Village Green Rehabilitation And Healthcare Center
VILLAGE GREEN REHABILITATION AND HEALTHCARE CENTER in BRISTOL, CT — inspection on March 12, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During that moment Resident #124's legs started falling off the side of disputing this citation. the bed and gravity took over and Resident #124 fell out of bed. RN #6 further identified Resident #124 used enable rails to assist with positioning and normally would have been able to assist with positioning.
An interview with the Director of Nursing Services (DNS) on 3/11/25 at 10:58 AM identified NA #9 was at the top of the bed between the wall and head of bed completing a bed change for Resident #124 when s/he observed Resident #124 moving around a lot and in questionable distress.
The DNS identified the root cause of the fall was NA #9 not calling for help when Resident #124 began moving around and showing questionable signs of distress and being unable to intervene when his/her legs began to fall off the side of the bed while focusing her attention on oxygen equipment.
Education was subsequently provided to stop and call for the nurse for a questionable change of condition.
An interview with the Medical Director on 3/11/25 at 12:09 PM identified the nurse aide should have called for help for any change of condition and focused on the resident while providing care.
An interview with the Director of Rehabilitation on 3/14/25 at 10:19 AM identified while Resident #124 could normally assist with positioning side to side with the use of enabler bars, any change of condition could compromise h/her ability to do so.
The nurse aides should be calling for help if a resident was experiencing a questionable change of condition.
Additionally, the Director of Rehabilitation indicated the nurse 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. NA #9 would not have been able to effectively intervene to prevent a fall if she was at the head of the bed.
Although requested, a policy for nurse aide reporting of a change of condition was not provided.
Attempts to interview NA #9, who is no longer employed at the facility, were unsuccessful.
2. A review of the facility smoking list identified (4) residents, Resident # 16, Resident #18, Resident #41 and Resident #125 actively smoked.
An observation on 3/11/25 at 9:04 AM identified a canopy set up in the designated smoking area.
The top of the canopy cover was made up of cloth like material.
The label directed to keep away from all flames.
An interview with the Director of Maintenance on 3/11/25 at 9:14 AM identified the canopy was placed the evening before as a replacement to the previous canopy damaged in the storm.
The canopy was subsequently removed after surveyor inquiry with a plan to research adequate accommodations for the designated smoking area.
075198
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 075198 B.
Wing 03/12/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Village Green Rehabilitation and Healthcare Center 23 Fair Street Bristol, CT 06010
F-F686 Based on clinical record review interviews and facility policy for 1 of 6 Residents reviewed for Pressure ulcer (#24), the facility failed to ensure staff completed weekly skin checks consistently, completed skin risk assessments quarterly or with change of condition and documented notification of the physician and responsible party with a new change in skin status.
The findings include:
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