Village Care and Rehabilitation Center, The

In the surveyor’s words

From the most serious findings on record at Village Care and Rehabilitation Center, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Feb 28, 2023

  Based on record review and interviews, the facility failed to provide cardiopulmonary resuscitation (CPR) prior to the arrival of fire department paramedics, contrary to the medical order set signed by one (#1) out of three residents reviewed for CPR. This failure created a situation for serious harm if not immediately corrected. Record review revealed on [DATE], Resident #1 had expressed and signed, along with his practitioner, a medical order set on a MOST form (medical orders for scope and treatment) to ensure his orders for life-sustaining treatment would be honored by health care professionals. The form read the resident wanted to receive CPR and full treatment - the primary goal to prolong life by all medically effective means. […]

• Actual harm, isolatedF689Oct 8, 2024

  Based on observations, record review, and interviews, the facility failed to ensure one (#1) of three residents reviewed for falls (#1) out of four sample residents received adequate supervision and assistance to prevent falls with injury. Resident #1 was admitted to the facility on [DATE] for rehabilitation therapy after undergoing surgical repair for a fractured right femur. The facility was aware upon the resident's admission for skilled nursing services that she had several falls in her prior living setting which resulted in the need for surgical repair after the resident fell and fractured her right femur. The facility also was aware that the resident needed to maintain non-weight-bearing status of her fractured leg. […]

• Actual harm, isolatedF689Feb 28, 2023

  Based on observation, interview and record review the facility failed to ensure the residents' environment remained as free from accidents hazards as possible for two (#3 and #4) of four residents reviewed for falls out of five sample residents. Specifically, the facility failed to: -Provide effective monitoring and supervision for safety of Resident #3 and Resident #4. -Provide/install anti-roll backs on Resident #3's wheelchair to prevent rolling. The facility failed to ensure Resident #4 had sufficient supervision with her risk of falling and leaning in her wheelchair. […]

• No harm, potential for more than minimal, widespreadF607Feb 28, 2023

  Based on record review and staff interviews, the facility failed to implement policies and procedures to thoroughly screen staff to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property, prior to a staff member providing direct care to residents. Specifically, the facility failed to: -Complete employee background checks before the facility allowed staff to work with residents in the facility, which included registered nurse (RN) #4; -Investigate concerns about registered nurse (RN) #4's background check; -Prevent RN #4, who had a suspended nursing license in another state, from providing direct patient care in the facility. […]

• No harm, potential for more than minimal, widespreadF843Feb 28, 2023

  Based on record review and staff interview the facility failed to have in effect a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs in order to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect for the one local area hospital. Findings include: I. Record review During the survey from 2/21/23 to 2/28/23, the hospital transfer agreement was requested from the nursing home administrator (NHA) via email on 2/23/23 at 4:47 p.m. -The facility was unable to provide a written agreement for the one area hospital. II. […]