Inspection Reports for Village Healthcare and Rehabilitation

The complaint investigation revealed failures in discharge documentation and notification processes affecting multiple residents, including lack of physician discharge orders, absence of documented reasons for discharge, and failure to provide written notices to residents and their representatives. Family members reported not being informed timely or given written discharge paperwork.

The facility failed to document valid reasons and physician orders for discharge for four residents and failed to provide sufficient preparation, orientation, and written notification to residents and their representatives regarding transfers or discharges for five residents. These failures placed residents at risk of diminished continuity of care, unsafe discharges, and lack of advocacy.

The complaint investigation found that CNA B did not provide adequate supervision to Resident #1 during incontinent care, leading to a fall. The fall was witnessed, and Resident #1 sustained serious injuries including a traumatic intracranial hemorrhage. The facility corrected the issue before the survey and provided in-service training to staff on falls, safety, abuse/neglect, and care procedures.

The facility failed to ensure adequate supervision of Resident #1 during care, leading to a fall and serious injury. The investigation included interviews, record reviews, and observations, confirming the fall was witnessed and related to inadequate supervision. The facility corrected the noncompliance before the survey began and implemented staff in-services and monitoring.

The complaint investigation focused on Resident #2's case where the facility did not initiate NFSS within 20 business days after the IDT meeting on 5/17/2024. The HHSC PASSR Unit Program Specialist confirmed the facility was out of compliance with Texas Administrative Code §554.2704(i)(7). Interviews with facility staff including the Director of Nursing, Director of Rehabilitation, MDS coordinator, and Administrator revealed communication and procedural issues contributing to the delay. The facility provided a loaner customized wheelchair during the delay. The new DOR initiated an IDT meeting scheduled for 4/11/2025 to address continuation of therapy and wheelchair services.

The facility failed to incorporate recommendations from the PASRR Level II determination and evaluation report for Resident #2 and did not initiate NFSS within the required 20 business days after the IDT meeting. This delay could cause residents with mental health disorders or psychiatric conditions to experience delays or lack of needed specialized services or equipment. Interviews and record reviews confirmed the failure to submit the NFSS request timely, with explanations involving staff transitions and communication gaps.

The complaint investigation was substantiated with findings of abuse and neglect related to Resident #1's fall and injury, failure to initiate PASRR services timely for Resident #2, inappropriate antipsychotic medication use for Resident #78, expired insulin storage, and infection control breaches during incontinent care for Resident #63.

The facility failed to protect residents from abuse and neglect, specifically Resident #1 who fell and fractured her right humerus due to inadequate assistance. The facility also failed to initiate PASRR specialized services timely for Resident #2, improperly prescribed antipsychotic medication without appropriate diagnosis for Resident #78, failed to discard expired insulin in medication carts, and failed to follow proper infection control practices during incontinent care for Resident #63.

The complaint investigation found that Resident #1 had an unwitnessed fall on 01/30/2025 resulting in right rib fractures, but the fall was not initially coded as a major injury in the MDS. The facility reported the fall to HHSC on 01/31/2025 and conducted in-services on abuse, neglect, and falls. The MDS was later corrected after hospital documentation was reviewed.

The facility failed to ensure Resident #1 was coded in the MDS for a fall with major injury on 01/30/2025, which could place residents at risk of receiving inadequate care. Interviews and record reviews confirmed the fall occurred with a major injury (right rib fracture), but the MDS initially did not reflect this injury accurately.

The visit was complaint-related due to concerns about inaccurate medical record documentation. Staff A admitted to documentation errors under stress but stated no negative outcomes occurred. The Director of Nursing confirmed the errors and stated no physician notification or change of condition was made because the errors were documentation mistakes.

The facility failed to accurately document blood sugar levels for two residents on specified dates, resulting in documentation errors that could potentially place residents at risk. Staff admitted to mistakes in recording blood sugar levels but reported no negative outcomes due to these errors.

The complaint investigation focused on issues related to care planning for drug use, fall prevention and supervision, and oxygen therapy administration. The investigation found substantiated deficiencies in these areas affecting multiple residents.

The facility failed to develop and implement a comprehensive care plan for recreational drug use for Resident #10, failed to provide adequate supervision and interventions to prevent repeated falls for Resident #4, and failed to administer oxygen at physician-ordered levels for Residents #1, #2, and #3. These failures posed risks of inadequate care and potential harm to residents.

The complaint investigation was substantiated based on findings that the facility staff failed to ensure residents received treatment and care in accordance with professional standards, resulting in delayed medical treatment for Resident #1.

The facility failed to document, monitor, and assess Resident #1's abnormal skin discoloration prior to and upon return from an outing, resulting in delayed identification of spiral angulated fractures. Staff interviews revealed lack of documentation and incomplete assessments, with the Director of Nursing acknowledging documentation lapses.

The complaint investigation found that Resident #22 eloped from the facility on 11/8/2022 at 11:13 PM, was missing for 19 minutes, and was found safe after being transferred to the ER. The resident had expressed pain and distress prior to elopement and reported staff were not responsive. The resident used a visible keypad code to exit the front door. The responsible party had previously expressed concern about the resident's risk of elopement but had not informed staff.

The facility failed to implement interventions to prevent Resident #22, who had severe cognitive impairment and was at risk for elopement, from leaving the facility. The resident exited through a front door secured by a keypad code that was visible and accessible. Staff were unaware of the resident's exit until after the fact. No injuries occurred, but the incident posed a serious risk of harm. The facility lacked policies on elopement prevention beyond admission risk evaluation.