Village Care of King

Based on record review and Administrator interview, the facility failed to maintain and produce documented evidence of a comprehensive and ongoing Quality Assurance and Performance Improvement program that demonstrated systematic identification, reporting, investigation, analysis, and prevention of adverse events; and the development, implementation, and evaluation of corrective actions or performance improvement activities for calendar year 2025. This deficient practice had the potential to affect all 94 of 94 facility residents. Findings included: Review of the facility's 2025 Quality Assurance and Performance Improvement plan policy revealed outlined principles of making resident care decisions based on data, goal setting for performance, the measurement of progress towards said goals and the utilization of all collected quality improvement data to guide day-to-day operations within the facility.Review of the Quality Assurance and Performance Improvement committee meeting minutes from January 2025 through December 2025 revealed signatures of interdisciplinary staff members in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to submit a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) for a resident with a serious mental health disorder for 1 of 3 residents reviewed for PASRR (Resident #96).Findings included:A PASRR Determination Notification letter dated 10/24/22 revealed Resident #96 had a Level I PASRR with no expiration date.Resident #96 was admitted to the facility on [DATE] with diagnoses that included major depression, post-traumatic stress disorder (PTSD), and anxiety.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had a serious mental illness and/or intellectual disability. He received antidepressant medication during the MDS assessment period. Pertinent diagnoses included major depression, insomnia, anxiety, and PTSD. A Psychiatric progress note dated 9/29/25 revealed Resident #96 was seen for evaluation of major depressive disorder, PTSD, and insomnia. He was taking duloxetine (an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to develop comprehensive care plans addressing behaviors and post-traumatic stress disorder (Resident #96) and hospice care (Resident #13) for 2 of 19 residents reviewed.The findings included: 1. Resident #96 was admitted to the facility on [DATE] with diagnoses that included major depression, post-traumatic stress disorder (PTSD), and anxiety.The admission Minimum Data Set (MDS) assessment (4/24/25) indicated Resident #96 was cognitively intact and was marked as having major depression, PTSD and anxiety. Resident #96 was not marked for any behaviors and received two antidepressants during the assessment period. The most recent quarterly MDS dated [DATE] did not include any behaviors. Review of Psychiatric note dated (9/29/25) confirmed diagnoses of major depressive disorder, PTSD, and insomnia; medications included duloxetine (antidepressant) daily for depression and trazodone (antidepressant) for depression and insomnia. It was noted Resident #96…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to protect a severely cognitively impaired resident's right to be free from physical and verbal abuse. During care on 6/26/2025 Nursing Assistant (NA) #5 held the resident's arms down on the bed, told him to shut up, and put her gloved hand over Resident #4's mouth while assisting with incontinence care. This deficient practice occurred for 1 of 2 residents reviewed for abuse (Resident #4).The findings included: Resident #4 was admitted on [DATE] with the diagnosis of non-Alzheimer's dementia. The quarterly Minimum Data Set, dated [DATE] revealed Resident #4 was severely cognitively impaired and was dependent on staff to turn in bed, with activities of daily living and incontinence care. Resident #4 did not refuse care and had no behavior towards staff. The most recent care plan, revised 3/7/2025, revealed Resident #4 had cognitive loss related to dementia. The goal was to provide positive experiences in his daily routine without overly demanding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews, the facility failed to implement their abuse policy and procedure in the area of reporting when Nursing Assistant (NA) #6 failed to immediately report she had observed NA #5 physically and verbally abuse Resident #4 when NA #5 held the resident's arms down on the bed, told him to shut up and put her gloved hand over Resident #4's mouth while providing incontinence care for 1 of 2 residents reviewed for abuse (Resident #4). The findings included: The facility policy for Abuse, Neglect and Exploitation, last reviewed on 7/11/2024, revealed the following statement: All allegations of abuse, neglect, involuntary seclusion, injuries of unknown source, and misappropriation of resident property must be reported immediately to the Administrator and Director of Nursing (DON). Review of the investigation report specified an allegation of abuse for Resident #4 that occurred on 6/26/2025 at about 11:00 PM. This allegation was reported by NA #6 to the facility Administrator on 6/27/25 at 3:40 PM. NA# 6 observed NA #5 put her hand over Resident #4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff, and Medical Director interviews, the facility failed to notify the physician of a change in condition for 1 of 3 residents (Resident #1) reviewed for notification of changes. On 10/22/24 Resident #1 was lifted manually by Nursing Assistant (NA) #1 from the shower chair to the bed, causing Resident #1's right leg to hit the shower chair, get caught in between the shower chair and the bed, causing severe pain and swelling. On 10/22/24 Nurse #1, was notified by NA #1 that Resident #1 complained of pain. Nurse #1 did not notify the physician. On 10/22/24, Nurse #2, was informed by Resident #1 of her right leg hurting, and did not notify the physician. On 10/23/24, Nurse #3, who worked from 11:00 pm (10/22/24) to 7:00 am (10/23/24), was notified by NA (Unknown) that resident complained of pain, and did not notify the physician. On 10/23/24, Nurse #4, who worked from 7:00 am to 11:00 pm, was notified by NA (Unknown) that resident complained of pain. Nurse #4 did not notify…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and resident, staff and Medical Director interviews, the facility failed to complete and document ongoing comprehensive assessments after Resident #1 reported leg pain which delayed medical treatment and interventions for 1 of 3 residents (Resident #1) reviewed for assessments. On 10/22/24 Resident #1 was lifted manually by Nursing Assistant (NA) #1 from the shower chair to the bed, causing Resident #1 right leg to hit the shower chair, get caught in between the shower chair and the bed, causing pain and swelling. On 10/22/24, between 11:00 am and 11:30 am, Nurse #1 was notified by NA #1 that Resident #1 complained of pain and Nurse #1 did not complete an assessment. Nurse #2 was assigned to Resident #1 on 10/22/24 from 3:00 pm to 11:00 pm and did not complete a comprehensive assessment and only documented she did not observe any bruising or open area. Nurse #3 (assigned to Resident #1 on 10/22/24 at 11:00 pm to 7:00 am on 10/23/24) and Nurse #4 (assigned to Resident #1 10/24/24 from 7:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and family member interviewa, staff interviews and record review the facility failed to provide a resident with information regarding application for Medicaid for 1 of 1 resident reviewed for discharge (Resident #1). Findings included: Resident #1 was admitted to the facility from the hospital on [DATE]. Resident #1's last date of skilled nursing services ended on 02/22/24 and he was discharged to his home on [DATE]. During an interview with Resident #1 on 03/18/24 at 10:45 AM he stated the Social Worker (SW) and the Business Office Manager (BOM) told him and his Family Member the facility did not do the Medicaid application. The SW told them they would have to apply for community Medicaid on their own. An interview was conducted with Resident #1's Family Member on 03/18/24 at 4:51 PM. He stated he tried to get the BOM to help file for Medicaid and she said Oh, we can't do that and the Social Worker said she could not help either. During an interview with the Social Worker on 03/19/24 at 10:20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and family member interviews, the facility failed to provide the resident a notification of discharge and did not send a copy of the notice to the Ombudsman for 1 of 1 residents (Resident #1) reviewed for discharge. Findings included: Resident # 1 was admitted to the facility on [DATE]. A review of the medical record review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. A record review revealed Resident #1 was his own responsible person. An interview on 03/18/24 at 10:45 AM with Resident #1 revealed he was aware he was to be discharged on 02/27/24 but he did not receive a written notification of his discharge. An interview on 03/19/24 at 10:20 AM the facility Social Worker (SW) revealed the facility did not send a written notice of transfer/discharge with Resident #1 or send a copy of the written notices to the Ombudsman. She stated Resident #1 was an insurance-initiated discharge and she was not required to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to complete a discharge summary for 1 of 1 resident (Resident #1) reviewed for planned discharge to the community. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, in part, infection following a procedure, hypertension, heart disease, muscle weakness, and peripheral vascular disease. A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact and discharge planning was in place as Resident #1 expected to be discharged to the community. A review of the medical record revealed a discharge instruction sheet dated 02/26/24 was provided to the resident on the day of discharge. The discharge instruction sheet included information on home health services and a list of medications. A review of the medical record revealed no discharge summary was completed prior to or after Resident #1 discharged home. Resident #1's care plan dated 01/16/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and medical record review, the facility failed to provide a CMS-10055 (Centers for Medicare and Medicaid Services) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) prior to discharge from Medicare part A services to one of three residents (Resident #77) reviewed for SNF Beneficiary Protection Notification Review. Findings included: Resident #77 was admitted to the facility on [DATE]. Medicare part A services began on the date of admission. The medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #77 on 3/21/23. The notice indicated that Medicare coverage for skilled services was to end 3/23/23. Resident #77 remained in the facility when Medicare coverage ended for an additional four weeks, and discharged home on 4/24/23. The medical record further revealed a CMS-10055 SNF ABN was not provided to the resident or resident representative. A telephone interview was conducted with the Social Worker Director on 5/11/23 at 1:59…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.