Village Green Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Village Green Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 3, 2022

  Based on record review and interviews with staff and Nurse Practitioner, the facility failed to provide care in a safe manner for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #293). The resident rolled off the bed during care which resulted in a laceration above the left eye and fracture of the left 7th and 8th ribs. The findings included: Resident #293 was admitted to the facility on [DATE]. His diagnoses included cognitive communication deficit, dementia without behavioral disturbance and generalized muscle weakness. […]

• No harm, potential for more than minimal, widespreadF804Feb 8, 2021

  Based on observation, record review, a test tray, resident and staff interviews the facility failed to serve palatable food according to their preferred temperature for 2 out of 2 residents (Resident #3 and Resident #4) sampled for palatable food. Findings included: The meal policy revised July 2017 in part read: Hot foods shall be held at a temperature of 136 degrees or above until served Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement. A lunch meal pass and test tray on 02/06/2021 was observed on Unit 2B at 12:10 PM with the Dietary Supervisor (DS). The cart arrived on the hall with ten trays. Nurse #1 walked to the cart and removed a tray and walked away with the cart door open. […]

• No harm, potential for more than minimal, patternF812Feb 20, 2025

  Based on observations and staff interviews, the facility failed to date opened food items and seal leftover frozen food stored in 1 of 1 reach-in freezer, 1 of 1 walk-in freezer, 1 of 1 dry goods storage area and failed to remove a bowl being used as a scoop observed nested in breadcrumbs in one of the dry ingredient storage bins in the kitchen. This practice had the potential to affect foods served to the residents. The findings included: On 02/16/25 at 11:28 A.M., an observation of the kitchen revealed the following: a. […]

• No harm, potential for more than minimal, isolatedF645May 13, 2026

  Based on record review and staff interviews, the facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted to the facility with a serious mental health disorder for 1 of 3 residents reviewed for PASRR (Resident #1).Findings included:Resident #1's Hospital Course and Treatment Encounter Note dated 2/21/26 indicated Resident #1's chronic conditions included post-traumatic stress disorder (PTSD) which was monitored during that hospitalization. […]

• No harm, potential for more than minimal, isolatedF744Feb 20, 2026

  Based on observation, record review, and interviews with residents, staff, Physician, and Psychiatric Nurse Practitioner, the facility failed to develop and implement individualized person-centered care plan approaches for a resident (Resident # 8) diagnosed with dementia who had a known pattern of verbal behaviors, to include yelling slurs and foul language, specifically targeting Resident # 9. Staff reported that they attempted redirection of Resident #8, but the behaviors had continued and no additional care plan interventions had been developed or implemented that focused on instructing staff on how to manage these verbal behaviors. […]