Village Health Care

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 5, 2026

  Based on observation, interview and record review it was determined the facility failed to comprehensively assess a resident for the use of an electric wheelchair and develop new interventions to reduce the risk of falls for 2 of 4 sampled residents (#s 3 and 73) reviewed for accidents. This failure resulted in Resident 73 sustaining a five-centimeter laceration (a jagged wound or cut in the flesh) to her/his right anterior (toward the front) lower leg, multiple leg fractures and a brief syncopal episode (fainting or passing out) secondary to blood loss. Findings include: The facility's 1/2025 Physical Restraints and Enablers/Devices Policy indicated a Device Evaluation was completed prior to a device being initiated. […]

• Actual harm, isolatedF760May 22, 2025

  Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#3) reviewed for medications. As a result, Resident 3 experienced significant clinical symptoms (increased swelling of the extremities, lowered oxygen levels and shortness of breath) related to the medication error and had a 10-day hospitalization stay. Findings include: Resident 3 admitted to the facility in 1/2025 with diagnoses including chronic obstructive pulmonary disease (damage to the airways and air sacs in the lungs which make it difficult to breathe) and congestive heart failure (a weakened heart condition the causes fluid buildup in the feet, arms, lungs and other organs). […]

• Actual harm, isolatedF689May 27, 2021

  Based on interview and record review it was determined the facility failed to ensure care plan interventions were followed for 1 of 3 sampled resident (#7) reviewed for accidents. The facility's failure resulted in Resident 7 sustaining serious bodily injury. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in disciplinary action and additional fall prevention training with instructions to follow the care plan for all staff. […]

• No harm, potential for more than minimal, widespreadF761Jun 5, 2026

  Based on observation, interview and record review it was determined the facility failed to monitor temperatures in the medication refrigerators for 3 of 3 medication refrigerators. This places residents at risk for receiving ineffective medications or vaccinations. Findings include:On 6/5/26, the CDC requires facilities to monitor temperatures in medication refrigerators to maintain a temperature between 36 and 46 degrees Fahrenheit (F).On 6/4/26 at 1:13PM, Staff 3 (Regional Director of Clinical Operations) provided the temperature logs for three medication refrigerators.A review of Station 1's medication temperature log for 5/2026 revealed missing temperatures on 5/1/26, 5/2/26, 5/8/26, 5/11/26, 5/14/26, 5/15/26, 5/16/26, 5/17/26, 5/22/26, and 5/29/26 (10 days).A review of Station 2's… […]

• No harm, potential for more than minimal, widespreadF880Feb 3, 2025

  Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene and infection control practices were followed during CBG monitoring for 1 of 1 sampled resident (#22) reviewed for dialysis and failed to ensure enhanced barrier and transmission based precautions were followed for 1 of 1 facility reviewed for infection control precautions. This placed residents at risk for infections, communicable diseases and cross-contamination. Findings include: 1. The Lippincott Manual of Nursing Practice, 10th edition, Fundamentals of Standard Precautions for Hand Hygiene indicated hand hygiene is the single most recommended measure to reduce the risk of transmitting micro-organisms. […]