Village Creek Rehabilitation And Nursing Center

During an observation

jeopardy to resident health or movie and voiced no concerns. Resident #14 said staff are monitoring us closely and he would never safety harm his girlfriend (Resident #55).

During an interview on 03/26/26 at 6:00 p.m. MA G said she was assigned to Resident #14 and indicated she was watching and listening for any abuse between

and that she was to make sure that Resident #14 did not physically or verbally abuse Resident #55 or any other residents. MA G said she was documenting on a flow sheet every 15 minutes and as needed. MA G said if an incident occurred to intervene immediately, keep residents safe and notify the Administrator immediately thereafter.

During an interview on 03/26/26 at 6:10 p.m., the ADON said she received training 03/25/26 from the DON and the Administrator on Abuse policy, reporting abuse immediately, intervene and protect resident, interventions, and notify Administrator/AC immediately.

If Administrator/AC not available or reachable notify DON.

She said the Administrator had 2 hours from the time of the incident to report abuse allegations to the state agency.

She said she trained staff on abuse, resident-to-resident altercations, intervening, separating resident, aggressors were watched while someone obtained help, and notified the administrator, staff to resident, protect resident and notify Administrator.

She said the aggressor in an altercation was placed on one on one immediately protocol, psych notified, and they review and release.

She said Resident #14 is on 1:1 monitoring for abuse or behaviors towards Resident #55 his girlfriend/roommate.

She said Residents #14 and #55 care plan interventions were updated.

She said that they were to follow the abuse policy even if the residents were in a relationship if abuse was suspected.

During an interview on 03/26/2026 at 5:40 p.m., the DON said she received training 03/25/2026 from Regional Nurse/CCS on abuse policy and reporting procedures to include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on Identifying abuse risk with residents in relationships.

She said she and the Administrator trained staff regarding the abuse policy and reporting procedure after she received her training from the Regional Nurse/CCS.

She said Resident #14 was placed on 1:1 monitoring until risk is fully mitigated.

She said both residents (14 and #55) have received updates on care plans, signed statements about refusing room changes and risk, psychosocial and physical assessments, and increased monitoring.

She said social services completed life satisfaction rounds with no negative findings.

She said she completed an audit of reportable incidents for the last 3 months regarding following the policy for reporting abuse and no negative findings identified during audit.

During an interview on 03/26/2026 at 6:45 p.m., the Administrator said she received training on 03/25/2026 from Regional Nurse/CCS on abuse policy and reporting procedures to include the different types of abuse, reporting of abuse, and what to do in the event of an allegation of abuse and additional focus on Identifying abuse risk with residents in relationships.

She said she and the DON trained staff regarding the abuse policy and reporting procedure after she received her training from the Regional Nurse/CCS.

She said Resident #14 was placed on 1:1 monitoring until risk was fully mitigated.

She said both Residents #14 and #55 had received updates on care plans, signed statements about refusing room changes and risk, psychosocial and physical assessments, and increased monitoring.

She said social services completed life satisfaction rounds with no negative findings.

She said she completed an audit of grievances for the last 3 months regarding following the policy for reporting abuse and no negative findings identified during audit.

She said her ongoing monitoring would include conducting daily reviews of incidents, grievances and behavioral notes and conducting random staff interviews for abuse reporting.

She said the abuse policy and reporting would be added to her QAPI review as well.

The Administrator was informed that the Immediate Jeopardy was removed on 3/26/26 at 7:30 p.m.

The facility remained out of compliance at a scope of pattern with the potential