Village Creek Rehabilitation And Nursing Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
did not match up. She has since been re-trained. The possible outcome for a resident that was not transferred properly could be a fall or injury to the resident. Record review of the facility's Safe Handling and Moving Protocol policy, dated 07/18/2018, indicated .ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident.expectations of assessment and communication.in order to ensure accurate level of assistance is communicated the charge nurse will notify current floor staff providing care;.via Electronic Health Record ADL and care guide set up.precautions and considerations.bariatric needs (obesity). The Administrator was notified on 11/19/25 at 2:00 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 08/11/2025. The facility took the following actions to correct the non-compliance on 08/11/2025: Record review of a document titled Ad Hoc QAPI dated as signed off on 08/11/2025 revealed these interventions were put in place before this surveyor's entrance on 11/18/2025. Issues: Resident #1 fell from bed while peri care was being provided by CNA. No injuries noted per hospital evaluation. Immediate actions:- Resident #1 received full head-to-toe assessment.- Resident #1 interviewed regarding fall.- The facility obtained statements from the AP and was suspended pending an investigation.- X-ray ordered per MD.- Family and MD notified.- Risk Management completed.- Immediate In-services initiated:-Neglect-Safe Peri Care and bed mobility for high-risk residents-Kardex Utilization- Comprehension quizzes completed after the in-services.- Life satisfaction rounds- Peer reviews and witness statements gathered.- Police were notified.- Ombudsman notified.- The residents care plan and Kardex were updated immediately to specify 2-person assist for peri care and bed mobility.- Facility wide care plan and Kardex audit were completed for required transfer assistance.Ongoing monitoring was initiated for 7 days, followed by weekly checks for four weeks. - Spot checks were completed and corrective actions taken, if needed Record review of in-service trainings titled, Abuse, Neglect, and Resident Rights, Training on Neglect and Prevention Response, Safe Peri-Care and Bed Mobility for High-Risk Residents, and Abuse, Neglect, and Drill Evaluation were all completed with signatures on 08/11/2025. All trainings included CNA A's signature. Interviews conducted all shifts beginning on 11/19/2025 at 9:42 AM through 11/21/2025 at 11:30 AM with the following staff CNA A, LVN B, LVN C, LVN D, CNA E, CNA F, MA G, CNA H, LVN I, LVN J, CNA K, CNA L, the Administrator, and the DON indicated they knew where to find how residents were to be transferred or level of bed mobility. The staff were able to verbalize understanding and information provided in the in-service/training. Record review of the facility folder that included all of the Facility Provider Report documentation included statements by resident and staff, x-ray results, risk management documentation, comprehension quizzes, all completed in-services, life satisfaction rounds, documentation of police and ombudsman notification, and complete audit documentation of Kardex, care plan, and the MDS assessments. Record reviews of random sample residents (Resident #1, Resident #2, Resident #3, and Resident #4) found no inconsistencies between the MDS, the Care Plan, and Kardex between 11/18/2025 through 11/21/2025. An observation of perineal care and bed mobility was completed on 11/19/2025 at 1:34 PM by CNA K and LVN J, no noncompliance found
during this observation. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 8/11/2025 and was removed on 08/11/2025. The facility corrected the noncompliance
before the investigation began.
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Village Creek Rehabilitation and Nursing Center in Lumberton, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Lumberton, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Village Creek Rehabilitation and Nursing Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.