Village Creek Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents for 2 of 3 halls (Hall 200 and Hall 400), and 1 of 1 kitchen reviewed for pest control. The facility failed to ensure 200 and 400 halls, and the kitchen were free from pests. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to identify and treat swelling on Resident #1's cheekbone following a fall and after Hospice Nurse E and CNA B had identified it on 10/09/25. The failure placed residents at risk for delayed treatment.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #10) reviewed for medication regimens. The facility failed to 's Pharmacy Consultant recommended the facility include anti-psychotic side-effect monitoring for Resident #10's Risperdal and Perphenazine medication orders on 06/18/25 and 07/23/25. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 5 residents (Resident #10) reviewed for unnecessary medication. The facility did not monitor Resident #10 for side-effects related to the use of the anti-psychotic medications Risperdal and Perphenazine. This failure could place the residents at risk for adverse consequences of medication.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure all drugs were stored in locked compartments for 1 of 6 carts (Cart #3) reviewed for medication storage. The facility failed to ensure Cart #3 was secured when not in use. This failure could place residents at risk of gaining access to medications not prescribed to them, leading to allergic reactions or overdoses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that that the facility is free of pests and rodents in 1 of 6 resident rooms (Resident #73) reviewed for pest control. The facility failed to ensure Resident #73's room was free of ants. This failure could place residents at risk of having pests in their rooms and insect bites.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Residents #8) reviewed for abuse. The facility failed to ensure Hospice Aide did not abuse Resident #8. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 05/08/24 and ended on 05/08/24. The facility had corrected the noncompliance before the survey began. This failure could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records that were complete and accurate for two (Resident #18 and Resident #28) of six residents reviewed for clinical records. 1. The facility failed to obtain physician orders for Resident #18 dialysis port site monitoring, vital signs, and documentation of the pre and post dialysis Vitals on the communication form. 2. The facility failed to document when the physician was notified when Resident #28's blood sugar exceeded 250. This failure could place residents at risk for incomplete and inaccurately documented medical record that included their progress treatment, services, and interventions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 3 (rooms [ROOM NUMBER]) of 10 rooms reviewed for environment. The facility failed to maintain total visual privacy by allowing the window blinds for room [ROOM NUMBER], 308, and 310 to be missing several slats. This failure placed residents at risk of a lack of privacy, feeling insecure, or uncomfortable in their rooms.

Inspectors wroteBased on interview and record review, the facility to ensure a new resident was not admitted with a mental disorder, unless the state mental health authority determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission, that the individual requires the level of services provided by a nursing facility and if the resident requires such level of services, whether the resident requires specialized services for one of six residents (Resident #10) reviewed for PASRR screening. The MDS Coordinator failed to ensure Resident #10's PL1 was accurate with the proper mental illness diagnoses when he was admitted . This failure could place residents at risk of not receiving specialized services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for one (Resident #48) of three residents reviewed for feeding tubes. LVN C failed to flush Resident #48's g-tube with 60cc of water before her bolus feeding (feeding method using a syringe to deliver formula through feeding tube) as ordered by the physician. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #18) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #18 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident bedrooms were designed or equipped to assure full visual privacy by having ceiling suspended curtains designed to give privacy for one (306 A bed and B Bed) of 4 triple occupied rooms reviewed for privacy. The facility failed to ensure room [ROOM NUMBER] had a privacy curtain between A bed and B bed. This failure placed residents at risk of loss of privacy and dignity and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision on 05/08/24 when Resident #1 sustained contusions and bruises to left side of face and left eye from an incident/accident. On 05/09/24, Resident #1 was diagnosed with a subdural hematoma ([SDH] occurs when a blood vessel in the space between the skull and the brain [the subdural space] is damaged) and admitted to the hospital. The facility failed to oversee the implementation of resident care policies. LVN A failed to initiate and document investigation of an incident/accident on 05/08/24, per the facility's policy and procedure Fall Management Program, when Resident #1 sustained an fall. [...]

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 16 of 34 days (02/26/23, 03/04/23, 03/05/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/22/23, 04/29/23, 05/20/23, 05/21/23, 05/28/23, 06/03/23, 06/04/23, 06/10/23, and 06/11/23) reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for 7 days (Saturdays and Sundays) between 02/26/26 until 06/11/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure all irregularities identified by the Pharmacist Consultant were reported to the attending physician and acted upon to minimize or prevent adverse consequences to the extent possible for 4 residents (Resident #78, Resident #77, Resident #45 & Resident #33) of 7 resident reviewed for drug regimen reviews, in that: 1. On 03/08/23 the Pharmacist Consultant recommended adding heart rate (pulse) to current hold parameters to Resident #78's order for Coreg (alpha and beta blocker used for hypertension) due to the medication having an effect on heart rate. The physician acknowledged the recommendation; however, the facility failed to ensure that the order was updated with hold parameters for pulse. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items and clean dishes were kept away from airborne contaminants and an unsanitary environment. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #24, Resident #83, and Resident#69) of 5 residents reviewed for infection control. The facility failed to ensure MA C disinfected the blood pressure cuff in between blood pressure checks for Residents #24, #83, and #69. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Residents #81) of 18 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #81's care plan accurately reflected being a smoker. This failure placed residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #37) of two residents reviewed for pressure ulcers in that: 1. The facility failed to order wound supplies as per physician orders when Resident #37 was seen on 06/12/23 by the Wound Care Physician. 2. LVN D failed to update physician wound care orders in the MAR when Resident #37 was seen by the Wound Care Physician on 06/12/23. These failures placed residents at risk for deterioration of existing pressure ulcers.