Village Creek Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that identify, report, and protect from further abuse of residents, for 2 of 6 residents (Resident #14 and Resident #55) reviewed for abuse. * On 03/04/26, CNA B witnessed Resident #14 yell at Resident #55 that she was a [f-ing retard]. The incident was not reported to the abuse coordinator (AC) or HHSC. No preventative measures were put in place to prevent further abuse. * On 03/20/26, CNA B and MA C both witnessed Resident #14 shove Resident #55 into trash and dirty linen barrels in her wheelchair. CNA B and MA C did not consider this to be abuse and did not report the incident to the abuse coordinator. An Immediate Jeopardy (IJ) situation was identified on 03/25/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure all nursing staff possess the competencies, and skill sets necessary to use, maintain and test the automated external defibrillator according to the manufacturer's guidelines for 1 of 1 facility automated external defibrillators and 4 of 4 licensed staff interviewed (LVN QQ, LVN L, LVN J and LVN H) and reviewed for nursing services. The facility failed to ensure nursing staff were competent to conduct testing of the facility's only AED according to the manufacture's guidelines. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:45 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate care and services to prevent urinary tract infections to the extent possible for 1 of 2 residents (Resident #5) reviewed for indwelling catheters/ quality of care. (Resident #5) 1. Resident #5 had blood present inside his suprapubic catheter (a tube inserted into the bladder to drain urine) tubing and catheter drainage bag from 03/21/2026- 03/24/2026. 2. The facility staff failed to assess, document, and report findings to the physician and Resident #5 continued with signs of a possible UTI. 3. Resident #5 did not have a suprapubic strap in place to prevent dislodgement or trauma. This failure could place residents at risk of not receiving the required level of care, trauma, or possible sepsis.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 16 residents reviewed for notification of changes. (Resident #41). The facility failed to notify Resident #41's physician regarding the pattern of low blood pressure and of her low blood pressure medication being held for 14 out of 23 days for the month of March 2026. This failure could place residents at risk for complications due to delayed or failed physician intervention.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 2 of 6 residents (Residents #9 and #10) reviewed for services provided to meet professional standards. 1. LVN A administered gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications) medications to Resident #9 without flushing the tube with water before and after medication administration or between medications on 03/24/26 during medication pass.2. LVN G mixed GlycoLax (laxative) in water then mixed crushed gastrostomy tube medications for Resident #10 with the mixture on 03/25/26 during the medication pass.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 5 errors out of 31 opportunities, resulting in a 16.13% percent medication error involving 3 of 6 residents reviewed for medication pass. (Residents #6, #9, and #10) * LVN A administered gastrostomy tube (a surgical opening into the stomach from the abdominal wall for the introduction of food and medications) medications to Resident #9 without flushing the tube with water before and after medication administration or between medications on 03/24/26 during medication pass. * LVN A administered Metoclopramide (gastrointestinal stimulant/anti nausea) to Resident #9 on continuous enteral feeding during the medication pass. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents were free of significant medication errors, for 3 of 8 residents (Residents #5, #4, and #10), reviewed for significant medication errors. * The facility did not ensure Residents #5, #4, and #10 did not receive Midodrine (medication used to raise the blood pressure) when there were parameters to hold the medication. This failure could place residents receiving medication to elevate the blood pressure at risk for stroke, hospitalization, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menus were followed and prepared according to the weekly menu for 1 of 4 meals reviewed for food and nutrition services. (Lunch meal) The facility failed to ensure the menu was followed for the lunch meal on 03/23/2026. This failure placed the residents at risk of not receiving meals that are adequate to meet their nutritional needs and a decline in nutritional health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 of 18 residents (Residents #56) records reviewed for resident assessments. The facility failed to ensure the discharge MDS assessment was completed and transmitted as required for Resident #56. This failure could place residents at risk of not receiving care and services as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use) for 1 of 5 residents (Residents #9) reviewed for unnecessary medications. The facility failed to hold Resident #9's Carvedilol (used to lower blood pressure) medication (for 2 administration) when the blood pressure was outside the prescribed parameters. These failures could place residents at risk for at risk for adverse reactions and decline in health condition .

Inspectors wroteBased on observation, interview, and record review 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 diseases and infections for 1 of 2 residents (Resident #9) observed for dressing changes. * LVN A did not change gloves, sanitize/wash hands between glove changes, and touched clean items with dirty gloves when providing dressing change to Resident #9. This failure could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and test the automated external defibrillator according to the manufacturer's guidelines for 1 of 1 facility automated external defibrillators reviewed for physical environment. 1. The facility did not maintain a working automated external defibrillator (AED - used during sudden cardiac arrest) for use in the administration of CPR. On [DATE], the AED was beeping, electrodes were not attached, and the machine had a red x indicating the AED was not in safe operating condition.2. The facility had not tested the AED according to the manufacture's guidelines from [DATE] to [DATE] (total of 23 days). These failures could place residents who had a full code status at risk of not receiving necessary life-saving measures, decline in health, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 7 residents (Resident #1) reviewed for reporting. The facility failed to ensure LVN A reported injury of unknown origin found on Resident #1 to the Administrator on 06/20/2025. This failure could place residents at risk for injuries of unknown origin not being reported.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to medication carts for 1 of 2 Nurse medication carts (Hall 100 Nurse Cart) reviewed for medication storage. LVN E failed to ensure the Hall 100 Nurse medication cart was kept locked and under direct observation where residents and unauthorized staff could not access it when left at the main nurse's station for six minutes. This failure could place residents at risk of unauthorized persons, as well as residents, at risk of gaining access to unlocked medications that were not prescribed to them.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents. The facility failed to provide adequate supervision with Resident #1 on 08/11/2025 while completing perineal care in bed. CNA A provided perineal care and Resident #1 rolled off the bed to the floor. Resident #1 initially complained of pain in his right arm after this fall. Resident #1 was sent to the hospital for further evaluation on 08/11/2025. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 8/11/2025 and was removed on 08/11/2025. The facility corrected the noncompliance before the investigation began. These failures placed residents at risk for hospitalization, harm and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 diseases and infections for 1 of 1 laundry area observed for infection control. The facility failed to ensure that dirty and clean linen had a separation of the airflow in the laundry. These failures could place the residents at risk of cross-contamination and the development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure Dietary Staff A and Dietary Staff B's hair was completely contained with an effective hair restraint. This failure could place residents at risk of being served unsanitary food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment for 2 of 4 linen/storage rooms (Hall 2 and Hall 3), 2 of 4 hall's ceiling vents (Hall 3 and Hall 4), and 1 of 1 nurses' station ceiling area reviewed for physical environment. The facility failed to maintain the ceiling in the Hall 2's linen/storage room. The facility failed to maintain the ceiling in Hall 3's linen/storage room and prevent odor. The facility failed to maintain the ceiling above 1 of 1 nurse's station free of stains. The facility failed to maintain the vent and ceiling around the vents on Hall 3. The facility failed to maintain the vents and ceiling around the vents on Hall 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for 2 of 20 residents (Resident #2 and #13) reviewed for environment. The facility failed to maintain a sanitary and comfortable homelike environment for Resident #2 and Resident #13's rooms. This failure could place residents at risk for a diminished quality of life due to the lack of a well-kept, home-like environment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents the right to be free from abuse for 1 of 16 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from sexual abuse on 08/28/24 and 09/02/24. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on monitoring behaviors after an inappropriate behavior was identified. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 2 of 16 residents (Resident #1 and Resident 3) reviewed for care plans. 1. The facility failed to develop and implement interventions in the care plan to prevent Resident #1's sexual abuse of Resident #2. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because resident care plans were not reviewed and revised. 2. The facility failed to develop and implement Resident #3's care plan and interventions to prevent Resident #3's verbal and emotional abuse of Resident #4. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 16 residents (Resident #6) reviewed for reporting allegations of neglect. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 16 residents (Resident #5) reviewed for accuracy of clinical records. The facility did not ensure ADL care was documented for Resident #5 on the ADL task sheet. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for services for 3 of 20 residents reviewed for PASRR (Residents #31, #60 and #67). The facility did not have an accurate PASRR level 1 screening for Residents #31, #60, and #67 upon admission therefore a PASRR Evaluation was not conducted. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with pressure injuries receive treatment and care in accordance with the comprehensive assessments, professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #67) reviewed for wound treatment. The facility failed to accurately assess Resident #67's newly identified pressure injuries on both of his heels and coccyx area, failed to notify the physician and obtain treatment orders, and failed to provide wound care for both heels and his coccyx area when the areas were identified on 11/25/23. This failure could place residents at risk for developing new pressure wounds, inconsistent care resulting in the deterioration of existing wounds, a decline in health, pain, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles in 2 of 2 nurse medication carts reviewed. (Halls 100 and 200 nurse medication carts) Four multi-dose Humalog insulin vials (used to lower blood sugar) had no label on bottle to identify resident and/or no open date on vial; A multi-dose glargine insulin vial (used to lower blood sugar) had no open date; A multi-dose Novolog insulin vial (used to lower blood sugar) had no open date; and Two multi-dose Humulin R insulin vials (used to lower blood sugar) had no open and no label on bottle to identify resident; This failure could place residents at risk of not receiving the therapeutic benefits of their medications.

Inspectors wroteBased on interview and record review, the facility failed to hire a part time or contracted social worker for a facility of 120 beds or less to provide social services a sufficient amount of time to meet the needs of the residents for 1 of 1 facility reviewed for a social worker. The facility did not employ or contract a qualified social worker as required by state regulations from 05/24/23 to 11/29/23. This failure could place residents at risk of administrative duties not being carried out to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to safeguard medical record information against loss, destruction, or unauthorized use for 2 of 20 residents reviewed for resident records. (Residents #20 and #70) The facility failed to ensure Resident #70's medical billing information was secured and protected from loss and unauthorized access. The facility failed to ensure Resident #20's billing information and payments were secured from loss and unauthorized use. This failure could place the residents at risk of unauthorized access to the residents' private information.

Inspectors wroteBased on interview and record review, the facility failed to maintain record of the required annual in-service records ensure the required in-service trainings for nurse aides were sufficient to ensure the continuing competencies of nurse aides, but must be no less than 12 hours per year and included abuse, neglect training for 5 of 5 staff, (CNA C, CNA E, CNA F, MA G and MA H), records reviewed for staff training. The facility failed to provide CNA C, CNA E, CNA F, MA G and MA H with Abuse/Neglect training and 12 hours of training per year. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of their personal and medical records for 2 of 20 residents reviewed for resident rights. (Residents #20 and #70) The facility failed to ensure Resident #70's medical supply billing information was secured and protected from public access. The facility failed to ensure Resident #20's billing information and payment source information were protected from public access. This failure could place the residents at risk of their private records being exposed to public access.

Inspectors wroteBased on interview and record review the facility failed to ensure the rights of residents to be free from abuse or neglect for 1 of 20 residents reviewed for abuse or neglect. (Residents #22) The facility failed to ensure Resident #22 was free from verbal abuse/neglect by CNA A. The failure could place residents at risk for abuse/neglect, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 2 of 20 residents (Resident #5 and #16) reviewed for PASRR. The facility failed to refer Resident #5 for PASRR Level II assessment to the state designated authority after their PL 1 was negative but acquired a diagnosis of bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 20 residents reviewed for care plans. (Resident #22) The facility did not develop a care plan for Resident #22's transfer assist and needs. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 11 of 14 residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, and #14) reviewed for abuse and neglect. The facility failed to implement their Abuse Policy and ensure all allegations of abuse were reported to HHSC within 2 hours of the allegation for Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, and #14. This failure could place residents at risk of further abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made in accordance with State law through established procedures for 11 of 14 residents (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #13, and #14) reviewed for abuse and neglect. The facility failed to report allegations of abuse immediately, but not later than 2 hours to HHSC when: *Resident #3 threatened to beat Resident #2 with his cane. *Resident #4 made an allegation of abuse regarding CNA A. *Resident #5 alleged Resident #6 kicked her in the back. *Resident #7 reported he was bit by Resident #8. *Community members accused the AD of being verbally abusive to Residents #5, # 6, #9, #10, #13, and #14 during a community outing. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were maintained on each resident with accurate and complete documentation for 16 of 31 residents (Residents #2, #3, #4, #5, #6, #7, #8, #12, #15, #16, #17, #18, #19, #20, #21, and #22) reviewed for complete medical records. The facility did not have the required documentation and/or follow up documentation of incidents involving Residents #2, #3, #4, #5, #6, #7, #8, #12, #15, #16, #17, #18, #19, #20, #21, and #22. This failure could place residents at risk of the medical record by not being an accurate representation of their medical condition or medical needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations from PASARR evaluation were incorporated for 1 of 1 resident reviewed for coordination of PASARR services. (Resident #1) Facility failed to provide specialized services for PASARR positive residents as agreed to during Resident #1's IDT meeting or provide information the services were no longer needed by the required timeframe. This failure could place the residents with intellectual and developmental disabilities at risk of not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions for resident care needed to provide effective and person-centered care and provide a summary of the baseline care plan to the resident and/or their representative for 1 of 4 residents reviewed for new admissions (Residents #11). The facility did not have a completed baseline care plan, within 48 hours of admission and did not provide a written summary to the resident or their representative for Resident #11. This failure could place residents at risk of not receiving care and services to meet their needs.