Country Village Care

In the surveyor’s words

From the most serious findings on record at Country Village Care, in the surveyor’s own words.

• Immediate jeopardy, patternF686Sep 23, 2025

  Based on observation, record review and interviews, the facility staff failed to ensure that a resident received treatment and care in accordance with professional standards of practice, to promote healing and prevent infection for 1 of 5 residents (CR# 1) reviewed for pressure ulcers. The facility failed to prevent progression of CR # 1's Stage 4 Sacral Pressure Ulcer (a severe pressure injury that extends through all layers of skin,) that was not getting better and enlarged from 2.20 cm in length, 1.10 cm in width, 0.10 cm in depth and 2.42 cm in area on 8/19/2025 to 5.40 cm in length, 6.00 cm in width, 2.30 cm in depth, and 32.40 cm ( 2nd degree) in Area on 9/10/2025, had odor an exhibited signs of infection. […]

• Immediate jeopardy, isolatedF755Feb 7, 2025

  Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (CR #1) of 5 residents reviewed for pharmacy services. -The facility failed to ensure CR#1's morphine (opioid pain-relieving medication that usually provides significant pain relief for short term or chronic pain) and Norco (combination of acetaminophen and hydrocodone to relieve moderate to severe pain) medications were not administered too close together to prevent accidental overdose on 01/01/25. An Immediate Jeopardy (IJ) was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 9:26 a.m. […]

• Immediate jeopardy, isolatedF760Feb 7, 2025

  Based on interview and record review the facility failed to ensure that its residents were free of any significant medication errors resident for 1 (CR #1) of 5 residents reviewed for pharmacy services. -The facility failed to ensure CR#1's morphine (opioid pain-relieving medication that usually provides significant pain relief for short term or chronic pain) and Norco (combination of acetaminophen and hydrocodone to relieve moderate to severe pain) medications were not administered too close together to prevent accidental overdose on 01/01/25. An Immediate Jeopardy (IJ) was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 9:26 a.m. […]

• Actual harm, isolatedF684Oct 25, 2024

  Based on observation, interview 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 (Resident #59) of 40 residents reviewed for quality of care. The facility failed to conduct skin assessments /assess skin on Resident #59's contracted right arm and forearm resulting in redness at site of contracture and forearm with brown exudate (moisture associated skin damage) and pungent odor. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions. Observed 3 of 3 Kitchen reviewed the facility stored outdated and deteriorated food. The facility failed to provide functional handwashing sinks with hot water. The facility failed to have monitor cold holding equipment temperatures due to non functional thermostats and lack of documented alternative checks.These failures had the potential to cause foodborne illness and cross contamination for residents.Observation on 01/06/2026 at 08:20 AM revealed the walk-in refrigerator had outdated and undated ready to eat foods, including containers lacking date marking. Brown, wilted lettuce was present and stored next to ready to eat foods. […]