Village Square Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to provide medication for Resident 1 for 3 consecutive days in 1 out of 3 residents reviewed for pain management. As a result , Resident 1 experienced distress due to not receiving the medication. Findings. An unannounced visit to the facility was conducted on 3/19/26 regarding a complaint related to a specific medication that was not administered by the facility. Per the Facility's admission Face sheet, Resident 1 was admitted to the facility on [DATE] with diagnoses that included Other Psychoactive Substance (chemical compounds that impacts the central nervous system to alter mood, perception, cognition and behavior) Abuse and Encounter for Other Specified Surgical Aftercare. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' controlled medications (medications that can cause physical and mental dependence and are regulated by the Drug Enforcement Administration) were secured in the facility's medication carts. Specifically, controlled substances, including Individual Patient's Narcotic Records (IPNR), were removed from the cart without the licensed nurses' (LNs) knowledge and were left unaccounted for 10 of 10 residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). This had the potential for affected residents' medication to not being available in the event they were needed. There were no missed doses for the affected residents.

Inspectors wroteBased on observation, interview and record review , the facility failed to ensure a low air loss mattress (help prevent skin breakdown) was in placed or implemented for one of one resident (Resident 1) with a pressure ulcer (localized injury to the skin). This failure had the potential to worsen Resident 1's skin injury. Findings. Per the facility's admission Record , Resident 1 was admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of sacral (area of the lower back) region, unstageable and Functional Quadriplegia (paralysis affecting all limbs and torso). On 6/26/25 at 11:20 A.M., an interview with Resident 1 was conducted. Resident 1 stated she had complained to a certified nursing assistant (CNA) to checked if the settings were right on the air-loss mattress on her bed. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure dietary staff covered their facial hair during meal preparation, cold food items were held on the tray line at temperature of 41 degrees Fahrenheit (F) or below, expired food items were discarded, and items in the walk-in freezer were stored in a manner to prevent freezer burn. These deficient practices had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide healthcare in a dignified manner when Resident #265 was left exposed during the provision of incontinence care and staff stood while they fed Resident #39. These deficient practice affected 2 (Resident #39 and Resident #265) of 2 sampled residents reviewed for dignity.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess a resident for their ability to self-administer their medication for 1 (Resident #171) of 25 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the family of a change in health status for one resident (1). As a result, it affects timely intervention and family ' s decision making to be involved in the care planning and address concern.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity for one of 10 sampled residents (Resident 9) when Certified Nursing Assistant (CNA) 1 was observed standing over Resident (9) while assisting in bed to eat. This deficient practice had the potential to not promote dignity and respect for Resident 9 to cause emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician ' s order to infuse the intravenous fluid [IVF] (IV- plastic tube inserted in the vein to deliver hydration, medications or nutrition) within 20-hour time for one of 10 residents (Resident 2) receiving an IVF. As a result, Resident 2's IV fluid was consumed over 26 hours. In addition, the IV tubing was not labeled with date and time it was used. This deficient practice had the potential for Resident 2 to experience IV related complications and infections that would impact resident's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician ' s order to infuse the intravenous fluid [IVF] (IV- plastic tube inserted in the vein to deliver hydration, medications or nutrition) within 20-hour time for one of 10 residents (Resident 2) receiving an IVF. As a result, Resident 2's IV fluid was consumed over 26 hours. In addition, the IV tubing was not labeled with date and time it was used. This deficient practice had the potential for Resident 2 to experience IV related complications and infections that would impact resident's health and well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a written notice and reason for the bed change was given to a roommate (Resident 6), for one of five residents (Resident 3) who required a bed change. This deficient practice had the potential to negatively affect Resident 6's rights and preferences for a new roommate from the bed change.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comfortable and home-like environment for four residents (1, 2, 3, 4) when: 1) Televisions (TV) were not functioning properly. 2) Room temperature (temp) levels were warmer (higher) than required. These failures had the potential to affect the resident ' s physical and psychosocial comfort and well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure nursing assessments and documentation of resident status was accurately completed for one of three residents (Resident 2), during a closed record review (record of a resident that was no longer at the facility). This failure had the potential for miscommunication of care provided to the resident, and resident harm due to incomplete and inaccurate information documented for Resident 2 ' s status and response to medical care.

Inspectors wroteBased on interview and record review, the facility failed to allow one of two sampled residents (1) to choose their own visitors. As a result, Resident 1 was at risk of decreased social interaction.

Inspectors wroteBased on record review, facility staff interview, and policy and procedure review, the facility failed to ensure the following systems were in place: 1) expired drugs were not available at the facility for administration to any of the facility's residents either in the facility's drug storage rooms, refrigerators, or in the facility's medication carts, 2) that medications and biologicals had been administered timely to all of the facility's residents, as outlined in the facility's policy and procedures, and 3) that all administered medications had been documented immediately after they had been administered to each resident. This deficiency had the potential for residents at the facility to receive expired medications and medications which had not been administered in accordance with their physician's orders. This failure could have resulted in negative outcomes for these residents.

Inspectors wroteBased on medication pass observation, interview with facility staff, review of the resident's clinical record, and review of the facility's policies and procedures the facility failed to ensure that 1 unsampled resident (82) had not been allowed to self-administer her medication without a physician's order to do so, and without prior approval from the facility's interdisciplinary team prior to doing so. This deficiency had the potential for this resident to administer medications to herself, in an unsafe manner, without an appropriate assessment, and without her physician's approval.

Inspectors wroteBased on observation, interview, and record review, the facility did not assure that 1 of 4 sampled residents (2) received the necessary services for limited range of motion as designated in the care plan. As a result, Resident 2 had potential to develop further limitations in mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound treatments were provided to 2 of 3 sampled residents (71 and 13) per the standard of practice. 1. For Resident 13, the facility failed to follow wound care orders. 2. For Resident 71, the facility failed to communicate changes to the interdisciplinary team (IDT) or physician, document wound care and wound progression, and implement an IDT to monitor the resident's wound. These failures put Resident 71 and Resident 13 at risk for delayed wound healing and infection.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 of 21 sampled residents (83) received correct treatment for the pressure ulcer (damage to skin and underlying tissue caused by constant pressure on the area) on the left foot. As a result, Resident 83 had the potential to suffer an infection of the left foot pressure ulcer and increased tissue breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 21 sampled residents (103) on intravenous (IV) antibiotic therapy had their peripherally inserted central catheter (PICC line- to provide access to a large vein for administration of medication for long-term use) monitored per professional standards and facility policy. This failure had the potential to affect Resident 103's care and delay the identification of catheter-related complications or infections.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that the actual hours worked for RNs, LVNs and CNAs were posted. This created the potential for residents and visitors to not know the actual nursing hours provided for the resident's care.

Inspectors wroteBased on clinical record review and facility staff interview the facility failed to ensure that 1 of 21 sampled residents (65), had not been put on Trazodone for a non-FDA approved indication, which resulted in this medication becoming an unnecessary drug for Resident 65, as this medication had been prescribed without an adequate (FDA approved) indication. This deficient practice resulted in this resident receiving Trazodone for a clinical indication, which had not been FDA approved, which could have caused this resident harm.

Inspectors wroteBased on medication room inspection, interview with facility staff, and review of the facility's policies and procedures the facility failed to ensure that the medication refrigerator on Station 2, had been secured and locked, as outlined in the facility's policies and procedures. This deficiency had the potential for medications to be stored in a manner, which created the possibility of controlled drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and clean the appliances, drawers, can opener, ice scoop container, storage shelf and plate warmer in the kitchen. As a result, there was the potential for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully implement infection control standards of practice when hand hygiene was not performed between glove changes during a wound treatment observation on 1 of 21 sampled residents (71). This failure had the potential for an increase in facility-acquired infection and medical complications for Resident 71.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conferences (a multidisciplanary team meeting with the resident or family to evaluate care plans) were conducted timely for five of nine residents (30, 34, 64, 76 and 88) reviewed. As a result, there was a potential for changes in the resident's care needs to not be evaluated by a group of health care professionals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1. Safe water temperatures in resident bathroom sinks were maintained. 2. Adaptive equipment to call staff was provided for a paraplegic resident (88). These failures had the potential to create an unsafe environment for the residents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure safe and sanitary conditions were followed regarding food safety and storage, when: 1. The ice machine bin was dirty, and 2. Three air gaps were improperly installed These failures had the potential to cause widespread foodborne illness for the 112 facility residents who consumed food from the Food and Nutrition Services Department.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and maintain a QAPI plan for when the facility's water distribution system was not maintained in proper working order.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two residents reviewed for dignity, were assisted with feeding in a respectful manner (47, 75). As a result, these failures had the potential to negatively impact Resident 47 and 75's self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to verify informed consent was obtained for three of three residents (70, 90, 297) reviewed for the right to be informed when: 1. Resident 70 and 90 did not have verification of consent for the administration of psychotropic medications; and, 2. Resident 297 was not informed prior to the application of a WanderGuard (Trademark) (an alert system device, designed to notify staff when persons at risk attempt to leave a facility). These failures did not provide Resident 70, 90 and 297, the right to be fully informed regarding care and treatment, in order to make health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to give one of three sampled residents (900) the Advanced Beneficiary Notice (ABN/CMS 10055) (a form which gave the choice to continue services under private pay if Medicare did not provide payment), including the appeal contact information, and the Notice of Medicare Non-Coverage Notice (NOMNC Form CMS 10123). As a result, Resident 900 did not have the choice to appeal the decision, or have knowledge of the costs to continue treatment in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice to a resident transferred to a hospital for one of three closed records (94) reviewed. This failure had the potential for Resident 94 to not be aware of his right to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan was initiated for three of six residents, reviewed for admission care plans. (76, 88, 30). This failure had the potential for Residents 76, 88 and 30 to not receive appropriate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop care plans for two of five residents (297, 34) reviewed for care plan development. As a result, there was a potential for residents to not receive the care required or ordered by their physicians.

Inspectors wroteBased on observation, interview and record review, the facility failed to transcribe admission wound treatment orders, therefore wound treatments were not performed for one of 1 residents (297) reviewed for nursing care issues. As a result, Resident 297 did not receive the care and treatment required to meet his physical needs. Resident 297 was admitted to the facility on [DATE], with the diagnoses of osteomyelitis of right foot (a serious infection of the bone) with right third toe amputation (removal), per the physician's History and Physical. On 2/11/19 at 8:01 AM, an observation and interview with Resident 297 was conducted. Resident 297 was sitting in a bedside chair. There was a tan colored wound dressing covering Resident 297's right toes. Resident 297 stated he had been admitted to the facility on [DATE], he had his third right toe amputated at the hospital due to an infection. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen was administered and monitored per the physician's order for 3 of three residents (75, 82, 63) reviewed for oxygen administration. These failures had the potential to affect the residents health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident (62) reviewed for dialysis (the process of removing toxins and excess fluid from the blood through a machine), care did not meet professional standards. As a result, the resident was at risk of developing undetected complications related to dialysis treatment. Resident 62 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (chronic irreversible kidney failure) and dependence on renal dialysis (a treatment to remove waste material from the kidneys) per the facility's Resident Face Sheet. Per Resident 62's physician order dated 2/12/19, After return from dialysis on M- (Monday) - W (Wednesday)-F (Friday) monitor AV shunt for bruit (auscultation of shunt for swooshing sound), thrill (lightly palpate for vibration of shunt), infection and pain . [...]

Inspectors wroteBased on observation, interview, and record review, two of four facility medication carts reviewed were found to have medications not stored in accordance with standard professional practices, when: 1. An opened insulin vial was not dated, and; 2. A pain cream was not labeled with the resident's name. This failure caused the potential for insulin to be expired, and the potential for pain cream to be administered to the wrong resident.

Inspectors wroteBased on food and nutrition services observations, staff interviews, and record reviews, the facility failed to ensure food and nutrition services department staff appropriately carried out tasks in a safe and sanitary manner. This repeated failure to ensure effective safe and sanitary practices may place residents at nutritional risk, and in turn, further compromise the health status of 112 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy related to food for residents brought in from outside the facility and did not ensure safe and sanitary practices. This repeated failure had the potential to result in widespread foodborne illness for 112 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program when: 1. During a dining observation in the main dining room, the AD was observed assisting residents without performing hand hygiene (cleaning of the hands) in between each resident contact. 2. During a dining observation in the main dining room, the AD was observed moving between four of 11 resident's, providing assistance without performing personal hand hygiene. 3. Resident 30's urinary catheter drainage bag was lying on the floor one of 2 residents reviewed for catheter care. As a result, there was a potential for cross contamination and the spread of infection.