Village Creek Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF607Mar 26, 2026

  Based on observation, interview and record review, the facility failed to implement written policies and procedures that identify, report, and protect from further abuse of residents, for 2 of 6 residents (Resident #14 and Resident #55) reviewed for abuse. * On 03/04/26, CNA B witnessed Resident #14 yell at Resident #55 that she was a [f-ing retard]. The incident was not reported to the abuse coordinator (AC) or HHSC. No preventative measures were put in place to prevent further abuse. * On 03/20/26, CNA B and MA C both witnessed Resident #14 shove Resident #55 into trash and dirty linen barrels in her wheelchair. CNA B and MA C did not consider this to be abuse and did not report the incident to the abuse coordinator. An Immediate Jeopardy (IJ) situation was identified on 03/25/26. […]

• Immediate jeopardy, isolatedF726Mar 26, 2026

  Based on interview and record review, the facility failed to assure all nursing staff possess the competencies, and skill sets necessary to use, maintain and test the automated external defibrillator according to the manufacturer's guidelines for 1 of 1 facility automated external defibrillators and 4 of 4 licensed staff interviewed (LVN QQ, LVN L, LVN J and LVN H) and reviewed for nursing services.The facility failed to ensure nursing staff were competent to conduct testing of the facility's only AED according to the manufacture's guidelines.An Immediate Jeopardy (IJ) was identified on [DATE] at 4:45 p.m. […]

• Immediate jeopardy, isolatedF689Nov 21, 2025

  Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents.The facility failed to provide adequate supervision with Resident #1 on 08/11/2025 while completing perineal care in bed. CNA A provided perineal care and Resident #1 rolled off the bed to the floor. Resident #1 initially complained of pain in his right arm after this fall. Resident #1 was sent to the hospital for further evaluation on 08/11/2025.The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 8/11/2025 and was removed on 08/11/2025. […]

• Immediate jeopardy, isolatedF600Nov 21, 2024

  Based on interviews and record review, the facility failed to ensure residents the right to be free from abuse for 1 of 16 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from sexual abuse on 08/28/24 and 09/02/24. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because all staff had not been trained on monitoring behaviors after an inappropriate behavior was identified. […]

• Immediate jeopardy, isolatedF656Nov 21, 2024

  Based on interviews and record review, the facility failed to develop and implement the comprehensive person-centered care plan used to maintain the resident's highest practicable physical well-being for 2 of 16 residents (Resident #1 and Resident 3) reviewed for care plans. 1. The facility failed to develop and implement interventions in the care plan to prevent Resident #1's sexual abuse of Resident #2. An IJ was identified on 11/19/24. The IJ began on 08/28/24 and was removed on 09/04/24. While the IJ was removed on 09/04/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because resident care plans were not reviewed and revised. 2. […]