Village Health & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to submit investigation findings for an incident in a timely manner, to the State Survey Agency, for 2 (#s 5 and 6) of 9 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions, staff failed to wear hair restraints in the kitchen area, and the facility failed to provide food at a safe and appetizing temperature for 4 (#s 6, 14,72, and 154) of 34 sampled residents. These deficient practices placed all residents who consumed meals prepared by the facility at risk of exposure to food-borne pathogens and or illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nursing staff had the necessary knowledge and skillset on the facility's post-fall protocol and physician notification, and a resident had a fall, with an injury and pain, and the proper notifications were not all made, for 1 (#85) of 34 sampled residents, and this resulted in a delay in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a thickened therapeutic diet as ordered for 1 (#91) of 34 sampled residents. The failure increased the risk of aspiration for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from accidents for a resident who sustained a fall with pain resulting in a fracture, who was on a blood thinner; and failed to promptly notify the physician of a fall with pain resulting in a fracture impacting the physician's opportunity to determine if a higher level of care or treatment was necessary at the time of the fall for 1 (#85) of 34 sampled residents. This deficient practice contributed to delayed care, increased pain and a femur fracture. During an interview on 8/26/25 at 9:36 a.m., resident #85 explained that she was admitted to the facility in July after she developed complications from a right hip replacement. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide prompt physician notification for a resident who sustained a fall resulting in injury with pain for 1 (#85) of 34 sampled residents. This deficient practice contributed to a delay in treatment, and the resident was found to have a fracture.

Inspectors wroteBased on the interview and record review, the facility failed to report allegations of resident abuse to the State Survey Agency within 24 hours of an incident for 2 (#s 99 and 129) of 5 residents sampled for Facility Reported Incidents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to wear appropriate PPE while caring for residents for 2 (#s 3 and 16); and failed to educate and monitor staff on cleaning practices for residents positive for c-diff, for 2 (#s 14 and 17) of 17 sampled residents. The deficient practices increased the risk to others for contracting infections due to the deficient practices.

Inspectors wroteBased on observation and interview, the facility failed to provide clean resident rooms for 3 (#s 72, 16 and 95) of 28 sampled residents, and failed to provide clean hallways, which had the potential to affect all staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to update resident care plans in a timely manner for 3 (# 1, #16 and #55) of 4 residents sampled for pressure ulcers and failed to revise a resident care plan to show effective behavior interventions following repeated resident to resident altercations for 1 (#33) of 3 residents sampled for behavior.

Inspectors wroteBased on interview and record review, the facility failed to complete accurate assessments for 1 (#33) of 3 sampled residents who had been involved in two altercations. This deficient practice had the potential to affect resident care and safety as it inaccurately depicted the residents' care needs.

Inspectors wroteBased on interview and record review, the facility failed to limit an as needed anti-anxiety medication order to 14 days or provide a rationale for continued extension of the medication, for 1 (# 33) of 1 sampled resident using an as needed medication.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment for 1 (#90) of 36 sampled residents. This resulted in the resident falling and sustaining a significant injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff wore beard coverings in the kitchen, failed to label and date food items in the walk-in freezer, and failed to properly cool left-over chicken. This deficient practice had the potential to affect all residents eating food from the facility's kitchen.

Inspectors wroteBased on interview and record review, the facility failed to implement a baseline care plan, for five days, for a newly admitted , nonverbal resident with a diagnosis of a subdural hematoma and stroke for 1 (#138) of 36 sampled residents. This deficient practice had the potential to affect the resident's quality of care.

Inspectors wroteBased on interview and record review, the facility failed to initiate a care plan for PTSD (Post-Traumatic Stress Disorder) for 1 (#55) of 36 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan related to catheter care for 1 (#107) of 36 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage catheter changes as the physician ordered for 1 (#107) of 36 sampled residents. This deficient practice had the potential to increase risk of infection and complications from multiple catheter changes. Findings Include: During an interview on 7/31/24 at 3:01 p.m., staff member L stated resident #107 had something wrong with his bladder which caused the catheter to keep clogging. Staff member L stated his catheter had not gone a full month without having to be changed. Staff member L stated she was not aware of any pain or recent infections for resident #107 related to his catheter. During an interview on 8/1/24 at 8:15 a.m., staff member B stated the nurses on the floor should have been moving the scheduled catheter change date out if they used the as needed catheter change order for resident #107. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was provided for a dialysis appointment for a resident receiving dialysis at a nearby facility for 1 (#121) of 36 sampled residents. This deficient practice had the potential to cause health complications for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide behavioral health services for a resident with PTSD, who had previously attended counseling for managing her mental health for 1 (#55) of 36 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff changed gloves and practiced hand hygiene, according to standard infection control practices, during pericare and wound care for 1 (#111); and failed to initiate enhanced barrier precautions for a resident with a PICC line for 1 (#390) of 36 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse within the required timeframe of two hours to the State Survey Agency and local law enforcement, for 1 (#16) of 1 sampled resident. Findings Include: During an interview on 7/20/23 at 8:36 a.m., staff member B stated the sexual abuse allegation made by resident #16 was reported to the weekend manager at 1900 (7:00 p.m.) on 4/2/23. Staff member B stated the weekend manager did not notify her, and the administrator, until 4/3/23 at 9:00 a.m., and therefore, the weekend manager had been removed from that position. Review of the facility reported incident received by the State Survey Agency showed the event for resident #16 was submitted on 4/3/23 at 7:10 a.m., and the five-day investigation was completed on 4/8/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately start investigating an allegation of sexual abuse by a staff member, for 1 (#16) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from a significant medication error, for 1 (#22) of 1 sampled resident. This deficient practice had the potential to cause an increased risk of bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the MDS (Minimum Data Set) for 3 (#s 16, 26, and 75) of 8 sampled residents.