The Village Healthcare Center

actions that can be measured.

observation, interview, and record review, the facility failed to ensure a care plan was developed for

for the staff not to be aware of discharge plans for Resident A.Findings:On January 30, 2026, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate resident discharge.On January 30, 2026, at 12:10 p.m., an interview was conducted with Resident A.

Resident A stated she would like to be discharged to her home but is aware she is not ready and prefers to stay longer in the facility to work with the physical therapist. On January 30, 2026, Resident A's record was reviewed.

Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included aftercare for below knee amputation (removal of a limb).A review of Resident A's Minimum Data Set (MDS - a resident assessment tool), dated January 12, 2026, indicated a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact).A review of Resident A's Progress Notes, dated January 14, 2026, at 12:15 p.m., indicated discharge plans to home with home health services.A review of Resident A's Order Summary Report, included a physician's order, dated January 29, 2026, which indicated LCD (last covered date) 2/1/26 (February 1, 2026) discharge 2/2/26 (February 2, 2026) home (Resident A's address).Further review of Resident A's care plan indicated there was no care plan related to discharge plans to go home.On January 30, 2026, at 1:05 p.m., an interview was conducted with Social Services Assistant (SSA).

The SSA stated the Social Services Director (SSD) is responsible to in developing a care plan related to discharge plans.

The SSA stated care plan on discharge is important to help plan where the resident is going to be discharged and what care needs and resources the resident would need before and at discharge.On January 30, 2026, at 1:10 p.m., an interview was conducted with the Administrator (ADM).

The ADM stated discharge care plan should be initiated upon admission which included discharge plans and care needs.On January 30, 2026, at 1:15p.m., an interview was conducted with the Director of Nursing (DON).

The DON stated there was no care plan developed related to discharge plans for Resident A.

The DON stated social services should have initiated a care plan on admission for discharge planning.

The DON stated it is important to have a care plan in place to ensure proper care would be provided to the residents to reach the discharge plan goal.A review of the undated facility's policy and procedure titled, Transfer of Discharge Policy, indicated, .When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical records and appropriate information will be communicated to the receiving health care facility or provider.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE