84, feeding both simultaneously.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from verbal and physical abuse. This deficient practice resulted in actual harm for 1 out of 4 sampled residents, Resident (R) 13. On 09/14/2025, R13 stated State Registered Nurse Aide (SRNA) 12 was mean and hurtful during care. R13 reported SRNA12 lifted her legs in the air and then dropped them onto the bed, which hurt her back. She further stated SRNA12 handled her roughly during care, causing pain in her arm.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 3 resident refrigerators, the refrigerator located on the second floor. Observation on 09/24/2025 of the resident refrigerator located on the second floor revealed two unlabeled lunch boxes sitting next to resident food.

Inspectors wrote6. A review of Resident #236's admission Record revealed the facility admitted the resident on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of dementia, mood disturbance, anxiety, depression, and lack of relaxation and leisure. A review of Resident #236's Quarterly MDS with an ARD of [DATE] revealed Resident #236 had a BIMS score of three (3), which indicated the resident was severely cognitively impaired. The MDS revealed the resident did not exhibit behaviors during the assessment lookback period. A review of Resident #236's Care Plan revealed a Focus area, initiated on [DATE] and revised on [DATE], that indicated Resident #236 had the potential to demonstrate physical behaviors related to dementia or other cognitive impairment. The care plan revealed the resident would jokingly swat at others at times. [...]

Inspectors wroteBased on interviews, record review, facility document and policy review, it was determined the facility failed to ensure a resident was protected against misappropriation of property for one (Resident #95) of 1 sampled resident reviewed for misappropriation of property.

Inspectors wroteBased on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure State Registered Nurse Aide (SRNA) #30 implemented care planned interventions to reduce the risk of accidents for 1 (Resident #93) of four (4) sampled residents reviewed for accidents. Specifically, on 06/01/2023 around 5:00 AM, SRNA #30 repositioned Resident #93 in the bed independently instead of utilizing a second staff member, as directed by the resident's care plan.

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections to properly prevent and/or contain COVID-19. Observation, on 09/17/2020 at 8:50 AM, during medication administration, revealed Licensed Practical Nurse (LPN) #5 dropped a pill on the top of the medication cart, picked up the pill with an ungloved hand, put the pill in the medication cup, and then administered the medication to Resident #78. Observations, on 09/15/2020 and 09/16/2020, in the kitchen, revealed staff wearing face masks inappropriately and performing improper hand washing.

Inspectors wroteBased on observation, interview, record review and review of the facility's policies, it was determined the facility failed to ensure all drugs and biological's were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys, for one (1) of twenty-two (22) sampled residents, Resident #36. In addition, the facility failed to ensure drugs and biological's were labeled, dated, and stored without food in accordance with currently accepted professional principles. Observation of Resident #36's room, on 09/15/2020, revealed a water basin, sitting on the shelf at the bedside contained treatment medications prescribed for Resident #36 . Record review revealed evidence the resident was assessed to safely self-administer medications. [...]

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to store and prepare food under sanitary conditions. A staff member entered the kitchen without wearing a hair net; unopened, unlabeled opened food was found on a kitchen shelf; and three (3) varieties of expired soup were sitting on cupboard shelves in three (3) unit kitchenette pantries.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure there was proper notification of the resident's representative and Physician for a significant change in the resident's weight for one (1) of twenty-two (22) sampled residents (Resident #21).

Inspectors wroteBased on observation, interview, record review, review of the facility's policies, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a Person-Centered Comprehensive Care Plan (CCP) for each resident to meet a resident's medical and nursing needs identified in the comprehensive assessment for four (4) of twenty-two (22) sampled residents (Residents #34, #36, #42, and #21). Resident #34 had an active order for oral Xanax (a medication given to decrease anxiety) as needed (PRN) every eight (8) hours with a start date of 07/16/2020 and an end date of 01/12/2021. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team (IDT) composed of individuals who had knowledge of the resident and his/her needs for one (1) of twenty-two (22) residents, (Resident #9). Review of Resident #9's Comprehensive Care Plan revealed no documented evidence of revision to reflect Resident #9's fall event on 09/01/2020 or interventions status-post fall.

Inspectors wroteBased on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for three (3) of twenty-two (22) sampled residents (Resident #9, Resident #28, and Resident #36). Resident #9 was being transferred from the wheelchair to the bed with a mechanical lift, on 09/01/2020, when it malfunctioned, causing the resident to to rest on the floor across the lift's legs. Resident #9 sustained a small skin tear to his/her right outer arm. Resident #28 was being transferred from the bed to the wheelchair with a mechanical lift, on 09/13/2020. Resident #28 lifted himself/herself forward in the lift and sustained a laceration to his/her right eyebrow, on 09/13/2020. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure a resident's nutritional status was maintained for one (1) of twenty-two (22) sampled residents (Resident #21). Resident #21 experienced a ten (10) pound weigh loss from 07/08/2020 to 08/07/2020; however, there was no documented evidence the resident was immediately re-weighed per policy.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure irregularities reported to the facility by the Pharmacy Consultant were acted upon. The Attending Physician failed to document in the resident's medical record that the identified irregularities has been reviewed and what, if any, action had been taken to address it for one (1) of eighteen (22) sampled residents (Residents #34).

Inspectors wroteBased on interview, record review and review of the facility's policy, it was determined the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to fourteen (14) days, except when extended by the physician or prescribing practitioner beyond fourteen (14) days with documented rationale in the resident's medical record for one (1) out of twenty-two (22) sampled residents (Resident #34). Resident #34 had an active order for Xanax 0.5mg by mouth every eight (8) hours as needed with a start date of 07/16/2020 and an end date of 01/12/2021 with no rational provided regarding the extension of one hundred eighty (180) days.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to have an effective system to ensure medical records were complete and accurate for one (1) of twenty-two (22) sampled residents (Resident #8).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were able to examine the results of the most recent surveys of the facility by Federal or State surveyors, by posting in a place readily accessible to residents. Observation, during tour in the facility on 09/15/2020 through 09/17/2020, revealed the Annual Survey results binder was not easily accessible to residents.