Village Healthcare and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 5, 2025

  Based on observations, interviews, and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance while providing care for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed when CNA B did not provide Resident #1 adequate supervision while providing incontinent care on [DATE] at around 11:50 AM, which led to Resident #1 falling from his bed, resulting in a traumatic intracranial hemorrhage (brain bleed). The non-compliance was identified as past non-compliance. The Immediate jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF600Apr 10, 2025

  Based on interview and record reviews the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 10 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse. CNA A attempted to provide Resident #1 care at bed side by herself knowing that Resident #1 required two person assistance for all activities, which lead to Resident #1 falling off the bed and sustaining a right humerus fracture. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/06/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. […]

• Immediate jeopardy, isolatedF689Apr 10, 2025

  Based on interviews and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance when being transferred for 1 of 10 residents (Resident #1) reviewed for accidents and hazards. The facility failed to provide adequate supervision to prevent Resident #1 from falling from bed, fracturing her right humerus. The non-compliance was identified as past non-compliance. The Immediate threat began on 11/06/24 and ended on 11/13/24. The facility had corrected the noncompliance before the survey began. […]

• No harm, potential for more than minimal, patternF627Nov 5, 2025

  Based on interview and record review, the facility failed to ensure there was a valid reason for discharge and a resident's physician order for discharge was documented when a discharge was conducted for four Residents (R #4, R #5, R #6, and R #7) of seven Residents whose discharge orders were reviewed, in that: The facilty failed to document a reason for discharge and a physician's discharge order for Resident's #4, #5, #6, and #7 prior to discharge. This failure could place residents at risk of diminished continuity of care and unsafe and/or improper discharges. […]

• No harm, potential for more than minimal, patternF628Nov 5, 2025

  Based on record review and interview, the facility failed to provide and document sufficient preparation and orientation of resident representative to ensure safe and orderly transfers or discharges from the facility for 5 of 5 residents (Resident #2, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for transfer and discharge. The facility failed to notify the residents and their responsible parties of the transfers or discharges with the reasons for the move in writing in a language and manner they understand. This failure placed residents at risk of not receiving an advocate who could inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .The findings included: 1. […]