Village Square Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812May 15, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff covered their facial hair during meal preparation, cold food items were held on the tray line at temperature of 41 degrees Fahrenheit (F) or below, expired food items were discarded, and items in the walk-in freezer were stored in a manner to prevent freezer burn. These deficient practices had the potential to affect all residents who received food from the kitchen. Findings included: 1. A facility policy titled, Personal Hygiene dated 2018, indicated, 6. Beards and or mustaches should be covered during meal preparation and service. During an observation on 05/12/2025 at 8:55 AM, [NAME] #3 prepared fish with his facial hair uncovered. […]

• No harm, potential for more than minimal, widespreadF880Jan 12, 2022

  Based on observation, interview, and record review, the facility failed to protect 95 of 95 residents from the spread of COVID-19 infection when: 1. The staff and visitors who entered the facility did not wear and follow the Transmission Based Precaution's (TBP) required Personal Protective Equipment (PPE) for the yellow zone (an area where residents who were exposed and who were showing symptoms were placed) that included N95 (respirator) masks and face shields consistently. In addition, staff and visitors did not wear the TBP's required PPE for droplet and contact isolation when inside the resident's room (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]). 2. […]

• No harm, potential for more than minimal, widespreadF867Mar 4, 2021

  Based on interview and review of facility documentation, the Quality Assurance and Performance Improvement (QAPI) committee failed to identify quality deficiencies related to the facility's Infection Control program and take corrective action to assure that pneumonia vaccinations were offered and provided in accordance with recognized national standards. This failure had the potential to affect all 86 residents who currently live in the facility (please refer to F883). Findings: On 3/3/21 at 2:40 P.M., a concurrent interview and document review was conducted with the facility's Director of Nursing (DON). The DON presented a document titled Pneumonia dated 4/00. The DON stated the document was the facility's current pneumonia vaccine policy. Under section Procedure the policy indicated, 2. […]

• No harm, potential for more than minimal, widespreadF883Mar 4, 2021

  Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer 25 of 25 residents reviewed for pneumonia vaccinations (Resident (R) R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R 18.R19, R20, R21, R22, R23, R24, R25 and R26) and/or their representatives, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer residents the opportunity to be vaccinated with PCV13 (type of pneumococcal vaccine) in accordance with CDC guidelines. […]

• No harm, potential for more than minimal, patternF755Feb 5, 2026

  Based on interview and record review, the facility failed to ensure residents' controlled medications (medications that can cause physical and mental dependence and are regulated by the Drug Enforcement Administration) were secured in the facility's medication carts. Specifically, controlled substances, including Individual Patient's Narcotic Records (IPNR), were removed from the cart without the licensed nurses' (LNs) knowledge and were left unaccounted for 10 of 10 residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). This had the potential for affected residents' medication to not being available in the event they were needed. There were no missed doses for the affected residents.Findings:On 12/12/25, the Department received a facility report incident related to pharmaceutical services. […]