Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Creek Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities experienced two unwitnessed falls in one day. After the first fall, swelling on the resident's cheekbone was observed by a hospice nurse and a CNA, but this change in condition was not reported to the nurse or addressed by facility staff. The swelling was not treated or communicated to the family until after the resident was transferred to the hospital following a second fall.
A licensed pharmacist did not complete the required monthly drug regimen review, including the medical chart, and the facility did not follow its own irregularity reporting guidelines as outlined in policy.
A resident with multiple mental health diagnoses was prescribed daily Risperdal and Perphenazine, but staff failed to include or implement required side-effect monitoring orders for these antipsychotic medications. Despite facility policy and care plan directives, nursing and leadership staff confirmed that systematic monitoring for medication side effects was not in place.
A medication cart was found with one drawer unsecured at the nurse's station, allowing access to various prescription medications for residents. Despite the lock being in the secured position, the drawer containing multiple types of medications could be opened, contrary to facility policy and staff expectations that medication carts remain locked when not attended by authorized personnel.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests, as observed by surveyors.
A hospice aide was observed striking a non-verbal resident during a bed bath, leading to a deficiency in protecting the resident from abuse. The resident, who had severe cognitive impairments and was on hospice care, was heard screaming abnormally by a CNA, who witnessed the incident. The hospice aide was not the regular caregiver and denied the allegations, but staff noted the resident's unusual distress.
The facility failed to maintain accurate clinical records for two residents, one requiring dialysis and the other with diabetes. A resident's dialysis monitoring lacked physician orders, while another's elevated blood sugar levels were not properly documented as reported to the physician. Staff acknowledged these oversights, highlighting issues in following established protocols.
The facility failed to maintain a safe and comfortable environment for residents in three rooms due to broken window blinds, compromising privacy. Staff were aware of the issue but did not effectively report it, leading to inaction. The Maintenance Manager was unaware of the problem, and the Administrator acknowledged the ongoing challenge of maintaining blinds in the secure unit.
A facility failed to ensure accurate PASRR Level 1 Screening for a resident with mental illness diagnoses, including schizophrenia and bipolar disorder, at the time of admission. The MDS Coordinator did not notice the diagnoses, leading to an incorrect PASRR result that could risk the resident not receiving specialized services. The oversight was identified when the necessary Form 1012 was submitted.
A resident with cerebral palsy and dysphagia, dependent on a feeding tube, did not receive a required water flush before a bolus feeding, as per physician orders. LVN C admitted to forgetting the flush due to nervousness during observation. The DON emphasized the importance of flushing to ensure tube patency.
A facility failed to provide adequate post-dialysis care for a resident with chronic kidney disease, as required by professional standards and the resident's care plan. Despite attending dialysis sessions regularly, there was no documentation of post-dialysis assessments, including vital signs and access site conditions. Interviews with staff revealed inconsistencies in following the protocol, and the facility's policy emphasized the need for collaboration and documentation, which was not adhered to.
A facility failed to provide adequate privacy curtains in a room with three residents, lacking a curtain between two beds. Staff interviews confirmed the requirement for three curtains in such rooms, but the missing curtain was not reported. The Maintenance Manager, responsible for curtain maintenance, had not addressed the issue, and the facility's policy did not specify curtain requirements.
A resident with severe cognitive impairment and a history of falls was inadequately supervised, resulting in a fall from a wheelchair and subsequent injuries, including a subdural hematoma. The facility failed to document and investigate the incident promptly, delaying the identification of the resident's injuries.
Failure to Identify and Treat Facial Swelling After Fall
Penalty
Summary
A deficiency occurred when the facility failed to identify and treat swelling on a resident's cheekbone following a fall, despite the swelling being observed by both a hospice nurse and a CNA. The resident, who had multiple complex diagnoses including severe cognitive impairment, dementia, diabetes, and psychiatric disorders, experienced two unwitnessed falls on the same day. After the first fall, the resident was assessed by the assigned LVN, who reported no injuries or swelling. However, later that day, the hospice nurse documented periorbital swelling to the left side of the resident's face and discussed it with facility staff. The hospice nurse also took a photograph of the swelling and noted it in her records, but no new physician orders were issued regarding the swelling, and there was no documentation of follow-up care for this condition by facility staff. Interviews revealed that the hospice nurse pointed out the swelling to a CNA during a transfer, but the CNA did not ensure that the nurse was made aware of the swelling, assuming the hospice nurse would report it. The assigned LVN and other CNAs stated they did not observe or were not informed of any swelling, and the swelling was not reported to the nurse by the CNA. The resident's family was not notified of the swelling until after the resident was transferred to the hospital following a second fall later that night. Facility documentation and interviews confirmed that the swelling was not addressed or treated by the facility prior to the resident's hospital transfer. The facility's policy required prompt notification of changes in a resident's condition, including injuries, to the physician and family. Despite this, the swelling observed after the first fall was not communicated or treated according to professional standards or the resident's care plan. The lack of timely identification and intervention for the facial swelling resulted in delayed treatment for the resident.
Failure to Ensure Monthly Pharmacist Drug Regimen Review
Penalty
Summary
A licensed pharmacist did not perform a monthly drug regimen review, including a review of the medical chart, as required. The facility also failed to follow irregularity reporting guidelines as outlined in their developed policies and procedures. This deficiency was identified based on the lack of evidence that the pharmacist completed the required monthly review and that irregularities were reported according to established protocols.
Failure to Monitor for Antipsychotic Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications by not monitoring for side effects related to the use of antipsychotic medications Risperdal and Perphenazine. The resident, a male with diagnoses including anxiety disorder, depression, and schizophrenia, was receiving both medications daily as ordered. The care plan specified that staff should monitor and document for side effects and effectiveness of psychotropic medications, listing specific symptoms to observe. However, review of the resident's orders and interviews with nursing staff, the ADON, and the DON revealed that there was no order in place for side-effect monitoring for these antipsychotic medications, despite facility policy and staff training indicating that such monitoring should be included whenever these medications are prescribed. Nursing staff and facility leadership acknowledged during interviews that the side-effect monitoring order was missing and that it should have been added when the antipsychotic medications were initiated. The facility's policy on psychotherapeutic drug management also required that side effects be documented on the Medication Administration Record. The absence of a side-effect monitoring order meant that the resident was not being systematically monitored for adverse reactions to the antipsychotic medications, as required by both the care plan and facility policy.
Medication Cart Found Unsecured, Allowing Access to Prescription Drugs
Penalty
Summary
A deficiency occurred when Medication Cart #3, which was stored at the nurse's station, was found to have an unsecured drawer despite the lock being in the secured position. During an observation, it was discovered that drawer #2 of the cart could be opened while the other drawers remained locked. The unsecured drawer contained prescription medication cards for residents of the 200 Hall, including blood pressure medications, anti-viral medications, sleep medications, potassium pills, thyroid medications, diabetic medications, cardiac medications, and anti-nausea medications. RN A confirmed that the cart should always be secured when not in use to prevent unauthorized access. Further interviews revealed that the expectation was for medication carts to be locked when not attended by authorized staff. The DON stated that the risk of an unsecured cart was that residents could access medications not prescribed to them. The facility's policy required that medication carts and supplies be locked when not attended by authorized personnel. The deficiency was identified through observations, record reviews, and staff interviews, which confirmed that the cart was not properly secured as required.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on observations or findings that indicated the absence of such a program, which is necessary to maintain a sanitary environment for residents.
Failure to Protect Resident from Abuse by Hospice Aide
Penalty
Summary
The facility failed to protect a resident from abuse, specifically involving a hospice aide who was observed striking the resident. The incident occurred when a CNA heard the resident screaming louder than usual and went to check on her. Upon entering the room, the CNA witnessed the hospice aide performing a bed bath on the resident and striking her on the side while telling her to be quiet. The resident, who was non-verbal and had severe cognitive impairments, was unable to communicate the distress she was experiencing. The resident involved was an elderly female with multiple diagnoses, including cerebral palsy, non-Alzheimer's dementia, and seizure disorder. She was dependent on staff for all activities of daily living and had significant memory and communication impairments. At the time of the incident, the resident was on hospice care due to her cerebral palsy and required assistance with personal care. The hospice aide involved was not the regular aide assigned to the resident, and the resident's cries were noted to be abnormal by the staff who were familiar with her. The incident was immediately reported by the CNA to the nursing staff, and the hospice aide was asked to leave the facility. The resident was assessed for injuries, and although no marks were found, the staff noted redness on her side. The facility's policy on abuse prevention and prohibition emphasizes zero tolerance for abuse, and the incident was reported to the appropriate authorities. The hospice aide denied the allegations, claiming she was stabilizing the resident during care, but the staff's observations and the resident's unusual distress indicated otherwise.
Deficiencies in Clinical Record Maintenance for Dialysis and Diabetes Management
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in their care. For Resident #18, the facility did not obtain physician orders for monitoring the dialysis port site, vital signs, and documenting pre and post-dialysis vitals on the communication form. This oversight was acknowledged by LVN G, who admitted to not checking for the necessary orders despite knowing the protocol. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) also recognized the lack of orders and the potential risks associated with not monitoring the dialysis site, which could lead to infection or a failed shunt. For Resident #28, the facility failed to document when the physician was notified of blood sugar levels exceeding 250 mg/dL, as required by the resident's care plan. Despite multiple instances of elevated blood sugar readings, documentation showed that the physician was only notified once. LVN F, responsible for Resident #28, admitted to not documenting the notifications, acknowledging it as poor nursing practice. The DON confirmed that the blood sugar parameters had been recently changed and emphasized the importance of documenting physician notifications in the resident's progress notes. The facility's policy on physician orders, dated June 2020, outlines the procedures for ensuring complete and accurate orders, including the responsibility of licensed nurses to document and implement orders. However, the failure to adhere to these procedures resulted in incomplete and inaccurately documented medical records for the residents, potentially impacting their treatment and care.
Deficiency in Maintaining Privacy Due to Broken Window Blinds
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in three rooms, specifically rooms 302, 308, and 310, where window blinds were broken and missing several slats. This deficiency was identified through observations, interviews, and record reviews. The broken blinds compromised the residents' privacy, making them feel insecure or uncomfortable in their rooms. During an observation on July 9, 2024, the broken blinds were noted, and further interviews with staff confirmed awareness of the issue. CNA D, who had been employed for four weeks, reported the broken blinds to the charge nurse but could not recall how long they had been broken. LVN E, assigned to the secure unit, also noticed the broken blinds and reported them in the maintenance logbook about two weeks prior, but no action had been taken. The Maintenance Manager stated that he had not received any requests to replace the blinds and expected staff to report such issues. The Administrator acknowledged the ongoing issue with blinds being broken by residents and emphasized the responsibility of staff to report and the Maintenance Manager to replace them. The facility's policies on privacy, dignity, and environment were reviewed, highlighting the importance of maintaining a homelike environment.
Inaccurate PASRR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a new resident was not admitted with a mental disorder without the appropriate determination from the state mental health authority. Specifically, the MDS Coordinator did not ensure that the PASRR Level 1 Screening for a resident was accurate regarding their mental illness diagnoses at the time of admission. The resident, a male with diagnoses of paranoid schizophrenia, bipolar disorder, and post-traumatic stress disorder, was admitted with a PASRR Level 1 Screening that incorrectly indicated no evidence of mental illness. This oversight could potentially place residents at risk of not receiving necessary specialized services. The MDS Coordinator admitted to entering the PASRR information without noticing the resident's mental illness diagnoses, which should have prompted a referral for another PASRR Level 1 evaluation. The facility's policy requires notification of the state-designated mental health authority if a resident with a mental disorder experiences a significant change in status. Interviews with the MDS Coordinator, DON, and Regional MDS Nurse revealed that the MDS Coordinator was responsible for reviewing PASRR Level 1 Screenings, while the Regional MDS Nurse oversaw the MDS Coordinator's work. The deficiency was identified when the MDS Coordinator submitted the necessary Form 1012 for the resident on the day of the interview.
Failure to Flush Feeding Tube Before Bolus Feeding
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received appropriate treatment and services to prevent complications. Specifically, LVN C did not flush Resident #48's g-tube with 60cc of water before administering a bolus feeding, as ordered by the physician. This oversight was observed during a tube feeding procedure, where LVN C checked the feeding tube for residuals, poured the formula, and administered medications without initially flushing the tube with water. Resident #48 is a female with cerebral palsy, quadriplegia, seizure disorder, and dysphagia, requiring a feeding tube. Her care plan indicated she was dependent on staff for tube feeding and water flushes. The facility's policy required flushing the feeding tube to ensure patency and prevent clogs. LVN C later acknowledged forgetting to perform the initial flush due to nervousness from being observed. The DON confirmed the importance of flushing the tube to maintain its patency.
Failure to Provide Adequate Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate post-dialysis care, consistent with professional standards and the resident's care plan. The resident, a female with acute kidney failure and chronic kidney disease stage 4, attended dialysis sessions three times a week. Despite the care plan's directives to monitor and document post-dialysis assessments, including vital signs and access site conditions, there was no nursing documentation of these assessments in the resident's electronic health record. Interviews with facility staff revealed inconsistencies in following the protocol for post-dialysis care. A Licensed Vocational Nurse (LVN) acknowledged the responsibility to monitor the dialysis access site and vital signs but admitted to not consistently performing these tasks. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that it was expected for nurses to complete post-dialysis assessments and document them on the dialysis communication forms. However, the ADON noted that some forms were missing documentation, despite instructing nurses to complete them. The facility's policy on dialysis care emphasized collaboration between nursing staff, dialysis providers, and physicians, including the documentation of dialysis services in the resident's medical record. Despite training sessions on the dialysis communication form, the facility failed to ensure compliance with these protocols, leading to a deficiency in providing adequate post-dialysis care for the resident.
Deficiency in Privacy Curtain Provision
Penalty
Summary
The facility failed to ensure that resident bedrooms were equipped to provide full visual privacy, specifically in a room occupied by three residents where only two privacy curtains were present. This deficiency was observed during a survey on July 9, 2024, when it was noted that there was no privacy curtain between A bed and B bed in a triple-occupied room. Interviews with staff, including a CNA and an LVN, confirmed that rooms with three residents should have three privacy curtains to ensure privacy and dignity. However, the missing curtain had not been reported or addressed by the staff. Further interviews revealed that the Maintenance Manager was responsible for ensuring the presence of privacy curtains and that they are removed and cleaned monthly. Despite this, the missing curtain had not been reported, and the Maintenance Manager had not removed any curtains from the relevant hall. The facility's policy on privacy and dignity, dated June 2020, emphasized the importance of maintaining privacy and dignity but did not specifically address the requirement for privacy curtains. The Administrator acknowledged the need for privacy curtains between each bed in rooms with multiple residents.
Inadequate Supervision and Documentation Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for a resident, who was under hospice care with a primary diagnosis of senile degeneration of the brain and a history of cerebral infarction, among other conditions. The resident, who had severe cognitive impairment and required moderate assistance with activities of daily living, was at increased risk for falls due to impaired cognition, Alzheimer's, impaired mobility, and impaired safety awareness. Despite these risks, the facility did not provide sufficient supervision, leading to an incident where the resident sustained contusions and bruises to the left side of the face and left eye after sliding out of a wheelchair. On the day of the incident, the resident was observed sliding out of the wheelchair in the TV room, but the licensed vocational nurse (LVN A) failed to initiate and document an investigation as per the facility's Fall Management Program. The resident was assisted back into the wheelchair and then to bed without a proper assessment for injuries. The following day, the resident was diagnosed with a subdural hematoma and admitted to the hospital. The facility's failure to document and investigate the incident promptly contributed to the delay in identifying the severity of the resident's injuries. Interviews with staff revealed that there was confusion about whether the resident's behavior constituted a fall, leading to inadequate documentation and response. The Director of Nursing (DON) was unaware of the incident until the family requested the resident be sent to the hospital. The lack of immediate and appropriate action following the incident placed the resident at considerable risk of serious injury, harm, and impairment.
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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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