Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Village Green Health And Rehabilitation during CMS and state inspections, most recent first.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
A resident with moderate dementia and a history of mood and behavioral issues repeatedly directed homophobic and sexually explicit slurs toward another cognitively intact resident, often in common areas and from the hallway outside the other resident’s room. Staff and another resident reported that these incidents occurred multiple times per week, and that the aggressive resident was difficult to redirect. Despite adding a general care plan problem for conflicts with peers and staff, the facility did not develop or document individualized, person-centered interventions specifically addressing the ongoing, targeted verbal abuse toward the other resident, and nursing and social service notes did not reflect the frequency or pattern of these behaviors.
Staff failed to document a resident’s acute gastrointestinal symptoms and PRN medication administration, resulting in an incomplete medical record. One nurse reported the resident had an episode of vomiting undigested food and was given ginger ale and soup, but this event and care were not recorded. On another shift, a different nurse stated the resident complained of gas and stomach pain and was given PRN Milk of Magnesia per a standing order, yet this medication administration was also not documented. The MD and DON acknowledged that clinical symptoms and PRN treatments should have been charted and confirmed that these entries were missing from the record.
The facility failed to date and seal opened food items in storage areas, including freezers and dry storage, and improperly stored a bowl in a bin of breadcrumbs. The Dietary Manager noted staff might have been too rushed to label items, but expected proper sealing and labeling. The Administrator also emphasized the need for labeling and appropriate storage.
A resident with dementia required daily stimulation as per her care plan, which included having her television and lights on by 10:00 AM. Observations showed these interventions were not implemented, and staff interviews revealed a lack of awareness and communication regarding the care plan. The care plan instructions were not included on the resident's care card, leading to the deficiency.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Failure to Implement Person-Centered Care Plan for Dementia-Related Targeted Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized, person-centered care plan approaches for a resident with dementia who exhibited a known pattern of targeted verbal behaviors toward another resident. Resident #8 was admitted with early onset Alzheimer’s disease, dementia, major depressive disorder, and a history of stroke, and was assessed as moderately cognitively impaired. His care plan was updated to include a problem of frequent conflicts with peers and staff, including cursing and yelling at his roommate and unprovoked expressions of anger, with general interventions such as staff intervening when inappropriate behaviors were observed, reminding him to communicate anger without being verbally aggressive, and referring him to psychiatry. Despite these care plan approaches, the facility did not create specific interventions addressing his ongoing, targeted derogatory name-calling toward Resident #9. Over time, staff and residents reported that Resident #8 repeatedly directed slurs and sexually explicit, derogatory language at Resident #9, often in common areas and from the hallway outside Resident #9’s room. On one documented occasion, a nurse noted that a nurse aide overheard Resident #8 cursing and yelling at another resident and redirected him away from that resident’s doorway; the targeted resident reported that the incident was unprovoked and that this type of behavior had occurred previously. In interviews, Resident #9 described that after initially thinking Resident #8 was “cool,” Resident #8 began calling him derogatory names almost daily when they were both outside their rooms, and two to three times a month from the doorway of his room, using terms such as “ole faggot,” “ole bitch,” and sexually explicit threats. Another cognitively intact resident corroborated that he had witnessed Resident #8 calling Resident #9 a “faggot” for no apparent reason. Multiple staff interviews confirmed that these behaviors were recurrent and directed specifically at Resident #9. Nurse aides and nursing staff reported that Resident #8 frequently called Resident #9 a “faggot” and threatened to beat him, that such incidents occurred multiple times per week in the dining/activity room, and that redirection was difficult because Resident #8 became angry when redirected. Staff also reported that Resident #8 had previously directed derogatory remarks at another resident but had shifted his focus to Resident #9. The social worker acknowledged that Resident #9 had reported being stared at and subjected to negative and sexual remarks by Resident #8 and that nurse aides were supposed to redirect Resident #8 and keep the residents separated, but she did not document these reports. The care plan nurse stated that the care plan had not been revised to specifically address Resident #8’s targeted verbal behaviors toward Resident #9, and the active care plan contained no problem or interventions related to this known pattern of derogatory name-calling. The psychiatric NP and medical director were not fully informed of the frequency and targeted nature of the behaviors, and the administrator confirmed there was no documentation that Resident #9 had provoked Resident #8. As a result, the facility continued to rely on ineffective, generalized behavior interventions and failed to implement individualized strategies to manage Resident #8’s dementia-related verbal behaviors toward Resident #9. The facility’s documentation and communication practices contributed to the deficiency. Nursing and social service notes for the months surrounding the incidents contained minimal entries about Resident #8’s behaviors toward Resident #9, despite multiple staff and resident accounts of frequent episodes. The psychiatric NP noted only one documented incident in the record and was not made aware that the derogatory language was occurring more often than charted or that it was specifically targeted at Resident #9. The social worker did not create written notes to track the timing and frequency of Resident #9’s complaints, and the DON was not aware of the specific details of the targeted verbal abuse. Although staff reported that one-on-one supervision had been used for Resident #8 in the past, there was no clear documentation of why it was initiated or discontinued, and no corresponding care plan revisions were made to address the ongoing pattern of verbal aggression toward Resident #9.
Failure to Document Acute Symptoms and PRN Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident experiencing acute medical symptoms and receiving PRN medication. A nurse reported that, a couple of days prior to 2/3/26, the resident vomited undigested food. She assisted with cleaning the resident and provided ginger ale and soup for supper, and recalled no further complaints or vomiting after that single episode. However, review of the resident’s record showed no documentation of this vomiting episode or the care provided at that time. On a separate shift, another nurse reported that during the night shift spanning 2/2/26 to 2/3/26, the resident complained of gas and stomach pain. The nurse stated she administered Milk of Magnesia under a standing PRN order but did not recall the exact time. Record review revealed no documentation of the administration of this PRN medication. The Medical Director stated that staff should document clinical symptoms and any treatment rendered, as this information is used when providers review acute illnesses. The DON confirmed that the vomiting episode and the PRN medication administration were not documented, leaving the resident’s medical record incomplete.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to properly date and seal opened food items in various storage areas, including a reach-in freezer, a walk-in freezer, and a dry goods storage area. Observations revealed that several food items, such as slider buns, pork loin, and pulled chicken, were not labeled with dates, and a box of pre-cooked egg patties was left open to air without a date. Additionally, an opened package of devil's food cake mix was found without a date in the dry storage area. These practices were observed during a kitchen inspection and were confirmed by the Dietary Manager, who acknowledged that staff might have been moving too quickly to properly label and seal food items. Furthermore, a black bowl was found inside a bin of breadcrumbs in the dry ingredient storage area, which the Dietary Manager admitted was likely being used as a scoop, contrary to proper storage practices. The Dietary Manager explained that staff might forget to label items during busy meal times, but it was her expectation that all opened food items be sealed and labeled with the name, date opened, and expiration date. The Administrator also stated that opened food items should be labeled with the date opened and a use-by date, and if they cannot be stored appropriately, they should be discarded.
Failure to Implement Resident's Activity Intervention
Penalty
Summary
The facility failed to implement an activity intervention on the comprehensive care plan for a resident diagnosed with dementia. The resident was admitted with severe cognitive impairment and required daily stimulation, as noted in her care plan, which included having her television and lights on by 10:00 AM each day. However, observations over several days revealed that the television and lights were not turned on, and the window blinds were often closed, leaving the resident lying in bed with her eyes open. Interviews with the resident's family and staff indicated a lack of awareness and communication regarding the care plan's requirements. The care plan's instructions were not included on the resident's care card, which is used by nursing assistants to track daily tasks. Both Nurse Assistants interviewed were unaware of any such instructions, and the Activity Director was also not informed of the care plan's requirements. The Activity Director stated that the former Social Service Worker was responsible for creating the care plan and should have ensured the information was communicated to the nursing staff. The Administrator confirmed that the Activity Director should have been aware of the care plan and that the information should have been placed on the care card.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fayetteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haymount Rehabilitation & Nursing Center, Inc. | 2 mi | ★★★★★ | 0 | 0 |
| The Carrolton Of Fayetteville | 2.2 mi | ★★★★★ | 4 | 0 |
| Carolina Rehab Center Of Cumberland | 3.2 mi | ★★★★★ | 11 | 0 |
| Woodlands Nursing & Rehabilitation Center | 3.3 mi | ★★★★★ | 0 | 0 |
| Highland House Rehabilitation And Healthcare | 3.4 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.