The June 14 incident at Village Green Rehabilitation and Healthcare Center involved a resident with a history of stroke, seizure disorder, and tracheostomy who had just started having the breathing tube capped during daytime hours. Federal inspectors found the facility failed to ensure staff called for help when residents showed signs of distress.
Nursing aide NA #9 was completing a bed change when the resident "started to flop around a lot," according to facility reports. Instead of calling for assistance, the aide left the bedside to check if the resident was receiving oxygen on the opposite side of the bed. During that moment, the resident's legs began falling off the side and "gravity took over," causing the resident to fall flat on their face.
The resident sustained a "severe comminuted fracture of the right maxillary sinus and orbital floor fracture and corneal abrasion," according to CT scan results. Two sutures were required for the right lower eyelid laceration.
RN #6, the nursing supervisor on duty, told inspectors the resident was "new to having the trach capped and started moving around a lot in bed" during the bed change. The aide "was on the other side of the bed" and "left the side of the bed to check the resident's oxygen on the opposite side."
The resident normally used enabler rails to assist with positioning and "would have been able to assist with positioning," RN #6 said. But any change of condition could compromise that ability.
Director of Nursing Services identified the root cause as the aide "not calling for help when the resident began moving around and showing questionable signs of distress." The DNS said education was subsequently provided to staff about stopping care and calling for the nurse when residents show questionable changes in condition.
The Medical Director confirmed that "the nurse aide should have called for help for any change of condition and focused on the resident while providing care."
The Director of Rehabilitation noted that aides "should not be at the head of the bed between the wall and bed when providing care and instead at the side of the bed." From the head position, "NA #9 would not have been able to effectively intervene to prevent a fall."
The facility revised the resident's care plan to require two staff members for care, with education provided to "suspend care if resident anxious or agitated and to ensure the resident is calm before continuing with care."
NA #9 is no longer employed at the facility. Inspectors were unable to interview the aide about the incident.
The facility also failed to maintain proper safety equipment in its designated smoking area. Inspectors found a canopy with cloth material labeled "keep away from all flames" covering the area where four residents actively smoked.
The Director of Maintenance said the canopy was placed "the evening before as a replacement to the previous canopy damaged in the storm." After inspectors questioned the safety, the canopy was removed with plans to "research adequate accommodations for the designated smoking area."
Manufacturer guidelines for the canopy directed users to "keep all flame and heat sources away from the tent fabric" because "the tent may burn if left in continuous contact with any flame source."
In separate violations, inspectors found the facility failed to update care plans when residents developed pressure ulcers and failed to ensure proper infection control protocols were followed.
One resident developed a stage 1 heel pressure ulcer, but the care plan was never updated to reflect the new condition. The wound nurse told inspectors that when the facility changed ownership from Genesis to Atlas, "assessments are not auto-populated" and "we do not miss them."
The MDS coordinator confirmed that pressure ulcer risk assessments were no longer automatically scheduled since the ownership change. "When we were Genesis we did auto populate but we do not now," the coordinator said.
For infection control, staff failed to follow Enhanced Barrier Precaution guidelines for residents with open wounds. One resident with a foot lesion had no signage on the door indicating special precautions were needed. The wound care nurse entered the room without proper protective equipment.
When asked if residents with open wounds should be on Enhanced Barrier Precautions, RN #2 said "I don't know. I only work here every other Sunday." The wound care nurse also said "I do not know I didn't think so."
After inspectors raised the issue, signage appeared on the resident's door and the wound nurse confirmed "he should have been on EBP and he hasn't been."
Similarly, another resident with a gastrostomy tube was on Enhanced Barrier Precautions, but the signage was blocked by an open supply box. During a dressing change observation, the nurse failed to wear a gown as required by the facility's infection control policy.
The facility also failed to ensure call bells were within reach of residents who needed them. Inspectors found one ventilator-dependent resident with the call bell on a tray table two feet away, despite the resident being unable to move their arms up. The resident was observed "mouthing words and asked the surveyor for pain medication."
Another ventilator-dependent resident had their call bell on the floor next to the bed. When staff clipped it to the sheets and asked the resident to test it, the resident "was unable to push the button fully to activate the call bell" due to limited hand strength.
The nursing aide suggested the resident "might benefit from a blue call bell, which is an adaptive call bell that is easier to push."
Additional violations included failure to complete annual competency evaluations for nursing aides, improper medication orders that didn't specify treatment locations, and disorganized emergency respiratory equipment that was blocked by wheelchairs and supply boxes.
The facility is disputing several of the citations related to the fall incident and tube feeding protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Village Green Rehabilitation and Healthcare Center from 2025-03-12 including all violations, facility responses, and corrective action plans.
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