Village Care of King

Inspectors wroteBased on record review and Administrator interview, the facility failed to maintain and produce documented evidence of a comprehensive and ongoing Quality Assurance and Performance Improvement program that demonstrated systematic identification, reporting, investigation, analysis, and prevention of adverse events; and the development, implementation, and evaluation of corrective actions or performance improvement activities for calendar year 2025. This deficient practice had the potential to affect all 94 of 94 facility residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for a resident with a serious mental health disorder for 1 of 3 residents reviewed for PASRR (Resident #96).

Inspectors wroteBased on record review and staff interviews, the facility failed to develop comprehensive care plans addressing behaviors and post-traumatic stress disorder (Resident #96) and hospice care (Resident #13) for 2 of 19 residents reviewed.

Inspectors wroteBased on record review, and staff, family member, Resident, Physician Assistant, and Medical Director interviews, the facility failed to provide supervision for Resident #1 who had a diagnosis of dementia, an addiction to cigarettes, and required supervision/touching assistance for walking 10 feet. Resident #1 left the facility unnoticed and unattended, walking along the side of a 35 mile an hour two-lane road to obtain cigarettes at a nearby store. Resident #1 was located approximately 1/2 mile away from the facility standing in a grassy field near the side of the road. The walking route to where the resident was located included an upward sloping sidewalk, a downward sloping sidewalk with a pond to the left, and then a dirt path that ended at the edge of the grassy field. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to protect a severely cognitively impaired resident's right to be free from physical and verbal abuse. During care on 6/26/2025 Nursing Assistant (NA) #5 held the resident's arms down on the bed, told him to shut up, and put her gloved hand over Resident #4's mouth while assisting with incontinence care. This deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #4).

Inspectors wroteBased on record review and staff interviews, the facility failed to implement their abuse policy and procedure in the area of reporting when Nursing Assistant (NA) #6 failed to immediately report she had observed NA #5 physically and verbally abuse Resident #4 when NA #5 held the resident's arms down on the bed, told him to shut up and put her gloved hand over Resident #4's mouth while providing incontinence care for 1 of 2 residents reviewed for abuse (Resident #4).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to provide care in a safe manner for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 10/22/24 Resident #1 was lifted manually by Nursing Assistant (NA) #1 from the shower chair to the bed, causing Resident #1 right leg to hit the shower chair, get caught in between the shower chair and the bed, causing severe pain and swelling. An x-ray completed on 10/24/24 confirmed Resident #1 sustained an acute distal tibia/fibula (the two long bones in the lower leg) fracture.

Inspectors wroteBased on record review, and resident, staff, and Medical Director interviews, the facility failed to notify the physician of a change in condition for 1 of 3 residents (Resident #1) reviewed for notification of changes. On 10/22/24 Resident #1 was lifted manually by Nursing Assistant (NA) #1 from the shower chair to the bed, causing Resident #1's right leg to hit the shower chair, get caught in between the shower chair and the bed, causing severe pain and swelling. On 10/22/24 Nurse #1, was notified by NA #1 that Resident #1 complained of pain. Nurse #1 did not notify the physician. On 10/22/24, Nurse #2, was informed by Resident #1 of her right leg hurting, and did not notify the physician. On 10/23/24, Nurse #3, who worked from 11:00 pm (10/22/24) to 7:00 am (10/23/24), was notified by NA (Unknown) that resident complained of pain, and did not notify the physician. [...]

Inspectors wroteBased on record review, and resident, staff and Medical Director interviews, the facility failed to complete and document ongoing comprehensive assessments after Resident #1 reported leg pain which delayed medical treatment and interventions for 1 of 3 residents (Resident #1) reviewed for assessments. On 10/22/24 Resident #1 was lifted manually by Nursing Assistant (NA) #1 from the shower chair to the bed, causing Resident #1 right leg to hit the shower chair, get caught in between the shower chair and the bed, causing pain and swelling. On 10/22/24, between 11:00 am and 11:30 am, Nurse #1 was notified by NA #1 that Resident #1 complained of pain and Nurse #1 did not complete an assessment. Nurse #2 was assigned to Resident #1 on 10/22/24 from 3:00 pm to 11:00 pm and did not complete a comprehensive assessment and only documented she did not observe any bruising or open area. [...]

Inspectors wroteBased on record review, resident, ombudsman, family, friend, staff, the Home Health Nurse, and Adult Protective Services Social Workers interviews the facility failed to develop and implement an effective discharge planning process for 1 of 3 residents, Resident #1, by not assessing the home environment which was described as not safe by the resident and family, discharging the resident to home where the resident did not have a functional phone to contact people or 911 in the event of an emergency and arranging for individuals who would be able to obtain the resident's prescription medications and assist with basic Activities of Daily Living (ADLs) such as transfer from the couch to a wheelchair, toileting, peri-care, meal preparation, and bathing. [...]

Inspectors wroteBased on resident and family member interviewa, staff interviews and record review the facility failed to provide a resident with information regarding application for Medicaid for 1 of 1 resident reviewed for discharge (Resident #1).

Inspectors wroteBased on record review and staff and family member interviews, the facility failed to provide the resident a notification of discharge and did not send a copy of the notice to the Ombudsman for 1 of 1 residents (Resident #1) reviewed for discharge.

Inspectors wroteBased on staff interviews and record review, the facility failed to complete a discharge summary for 1 of 1 resident (Resident #1) reviewed for planned discharge to the community.

Inspectors wroteBased on observation, record review and interview of staff, physician, resident, the facility failed to protect Resident #1 from rolling out of bed during the provision of personal care. Resident #1 fell from her bed to the floor. Resident #1 was sent to the emergency room and was diagnosed with a distal femur fracture (fractures of the thighbone that occur just above the knee joint) of both legs. The fractures resulted in hospitalization, treatment with Heparin (blood thinner) to prevent blood clots in the lower legs and Fentanyl (a controlled substance used to treat severe pain) for pain. The resident had to wear knee braces to both legs for stability until healed which can cause skin breakdown and significantly limit her ability to move/transfer during care, dialysis, or simple shifting herself in the bed. This deficient practice affected one of two sampled residents (Resident #1).

Inspectors wroteBased on staff interviews and medical record review, the facility failed to provide a CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare part A services to one of three residents (Resident #77) reviewed for SNF Beneficiary Protection Notification Review.