Village Green Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Mar 12, 2025

  Based on clinical record review, observation, facility documentation, review of facility policy and interviews for 1 of 7 sampled residents (Resident #124) reviewed for accidents, the facility failed to ensure necessary care and services were immediately sought and provided to ensure Resident # 124 safety and prevent a fall with major injury, when Resident # 124 exhibited a change in condition, subsequently fell out of bed and sustained an eyelid laceration and fracture to the face and failed to ensure the area designated for smoking was free from accident hazards. The findings included: 1. […]

• Actual harm, isolatedF805Jul 8, 2024

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed accidents, the facility failed to ensure a resident with dysphagia was provided the correct liquid consistency in accordance with physician orders, resulting in respiratory distress and hospitalization . The findings include: Resident #1's diagnoses included cerebrovascular infarction with hemiplegia and hemiparesis, dysphagia (difficulty swallowing) and vascular dementia. The RCP dated 5/12/2024 identified Resident #1 was at risk for impaired swallowing related to cerebrovascular accident and dementia. […]

• No harm, potential for more than minimal, patternF584Mar 1, 2023

  Based on observation, review of facility policy, facility documentation and interview for 1 resident (Resident #63) reviewed for the environment, the facility failed to ensure resident's wheelchair was maintained in a clean and sanitary manner and for 2 of 3 units, the facility failed to maintain a clean, sanitary, comfortable and homelike environment. The findings include: 1. Resident #63's diagnoses included schizophrenia, heart failure and depression. The quarterly MDS dated [DATE] identified Resident #63 had intact cognition and required supervision with locomotion on and off unit, was independent with ambulation and used a walker and wheelchair for mobility. […]

• No harm, potential for more than minimal, patternF689Mar 1, 2023

  Based on review of the clinical record, facility documentation, facility policy and interviews for 4 of 4 residents (Resident #12, 41, 62 and 63) reviewed for smoking, the facility failed to ensure that smoking assessments were completed timely. The findings include: 1. Resident #12 was admitted to the facility with diagnoses that included Schizophrenia, COPD, and nicotine dependence. The quarterly MDS dated [DATE] identified Resident #12 had intact cognition. The care plan dated 2/1/23 identified that Resident #12 may smoke with supervision per the smoking assessment. […]

• No harm, potential for more than minimal, patternF726Mar 1, 2023

  Based on review of facility documentation, facility policy, and interviews, the facility failed to complete nursing competencies related to IV and respiratory therapy. The findings include: 1. Although requested, the DNS did not provide IV Therapy nurse and nurse aide competencies for 2022. Interview with the DNS on 2/23/23 at 10:24 AM indicated she was responsible to make sure IV Therapy nurse and nurse aide competencies were completed annually and she indicated they had not been done since 2021. Review of the Intravenous Infusion Therapy Manual identified the purpose was to provide comprehensive and integrated infusion care to patients. The facility administrator is responsible for staffing qualified nurses to care for patients' infusion therapy. […]