Village Health & Rehabilitation

Based on interview and record review, the facility failed to submit investigation findings for an incident in a timely manner, to the State Survey Agency, for 2 (#s 5 and 6) of 9 sampled residents.

Findings include: A review of a facility-reported incident, submitted to the State Survey Agency on 9/4/25, involving a resident-to-resident interaction for residents #'s 5 and 6, showed the facility's investigation findings were submitted on 9/12/25 and were due by 9/11/25.

During an interview on 11/19/25 at 10:30 a.m., staff member B stated a resident-to-resident incident was to be reported to the State Survey Agency with 24 hours, and the facility investigation findings were to be submitted within five days, not including weekends and holidays.A review of a facility policy, titled Incidents and Accidents, with a last reviewed date of 10/27/25, showed:Policy:It is the policy of this facility for staff to utilize the facility on-line risk management system to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Policy Explanation: .Meeting regulatory requirements for analysis and reporting of incidents and accidents. [sic]

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 REPRESENTATIVE'S SIGNATURE

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