Village Healthcare and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a valid reason for discharge and a resident's physician order for discharge was documented when a discharge was conducted for four Residents (R #4, R #5, R #6, and R #7) of seven Residents whose discharge orders were reviewed, in that: The facilty failed to document a reason for discharge and a physician's discharge order for Resident's #4, #5, #6, and #7 prior to discharge. This failure could place residents at risk of diminished continuity of care and unsafe and/or improper discharges.

Inspectors wroteBased on record review and interview, the facility failed to provide and document sufficient preparation and orientation of resident representative to ensure safe and orderly transfers or discharges from the facility for 5 of 5 residents (Resident #2, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for transfer and discharge. The facility failed to notify the residents and their responsible parties of the transfers or discharges with the reasons for the move in writing in a language and manner they understand. This failure placed residents at risk of not receiving an advocate who could inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance while providing care for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed when CNA B did not provide Resident #1 adequate supervision while providing incontinent care on [DATE] at around 11:50 AM, which led to Resident #1 falling from his bed, resulting in a traumatic intracranial hemorrhage (brain bleed). The non-compliance was identified as past non-compliance. The Immediate jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interview and record reviews the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 10 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. CNA A attempted to provide Resident #1 care at bed side by herself knowing that Resident #1 required two person assistance for all activities, which lead to Resident #1 falling off the bed and sustaining a right humerus fracture. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/06/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. The facility was informed about the past non-compliance on 4/10/25 at 3:55 pm. This failure could place residents at risk of neglect .

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of 10 residents (Resident #1) reviewed for accidents and hazards. The facility failed to provide adequate supervision to prevent Resident #1 from falling from bed, fracturing her right humerus. The non-compliance was identified as past non-compliance. The Immediate threat began on 11/06/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. This deficient practice has the potential to affect all residents in the building by causing resident injuries, such as falls, fractures, and even death due to improper supervision.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report for 1 of 5 residents (Resident #2) reviewed for PASRR. The facility failed to initiate an NFSS within 20 business days following the date the services were agreed upon in the IDT meeting. This failure could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.

Inspectors wroteBased on interview and record review the facility failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #78) of 33 residents whose records were reviewed for pharmacy services. The facility failed to ensure Resident #78 was not prescribed an antipsychotic (Aripiprazole) without appropriate diagnosis for its use. This deficient practice could place residents without a proper diagnosis for taking antipsychotic medications at risk for receiving unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 3 medication carts (medication cart located in 200 hallway) reviewed for medication storage and labeling. The facility failed to ensure that all insulin in medication cart in 200 hallway were not past their expiration date. The facility's failure could result in residents receiving medications at their best therapeutic level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish 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 resident (Resident # 63) observed for infection control issues in that: CNA B reused wipes when she cleansed the perineal area and did not sanitize hands between glove changes. This deficient practice could place residents at risk for infection due to improper hand sanitizing and incontinent care practices.

Inspectors wroteBased on interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded in the MDS for a fall with major injury on 1/30/25. This failure could place residents at risk of receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 4 residents (Resident #73, Resident #305) reviewed for accuracy of records. 1. The facility failed to accurately document Resident #73's blood sugar level on 01/24/2024 at 3:51 p.m. 2. The facility failed to accurately document Resident #305's blood sugar level on 01/21/2024 at 4:41 p.m. These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 1 resident (Resident #4) of 5 residents reviewed for supervision and interventions, in that The facility failed to ensure Resident #4 received supervision and effective interventions to prevent Resident #4 from repeated falls with injuries. This failure could place residents at risk for accidents and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 3 of 12 residents (Resident #1, #2, #3) reviewed for oxygen in that: 1. Resident #1 's oxygen was administered at 1.5 Liters Per Minute instead of 3 Liters Per Minute via nasal cannula as ordered by the physician. 2. Resident #2's oxygen was administered at 4 Liters Per Minute instead of 2 Liters Per Minute via nasal cannula as ordered by the physician. 3. Resident #'3's oxygen was administered at 3.5 Liters Per Minute instead of 3 Liters Per Minute via nasal cannula as ordered by the physician. This deficient practice placed 12 residents who received oxygen continuously and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet the residents' psychosocial needs for one (Resident#10) of three residents reviewed for comprehensive person- centered care plan for recreational drug use. The facility did not care plan Resident #10's recreational drug use after paraphernalia was found in his room. This failure could affect residents and place them at risk of not receiving appropriate interventions.

Inspectors wroteBased on interview and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 (Resident #1) reviewed for quality of care. The facility failed to document, monitor, and assess Resident #1's abnormal skin discoloration prior to and upon return of Resident #1's outing (on pass) to her home after RP reported the discoloration to staff. This failure could affect residents by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death.

Inspectors wroteBased on, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 (Resident #22) of 15 residents reviewed for supervision. The facility did not implement interventions to prevent Resident #22 from eloping from the facility. This failure could have resulted in serious harm to the resident.