Village Health & Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 28, 2025

  Based on interview and record review, the facility failed to ensure a resident was free from accidents for a resident who sustained a fall with pain resulting in a fracture, who was on a blood thinner; and failed to promptly notify the physician of a fall with pain resulting in a fracture impacting the physician's opportunity to determine if a higher level of care or treatment was necessary at the time of the fall for 1 (#85) of 34 sampled residents. This deficient practice contributed to delayed care, increased pain and a femur fracture.During an interview on 8/26/25 at 9:36 a.m., resident #85 explained that she was admitted to the facility in July after she developed complications from a right hip replacement. […]

• Actual harm, isolatedF689Aug 1, 2024

  Based on interview and record review, the facility failed to provide a safe environment for 1 (#90) of 36 sampled residents. This resulted in the resident falling and sustaining a significant injury. Findings include: Review of resident #90's EMR admission assessment, dated 2/3/2023, showed, .2. Fall Risks . 3. Requires use of assistive devices . 5. Impaired mobility/assist with toileting . 8. hx of falls in last month, 9. hx of falls in last 1-6 months . 4. Current fall preventative measures in place . 5. Frequent checks . 8. Call light within reach when in room . [sic] Review of resident #90's EMR nursing progress notes, dated 3/17/2024, showed, Nurse's Description: Heard CNA radio for help saying a resident is out of bed. […]

• Actual harm, isolatedF692Jul 7, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate nutrition to maintain a resident's desired body weight for 1 (#72), of 5 sampled residents. This deficient practice contributed to the resident having a severe weight loss of 22.6% in less than 6 months, and the resident was having swallowing difficulties and pain with swallowing. Findings include: During an interview and observation on 7/5/22 at 1:22 p.m., resident #72 was sitting in her wheelchair in her room. Her clothing appeared baggy and too large for her. Resident #72 stated she had lost a lot of weight because . her food gets stuck on the way down when she is trying to eat, and it hurts. She stated she does not really eat anything solid because it just gets stuck. […]

• No harm, potential for more than minimal, widespreadF812Aug 28, 2025

  Based on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions, staff failed to wear hair restraints in the kitchen area, and the facility failed to provide food at a safe and appetizing temperature for 4 (#s 6, 14,72, and 154) of 34 sampled residents. These deficient practices placed all residents who consumed meals prepared by the facility at risk of exposure to food-borne pathogens and or illness. Findings include:During an observation of the kitchen on 8/25/25 at 3:12 p.m., the following concerns were identified: - The juice dispenser had a sticky liquid on the dispenser nozzles, the front panel of the dispenser, and the backsplash.- The coffee dispenser had dried coffee on the front tray and on the dispenser nozzles.- A… […]

• No harm, potential for more than minimal, widespreadF880Apr 3, 2025

  Based on observation, interview, and record review, the facility staff failed to wear appropriate PPE while caring for residents for 2 (#s 3 and 16); and failed to educate and monitor staff on cleaning practices for residents positive for c-diff, for 2 (#s 14 and 17) of 17 sampled residents. The deficient practices increased the risk to others for contracting infections due to the deficient practices. Findings include: 1. During an observation on 4/1/25 at 12:14 p.m., 12 resident rooms were identified for special droplet/contact precautions, eight resident rooms were identified for enhanced barrier precautions, and three resident rooms were identified for contact precautions. Inspection of two PPE supply containers were found to have no N-95 masks available for use in the 300 hallway. […]