Village House Nursing & Rehabilitation Center

Based on surveyor observation, record review, and staff interview, the facility failed to ensure that food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the main kitchen.Findings are as follows:1. Review of the Food and Drug Administration (FDA) Food Code 2022 Edition, Section 5-202.13 states in part, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE .may not be less than 25mm [millimeter] (1 inch).During a surveyor observation on 3/9/2026 at approximately 9:30 AM, of the main kitchen during the initial walk through, in the presence of Cook, Staff H, the ice machine did not have a one-inch air gap, as required.During a surveyor interview immediately following the above observation with Staff H, he acknowledged that the ice machine did not have a one-inch air gap. 2. Review of the FDA Food Code 2022 Edition, Section 6-305.11(B) states in part, .lockers or other suitable facilities shall be provided for the orderly storage of EMPLOYEES' .possessions.During a surveyor…

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 clinical record review and staff interview, the facility failed to ensure that residents are free of any significant medication errors for 1 of 1 resident reviewed who was treated with antibiotics for infected heel wounds, Resident ID #3.Findings are as follows:1. According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe that the orders are in error or would harm the clients.Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, pressure ulcer of the right and left heels.a. Record review revealed the following progress notes:-2/4/2026 at 4:45 PM: The resident's bilateral heel wounds were noted to be tender, reddened, and had a foul odor. Additionally, the resident's physician ordered wound cultures to be obtained.-2/8/2026 at 3:55 PM: The resident's wound cultures were positive for an infection and the resident's provider ordered two oral…

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 surveyor observation, clinical record review and staff interview, the facility failed to meet professional standards of quality related to following physician's orders for 1 of 1 resident reviewed with an order for a cervical collar, Resident ID #11, for 1 of 1 resident reviewed with an order for no straws, Resident ID #70 and for 2 of 2 residents reviewed for non-pressure wounds, Resident ID #s 88 and 98.Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment, Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients .1. Record review revealed Resident ID #11 was admitted to the facility in November of 2022 with diagnoses including, but not limited to, Parkinson's disease (a progressive neurological disorder that primarily affects movement), scoliosis (a condition characterized by an abnormal side to side curvature of the spine),…

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, surveyor observation and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 1 resident observed with medications at the bedside, Resident ID #9 and for 1 of 2 medication rooms observed during the medication storage task.Findings are as follows:Record review of a facility policy titled, Medication Storage states in part, .It is the policy of this facility that medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations.to support safe effective drug administration.medications are stored in a controlled environment. This may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. 1. During surveyor observations of Resident ID #9, s/he was observed with one bottle of AREDS (an eye vitamin) and one 16-ounce bottle of chlorhexidine mouthwash (an antibacterial mouthrinse) on his/her bedside table on the following dates and times:3/9/2026 at…

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 surveyor observation, clinical record review and staff interview, the facility failed to ensure that resident records are complete and accurately documented, for 1 of 1 resident reviewed who was treated with an antibiotic for infected heel wounds, Resident ID #3 and for 1 of 2 residents reviewed for a non-pressure wound, Resident ID #88.Findings are as follows:1. Record review revealed the resident was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, pressure ulcer of the right and left heels.Record review revealed the resident had wound cultures obtained of his/her right and left heel wounds.Review of a progress note dated 2/8/2026 at 3:55 PM revealed that the resident's wound cultures were positive for infectious organisms and the resident's provider ordered two oral antibiotics, ciprofloxacin 250 milligrams (mg) twice daily for ten days and metronidazole 250 mg three times daily for ten days.Record review revealed the physician's order for metronidazole 250 mg was incorrectly transcribed to be administered twice daily, instead…

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 clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program that must include, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 2 of 5 residents reviewed for antibiotic use, Resident ID #s 2 and 3.Findings are as follows:Review of a facility policy titled, Antibiotic Stewardship Program, last reviewed 12/31/2024, states in part, It is the policy of this facility to recognize the need to monitor antibiotic use in order to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The antibiotic stewardship program is directed toward the correct use of an antibiotic- the five D's.the right dose, the duration.1. Record review revealed Resident ID #3 was readmitted to the facility in January of 2026 with diagnoses including, but not limited to, pressure ulcer of the right and left heels.Record review…

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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare, store, and distribute food according to professional standards of food service safety, relative to the main kitchen and 1 of 2 nourishment areas observed. Findings are as follows: 1. Review of the Rhode Island Food Code, 2018 Edition, section 3-501.17 states in part, .(B) .refrigerated, ready-to-eat time/temperature control for safety food .shall be clearly marked, at the time the original container is opened in a food establishment .and: (1) the day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date . During the initial tour of the main kitchen on 1/6/2025 at approximately 9:00 AM, in the presence of the Food Service Director (FSD), the dry storage area of the kitchen contained the following: -One bottle of Hershey's syrup opened and undated.…

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 interview, it has been determined that the facility failed to implement comprehensive person-centered care plans for each resident, for 2 of 2 residents reviewed with indwelling urinary catheters (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 33 and 38. Findings are as follows: 1. Record review revealed Resident ID #38 was admitted to the facility in October of 2024 with a diagnosis including, but not limited to, cutaneous vesicostomy (an opening is created in the belly, through which urine can continuously pass). Record review revealed the resident has a supra pubic catheter (a thin tube used to drain urine from the bladder). Review of the resident's care plan dated 11/21/2024, revealed the resident requires an indwelling urinary catheter due to obstructive uropathy and neurogenic bladder (bladder dysfunction caused by damage to the nervous system) with interventions including, but not limited to, monitor urinary output and report abnormal findings. Further record review failed to reveal evidence…

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 surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to Enhanced Barrier Precautions (EBP; involves using a gown and gloves during high-contact resident care activities), for 1 of 2 wound treatments observed, involving Resident ID #38. Findings are as follows: Review of a facility policy titled, Guidelines for Management of MDROs [Multidrug Resistant Organism] states in part, .Enhanced Barrier Precautions - it has been determined by the CDC [Centers for Disease Control and Prevention] that focusing on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, which can persist for long periods of time (e.g., months) and result in the silent spread of MDROs. Enhanced Barrier Precautions .requires gown and gloves for certain residents (those with existing MDROs, colonization of MDROs or those residents in close physical…

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 interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 3 residents reviewed, Resident ID #1. Findings are as follows: Record review of a community reported complaint received by the Rhode Island Department of Health on 7/11/2024 alleges, Resident ID #1 lost 20 pounds in 5 weeks while a resident at the facility. Review of the facility's policy titled, Weight Loss/ Gain Protocol and Heights states in part, .All residents are to be weighed upon admission and at least monthly; so as to monitor for weight loss or gain, to assess for underlying causes of weight loss or gain, to intervene accordingly and timely to allow for an optimal level of well-being .For purpose of this policy, a significant weight discrepancy is defined as .A weight change of 3 pounds or more in one week (if resident on weekly weights) .A loss/gain of 5% or greater…

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, resident representative interview, and staff interview it has been determined that the facility failed to complete a discharge summary that includes, but is not limited to, a final summary of the resident's status at discharge and a reconciliation of the resident's medications for 1 of 2 discharged residents reviewed, Resident ID #2. Findings are as follows: Record review of a facility policy titled, Medication Reconciliation Process states in part, It is the policy of this facility to perform medication reconciliation for every resident upon admission, transfer or discharge .when a resident is discharged /transferred, a listing of all medications is to be provided as part of the discharge process utilizing the inter-agency transfer form .the nurse is to give a copy of the transfer form to the resident/resident representative for their records . Record review of a facility reported incident submitted to the Rhode Island Department of Health on 4/25/2024 indicates that Resident ID #2's family is alleging that s/he was neglected during his/her respite stay at…

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.