Village Creek Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Village Creek Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (Residents #8) reviewed for abuse. The facility failed to ensure Hospice Aide did not abuse Resident #8. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 05/08/24 and ended on 05/08/24. The facility had corrected the noncompliance before the survey began. This failure could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm. Findings included: Review of Resident #8's annual MDS assessment dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689May 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision on 05/08/24 when Resident #1 sustained contusions and bruises to left side of face and left eye from an incident/accident. On 05/09/24, Resident #1 was diagnosed with a subdural hematoma ([SDH] occurs when a blood vessel in the space between the skull and the brain [the subdural space] is damaged) and admitted to the hospital. The facility failed to oversee the implementation of resident care policies. […]

• No harm, potential for more than minimal, patternF925Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents for 2 of 3 halls (Hall 200 and Hall 400), and 1 of 1 kitchen reviewed for pest control. The facility failed to ensure 200 and 400 halls, and the kitchen were free from pests.This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.Findings included:Hall 400Interview on 07/02/26 at 9:57 AM, Resident # 1 stated he had seen a few flies in his room. He said, most of the time, it was in the evening. He said he waved them off and found them irritating. […]

• No harm, potential for more than minimal, patternF842Jul 11, 2024

  Based on interview and record review, the facility failed to maintain clinical records that were complete and accurate for two (Resident #18 and Resident #28) of six residents reviewed for clinical records. 1. The facility failed to obtain physician orders for Resident #18 dialysis port site monitoring, vital signs, and documentation of the pre and post dialysis Vitals on the communication form. 2. The facility failed to document when the physician was notified when Resident #28's blood sugar exceeded 250. This failure could place residents at risk for incomplete and inaccurately documented medical record that included their progress treatment, services, and interventions. Findings include: 1. […]

• No harm, potential for more than minimal, patternF727Jun 15, 2023

  Based on interview and record review the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, seven days a week for 16 of 34 days (02/26/23, 03/04/23, 03/05/23, 04/02/23, 04/08/23, 04/09/23, 04/15/23, 04/22/23, 04/29/23, 05/20/23, 05/21/23, 05/28/23, 06/03/23, 06/04/23, 06/10/23, and 06/11/23) reviewed for nursing services. The facility failed to have RN coverage for eight consecutive hours for 7 days (Saturdays and Sundays) between 02/26/26 until 06/11/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment. […]