Village Crest Center for Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Village Crest Center for Health & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 3, 2026

  Based on observation, clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for accidents, the facility failed to ensure the resident was transferred in accordance with the plan of care. The failure resulted in a resident to fall and a right tibial and trimalleolar (three ankle bones) fracture. The findings include: Resident #1's diagnoses included atrial fibrillation, osteoporosis, muscle weakness, and anxiety. The Quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of eight out of fifteen (8/15), indicative of moderate cognitive impairment and was dependent assistance with ADL's and transfers. […]

• Actual harm, isolatedF689May 6, 2025

  51183 Based on interviews, review of the clinical record, facility documentation, and facility policy for 1 of 5 residents (Resident #24) reviewed for falls, the facility failed to provide a transfer according to physician orders which resulted in a fall with injury and failed ensure all appropriate doors were secured on the locked memory care unit. The findings include: 1. Resident #24's diagnoses included transient cerebral ischemic attack, morbid obesity, and difficulty in walking. […]

• Actual harm, isolatedF689Sep 19, 2024

  Based on a review of clinical records, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to provide adequate assistance during a bed linen change and as a result, the resident rolled out of bed onto the floor sustaining a left hip fracture. The finding includes: Resident #1 had diagnoses that included Alzheimer's disease, generalized muscle weakness, and difficulty walking. Review of Resident #1's side rail evaluation dated 6/14/24 identified the indication and use of the side rails is per the request of Resident #1 and h/her responsible party. […]

• No harm, potential for more than minimal, widespreadF812May 6, 2025

  Based on the tour of the Dietary Department and Nourishment Rooms, staff interviews, and review of facility policies, the facility failed to ensure opened items were labeled and dated when opened, food that was expired was discarded and the 3 of 3 nourishment refrigerator/freezer/ice makers were sanitary. The findings included: Tour of the Dietary Department on 4/28/25 at 10:40 AM during the initial walk through with the Dietary Director identified the following: a. 16 hot dog buns were in an opened package and not dated when opened b. 1 loaf of French bread, opened and not dated when opened c. 2 slices of French toast on a plate, covered with plastic wrap and located in the walk in refrigerator and not dated when opened d. 8 donuts in a box that was opened and not dated when opened e. […]

• No harm, potential for more than minimal, patternF791May 6, 2025

  Based on observation, review of the clinical record, facility policy and interviews for 1 of 2 residents (Resident #33) reviewed for dental services, the facility failed to ensure timely dental services were provided related to non-restorable teeth. The findings include: Resident #33's diagnoses included weakness and partial paralysis affecting the left side following a stroke, dementia, and depression. The face sheet identified Resident #33's payor source was Medicaid. The Resident Care Plan (RCP) dated 2/14/23 and currently in effect identified Resident #33 had oral/dental health problems related to poor dentition. […]