Croasdaile Village

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 8, 2026

  Based on observations, record reviews, and interviews with staff, the facility failed to provide a safe transfer for Resident #2 when Nurse Aide (NA) #1 transferred Resident #2 from her wheelchair to the bed without using a mechanical lift causing Resident #2 to sustain a laceration to her lower left leg. The resident was prescribed a blood thinner twice a day which increases the risk of bruising and bleeding. Resident #2 was transferred to the hospital for evaluation and treatment where it was noted the laceration was 25 centimeters (9.8 inches) in length and had a depth of 20 millimeters (0.7 inches) with extensive bleeding. The laceration was closed with 11 sutures and a dressing was applied. […]

• No harm, potential for more than minimal, patternF759Feb 23, 2023

  Based on observations, staff interviews, and record review, the facility failed to have a medication error rate of less than 5% as evidenced by 3 medication errors out of 28 opportunities, resulting in a medication error rate of 10.7% for 1 of 3 residents (Resident #20) observed during medication pass. The findings included: 1. Resident #20 was admitted to the facility on [DATE]. Her cumulative diagnoses included Parkinson's disease and atherosclerotic heart disease (a build-up of plaque in the arteries). On 2/21/23 at 9:11 AM, Nurse #1 (an agency nurse) was observed as she prepared and administered 10 oral medications for administration to Resident #20. […]

• No harm, potential for more than minimal, patternF760Feb 23, 2023

  Based on facility staff, Nurse Practitioner (NP) and Medical Doctor (MD) interviews and record reviews, the facility failed to administer an anticoagulant medication to a resident for a period of 10 days during his stay in the facility. This occurred for 1 of 6 residents (Resident #240) whose medications were reviewed. The findings included: Resident #240 was admitted to the hospital from 10/27/21 to 11/17/21. His Hospital Discharge Summary dated 11/17/21 reported the resident was admitted for a diagnoses which included an acute embolic cerebral vascular accident (CVA). An embolic CVA is a stroke caused by a blood clot that formed elsewhere in the body and traveled through the bloodstream to the brain. […]

• No harm, potential for more than minimal, isolatedF638Aug 14, 2025

  Based on record reviews and staff interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame for 1 of 7 residents (Resident #45) reviewed for resident assessments. Findings included:Record review revealed Resident 45's admission MDS assessment was dated 4/2/25. There was no quarterly MDS assessment within 92 days available for review. On 8/14/25 at 2:10 PM, during an interview, the MDS Coordinator indicated that Resident #45 was discharged and readmitted three times in two months. After the 4/2/25 admission MDS assessment, the quarterly MDS assessment should have been set up within 92 days, on 7/3/25, but it was missing. […]

• No harm, potential for minimal, patternF640Aug 14, 2025

  Based on record reviews and staff interviews, the facility failed to transmit quarterly Minimum Data Set (MDS) assessments within the required time frame for 2 of 7 residents (Resident #53, Resident #68) reviewed for resident assessments. Findings included: 1. Resident #53 was admitted on [DATE]. Review of Resident 53's quarterly MDS assessment, dated 6/26/25, revealed the MDS assessment was signed as completed by the MDS Coordinator on 7/1/25 and indicated as ready to export. The MDS assessment was transmitted to the national database on 8/12/25.On 8/14/25 at 1:55 PM, during an interview, the MDS Coordinator indicated the 6/26/25 assessment was completed and signed on 7/1/25 and should have been transmitted within 14 days of completion. […]