Village Place Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 11, 2025

  Based on record review, review of facility's policies and procedures, and staff interviews, the facility failed to protect residents' rights to be free from neglect by failing to follow established processes to document and report a resident's fall to ensure timely and appropriate post-fall evaluation for 1 (Resident #900) of 3 residents reviewed. Resident #900 had severe cognitive impairment and required substantial to maximal assistance with activities of daily living, including transfers. On 4/17/25 at 7:30 p.m., Resident #900 was found on the floor in his room. The licensed nurse on duty failed to document the fall, failed to evaluate the resident for injuries such as fractures, and failed to notify the Director of Nursing or physician of the fall. […]

• Immediate jeopardy, isolatedF689Jun 11, 2025

  Based on record review, review of facility's policy and procedure, and staff interviews the facility failed to protect 1 (Resident #900) of 3 residents reviewed from avoidable falls and fall related serious injuries by failing to ensure an effective system was in place to consistently document, report and follow up on residents' falls. Resident #900 was admitted to the facility on [DATE] with a history of falls resulting in hospitalization. Resident #900's cognition was severely impaired. On 4/17/25 at 7:30 p.m., Resident #900 was found on the floor in his room. The facility failed to evaluate Resident #900 after the fall, failed to document the fall in the clinical record, and failed to notify the physician and Director of Nursing for post-fall assessment. […]

• Immediate jeopardy, isolatedF726Jun 11, 2025

  Based on record review, review of facility's policy and procedures and staff interviews the facility failed ensure nursing staff had the appropriate skills set, competencies and oversight to provide safe nursing care and meet the needs of 1(Resident #900) of 3 residents reviewed for falls. Resident #900 was admitted to the facility on [DATE] after a fall resulting in hospitalization. Resident #900's cognitive skills for daily decision making were severely impaired. The resident was rarely understood. On 4/17/25 Resident #900 was found on the floor in his room. […]

• Immediate jeopardy, isolatedF835Jun 11, 2025

  Based on record review, staff interviews and review of facility policy and procedure the facility administration failed to utilize its resources effectively to prevent the neglect of 1 (Resident #900) of 3 sampled residents and maintain oversight to ensure nursing staff competency to deliver safe nursing care and related services. Resident #900 was admitted to the facility on [DATE]. Resident #900's cognition was severely impaired. Resident #900 was dependent on staff for activities of daily living. On 4/17/25 Resident #900 was found on the floor in his room. The fall was not documented in the clinical record. […]

• No harm, potential for more than minimal, patternF602Jun 11, 2025

  Based on record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to implement processes to prevent the misappropriation of residents' medications for 4 (Residents #8, #1, #10, and #22) of 4 residents reviewed. The findings included: Review of the facility's policy titled, Abuse Prevention Program revised December 2016 revealed, Our residents have the right to be free from . misappropriation of resident property . Review of the facility's policy titled, Controlled Substances revised December 2012 revealed, Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. […]