Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Village Crest Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident who required a mechanical lift and two-person assistance for transfers was instead transferred by a single nurse aide without the lift, resulting in a fall and ankle fractures. Additionally, several doors on the locked memory care unit, including those to rooms containing hazardous materials, were found unsecured, contrary to facility policy requiring a secure environment for resident safety.
Surveyors found that the facility failed to properly label and date opened food items, did not discard expired foods, and did not maintain sanitary conditions in nourishment room refrigerators, freezers, and ice makers. Multiple opened and undated food items, expired products, and unsanitary equipment were observed throughout the dietary department and nourishment rooms. The Dietary Director was unaware of proper labeling and inventory procedures, and cleaning rounds were not conducted frequently enough to ensure compliance.
A resident with a history of stroke, dementia, and poor dentition experienced significant delays in receiving necessary dental care, including extractions and denture fabrication, despite repeated referrals and documented need. Communication lapses among nursing staff, dental providers, and the receptionist, as well as missed transportation and lack of documentation of barriers, led to the resident continuing to experience dental pain and difficulty eating.
Staff did not consistently wear required PPE, such as N95 masks, gowns, gloves, and eye protection, when entering rooms under droplet/contact precautions for residents with COVID-19 or other infections. Documentation of isolation precautions was inconsistent, and PPE was not always readily available, leading to lapses in infection prevention. Staff interviews confirmed knowledge of the requirements but revealed non-compliance due to rushing or missing equipment.
A resident admitted with chronic venous hypertension, bilateral lower extremity cellulitis, and a surgical wound did not have comprehensive wound treatment or dressing change orders in place upon admission. Although hospital discharge records indicated the need for daily dressing changes and topical treatments, the facility's physician orders and documentation failed to specify wound care for all affected areas. Nursing staff applied dressings without proper orders, and staff interviews confirmed that necessary wound care directives were not obtained or clarified at the time of admission.
A resident with multiple chronic conditions was admitted and identified as wishing to be DNR, but the care plan incorrectly listed the individual as full code, and no physician order for code status was present on admission. The discrepancy was confirmed during review, and facility policy requiring written documentation and physician order for code status was not followed.
A resident with orthostatic hypotension and a history of falls did not receive daily orthostatic blood pressure monitoring as ordered by the physician. The order was not correctly transcribed into the EHR, resulting in its omission from the MAR and TAR, and nursing staff were unaware of the requirement. This failure was not detected during routine audits, leading to the deficiency.
Two residents receiving IV antibiotics did not have appropriate physician orders or maintenance protocols in place for peripheral IV site care, including timely site rotation and dressing changes. The required batch order set for IV maintenance was not implemented at the time of IV initiation, resulting in IV sites remaining in place longer than recommended and without proper documentation or monitoring.
Expired medications and supplies were found in two medication rooms, including hemoccult cards, developer, and COVID-19 test kits. A Schedule IV controlled medication, Lorazepam, was stored in a refrigerator without being secured in a locked, affixed box, and staff were unaware of the lock box's status. The DNS was not aware of these issues, and facility policy for controlled substance storage was not followed.
A resident with a history of stroke and dementia received two doses of the Pfizer COVID-19 vaccine only nine days apart due to a failure in communication and documentation review by nursing staff. The nurse administering the second dose was unaware of the prior administration, as vaccine documentation was only entered in the EMR's vaccination section and not in progress notes, and information was relayed through shift reports.
A heavy accumulation of various debris, including furniture and equipment, was observed alongside the dumpsters, with staff confirming the items had been left for over a week and the area was not kept clean. The responsible staff delayed arranging for removal and was unfamiliar with the facility's policy requiring regular inspection and maintenance of disposal areas.
State survey results were not accessible to residents on the secured unit, as confirmed by resident interviews and facility observations. While the latest survey results were available in the lobby, the secured unit only had outdated information, and staff were unsure about the location or requirement for survey postings on each floor.
Medication storage rooms were found unclean and poorly maintained, with dirty floors, expired hemoccult supplies, broken tiles, and a soiled sink. An LPN and the Director of Facilities Housekeeping confirmed that cleaning and maintenance responsibilities were not consistently fulfilled, and required issues were not documented or reported as per facility policy.
A resident with severe cognitive impairment and mobility deficits was not provided adequate assistance during a bed linen change, resulting in the resident rolling out of bed and sustaining a left femur fracture. The resident was dependent on staff for bed mobility and had side rails in use as enablers. During the linen change, a nurse aide released their hold on the resident to secure the sheets, at which point the resident rolled off the bed despite the side rails being up. The resident was later found to have an acute hip fracture and was transferred to the hospital.
A resident with Alzheimer's disease and severe anxiety, known for frequent wandering and agitation, was not adequately supervised or redirected, leading to an incident where the resident entered another resident's room and engaged in inappropriate sexual contact. Staff and clinical notes documented the resident's behaviors, but interventions were insufficient to prevent the event, resulting in a failure to protect residents from abuse.
A resident with significant mobility impairments and high risk for pressure injuries did not have a comprehensive care plan developed or implemented to prevent skin breakdown upon admission. Documentation shows that interventions were only formally established after the resident developed a heel blister, which progressed to a deep tissue injury, despite facility policy requiring early care planning for high-risk individuals.
A resident with Alzheimer's and anxiety was repeatedly observed by staff wandering into other residents' rooms, displaying agitation and anxiety, and at times could not be redirected. Despite multiple nursing notes and staff awareness of these behaviors, the care plan was not updated to address the specific issue of wandering into others' rooms until after an incident involving inappropriate contact occurred. The DON was unaware of the extent of the wandering prior to this event, and the care plan did not reflect the resident's actual behaviors as required.
Failure to Follow Transfer Orders and Secure Memory Care Unit
Penalty
Summary
A deficiency occurred when a resident with a history of transient cerebral ischemic attack, morbid obesity, and difficulty walking was not transferred according to physician orders. The resident was assessed as moderately cognitively impaired, non-ambulatory, and required the use of a mechanical lift (Sarita) with the assistance of two staff members for transfers. However, the nurse aide care card contained conflicting instructions, and a nurse aide attempted to transfer the resident alone without the mechanical lift. During the transfer, the resident's legs buckled, resulting in a fall and subsequent fractures to the right ankle, confirmed by x-ray. The nurse aide reported confusion regarding the care card instructions and did not seek clarification before proceeding with the transfer. Additionally, the facility failed to ensure that all appropriate doors were secured on the locked memory care unit. Observations revealed that the shower room contained potentially hazardous items and was not secured, the dentist office door was propped open, and the soiled utility room door with a keypad lock had been bypassed and was not locked. The soiled utility room contained bottles of cleaning solution, and staff were unaware that these doors were unsecured. The maintenance director demonstrated how the keypad could be bypassed and acknowledged the need for a more secure lock. Interviews with staff confirmed that the unsecured doors and access to hazardous materials were not in accordance with facility policy, which required all doors on the secured memory care unit to be locked for resident safety. The facility's policy for the memory care unit emphasized maintaining a secure environment to ensure the safety and well-being of residents, but this was not followed at the time of the survey.
Deficient Food Storage, Labeling, and Sanitation in Dietary and Nourishment Areas
Penalty
Summary
Surveyors identified multiple failures in the facility's dietary department and nourishment rooms regarding food storage, labeling, and sanitation. During a tour, numerous food items were found opened and not labeled or dated, including hot dog buns, French bread, French toast, donuts, egg noodles, honey, peas, elbow macaroni, rice, and pinto beans. Some items were also found to be expired, such as egg noodles and pinto beans, yet had not been discarded. Additionally, prepared foods in the walk-in refrigerator, such as meatloaf, cheese, tomato juice, soup, sliced beef with gravy, and egg noodles, were either undated, not labeled, or held beyond the recommended time frame for safe consumption. Further observations in the nourishment rooms on multiple floors revealed unsanitary conditions and improper food handling. The 2nd floor nourishment room had a soiled coffee maker, expired cereal, uncovered and undated food items, and a refrigerator with visible brownish drip marks. The 3rd floor nourishment room had an ice maker with a brown substance in the scoop container, debris behind the ice maker, opened and undated brown sugar, an unidentified foil-wrapped item, and a refrigerator with a tacky, brown substance. The 4th floor nourishment room also had an ice maker with heavy accumulation of brown and white substances, an ice scoop container with a brown substance, and opened, undated containers of mayo and salsa. Interviews with the Dietary Director revealed a lack of awareness regarding the facility's policy on labeling and dating opened food items and the process for discarding expired food. The director acknowledged that the nourishment room refrigerators, freezers, and ice makers required cleaning and that the dietary department was responsible for maintaining their cleanliness. However, rounds to check cleanliness were not conducted frequently enough to ensure compliance with facility policy and food safety standards.
Failure to Provide Timely Dental Services for Resident with Non-Restorable Teeth
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely dental services were provided to a resident with multiple non-restorable teeth. The resident, who had a history of stroke with partial paralysis, dementia, and depression, was identified as having poor dentition and expressed ongoing concerns about dental pain and the desire for dental repairs. Despite repeated assessments by dental staff and clear documentation of the need for dental intervention, including referrals for full mouth rehabilitation and later for removal of all remaining teeth and denture fabrication, there were significant delays in arranging the necessary dental appointments. The clinical record and interviews revealed that although referral letters and recommendations were uploaded into the electronic medical record (EMR) and communicated to nursing staff, the process for scheduling outside dental appointments was not effectively followed. The receptionist responsible for making appointments did not recall receiving earlier referrals and only scheduled appointments after significant delays. Missed transportation and a lack of follow-up further contributed to the postponement of dental care. Nursing staff and the Director of Nursing Services were unaware of the earlier referrals and did not document barriers or reasons for the delays in the EMR, as required by facility policy. Observations confirmed the resident continued to experience dental pain, had visible tooth fragments, and required modified meals due to the condition of their teeth. The resident expressed dissatisfaction with the facility's assistance in obtaining timely dental care and was unclear about when the necessary dental procedures would occur. The facility's policy required documentation of delays and assistance with transportation, but these steps were not consistently implemented, resulting in a prolonged period without appropriate dental intervention for the resident.
Failure to Ensure Proper PPE Use and Consistent Infection Control Documentation
Penalty
Summary
Nursing staff failed to consistently don the required Personal Protective Equipment (PPE) when entering rooms under transmission-based precautions for droplet/contact isolation, as observed in multiple instances involving residents with COVID-19 or other infectious conditions. In several cases, staff entered rooms with posted signage indicating the need for gown, N95 mask, eye protection, and gloves, but were observed wearing only a surgical mask or missing other required PPE. Staff interviews confirmed awareness of the PPE requirements but cited reasons such as being in a rush or lack of available equipment for non-compliance. Documentation related to infection control precautions was also found to be inconsistent. For one resident who tested positive for COVID-19, nursing notes alternated between documenting transmission-based precautions and enhanced barrier precautions across different shifts and days, despite a physician's order specifying the type and duration of isolation. This inconsistency in documentation could lead to confusion among staff regarding the appropriate level of precautions to implement. Additionally, there were instances where staff failed to ensure PPE was readily available outside isolation rooms, particularly eye protection, resulting in staff entering rooms without full PPE. Interviews with the Infection Preventionist and Director of Nursing confirmed that facility policy required full PPE for all staff entering rooms under transmission-based precautions, regardless of which resident was being attended to. The facility's own policies and posted signage were not consistently followed, leading to lapses in infection prevention and control practices.
Failure to Obtain Comprehensive Wound Care Orders Upon Admission
Penalty
Summary
The facility failed to obtain and document comprehensive wound treatment and dressing change orders upon admission for a resident with significant skin conditions, including a surgical wound and a venous stasis ulcer. The resident was admitted with chronic venous hypertension, cellulitis of the lower limbs, and a left foot abscess that had undergone surgical debridement. Hospital discharge records indicated the need for daily dressing changes and specific topical treatments, but did not provide clear or complete instructions for all affected areas. Upon admission, the nursing assessment and skin assessment identified multiple wounds, but the physician's orders only addressed topical application of Sodium Hypochlorite to foot ulcers, omitting detailed wound care and dressing instructions for the bilateral lower extremities and the surgical site. Nursing documentation showed that the resident required assistance with activities of daily living and had visible dressings on both lower extremities, with evidence of drainage on the left side. Despite this, the Treatment Administration Record and care plan interventions referenced wound care in general terms without specifying the type, frequency, or method of dressing changes for each wound. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing Services, confirmed that wound treatment orders were incomplete and that nursing staff had been applying dressings without proper physician orders since admission. Staff acknowledged that the hospital discharge instructions were unclear and that clarification should have been sought immediately upon admission. Further review revealed that the admitting nurse did not clarify or obtain the necessary wound care orders, and subsequent provider notes also failed to specify comprehensive wound care directives. The lack of clear, site-specific, and physician-authorized wound treatment orders resulted in nursing staff performing dressing changes without appropriate guidance. This deficiency was identified through observation, record review, and staff interviews, all of which confirmed that the required wound care orders were not in place at the time of admission.
Failure to Accurately Reflect Code Status in Care Plan
Penalty
Summary
The facility failed to ensure that the care plan accurately reflected a resident's code status. A resident admitted with chronic obstructive pulmonary disease, diabetes, and a history of falls was identified in the social service assessment as a full code, but the signed advanced directive consent form indicated the resident's wishes were for Do Not Resuscitate (DNR). Despite this, the care plan listed the resident as a full code, and there were no physician orders on admission specifying the code status. The admission Minimum Data Set (MDS) assessment documented that the resident was moderately cognitively impaired and required varying levels of assistance with daily activities. During an interview and review of the care plan, it was confirmed that the care plan was incorrect and should have reflected the resident's DNR status. Facility policy required that code status be documented in writing after consent and that a physician's order be obtained, but these steps were not completed at the time of admission, resulting in the care plan not matching the resident's documented wishes.
Failure to Monitor Orthostatic Blood Pressures Due to Transcription Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that orthostatic blood pressures were monitored daily as ordered by the physician for a resident with a history of orthostatic hypotension and repeated falls. The resident, who was cognitively intact and required some assistance with transfers and toileting, had a care plan that included monitoring for signs and symptoms of orthostatic hypotension. Despite a physician's order for daily orthostatic blood pressures, the order was not transcribed onto the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and as a result, the blood pressures were not taken or documented. Interviews with nursing staff and review of the clinical record revealed that the order was incorrectly entered into the electronic health record (EHR) and was not carried over to the MAR or TAR. This transcription error was not identified during routine order audits, and nursing staff were unaware of the order or its requirements. The facility's policy required accurate transcription and verification of orders, but this process was not followed, leading to the omission of the required monitoring for the resident.
Failure to Ensure Proper Physician Orders and Maintenance for Peripheral IV Administration
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for two residents by not having proper physician orders in place for the maintenance and rotation of peripheral IV sites. For one resident with diagnoses including COVID-19, myocardial infarction, and hyponatremia, the clinical record showed that IV Ceftriaxone was started for a urinary tract infection. However, there was no corresponding physician order for the IV medication or for the required site maintenance, such as rotating the access site every 96 hours. The resident’s IV site dressing was observed to be 11 days old, and the site was not rotated or removed as per protocol, with the batch order set for IV maintenance not implemented until several days after IV initiation. Another resident, diagnosed with sepsis, a right femur fracture, and chronic obstructive pulmonary disease, was started on IV Ceftriaxone for cellulitis. Similarly, there was no physician order corresponding to the medication administration record, and the batch order set for IV site maintenance was not in place when the IV was started. The IV site was not discontinued within the recommended 96-hour period, and the facility did not provide a written policy for peripheral IV site maintenance when requested. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the required batch order set, which includes parameters for site rotation, flushing, and monitoring, was not implemented at the time of IV initiation for either resident. The DNS acknowledged that the oversight resulted in IV sites remaining in place longer than recommended and that appropriate orders were not obtained for each resident started on a peripheral IV.
Expired Medications and Improper Storage of Controlled Substances
Penalty
Summary
Surveyors identified that expired medications and supplies were not properly disposed of in two of three medication storage rooms. On the 4th floor, expired hemoccult cards and developer were found in a cabinet drawer, along with unopened tubes of Collagen Hydrogel and an indwelling catheter, some of which were expired. On the 3rd floor, an unopened box of Lorazepam, a Schedule IV controlled medication, was stored in a medication refrigerator without being secured in a locked, affixed box as required. The lock box present in the refrigerator was marked 'DO NOT USE,' and staff were unaware of the reason or unable to access it. The Director of Nursing Services (DNS) was not aware that the lock box was not being used for controlled medications or that it was marked as unusable. A review of the maintenance log did not show any entry regarding the lock box being broken. Additionally, expired COVID-19 test kits and a partially used gallon of distilled vinegar with a past use-by date were found in the 3rd floor medication room. The pharmacy consultant confirmed that non-medication items would not typically be reviewed during monthly inspections and could not confirm if the Lorazepam was present during the last inspection, as it was not noted in the summary report. Facility policy requires Schedule II-V medications to be kept in a separately locked, permanently affixed compartment, with a different access system from non-scheduled medications, which was not followed in this instance.
Improper COVID-19 Vaccine Administration Interval
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, dementia, and prior COVID-19 infection received two doses of the Pfizer COVID-19 2024-2025 vaccine only nine days apart, rather than the recommended interval. The resident was documented as cognitively intact and required varying levels of assistance for daily activities. The immunization report showed that the first dose was administered on 10/9/24 and the second on 10/18/24, both in the left deltoid, while the resident was in the facility. The registered nurse responsible for vaccine administration stated that her process included obtaining consent, providing the Vaccination Information Sheet, and documenting the vaccination in the electronic medical record (EMR). She was unaware that the resident had already received the vaccine earlier in the month and indicated that she would not have administered the second dose had she seen the prior documentation. The nurse also noted that vaccine administration was communicated during shift reports and only documented in the vaccination section of the EMR, not in progress notes. Facility policy required documentation of immunizations in the medical record, including specific details, but did not specify documentation in progress notes.
Improper Disposal and Accumulation of Debris in Dumpster Area
Penalty
Summary
Surveyors observed a significant accumulation of debris, including a discarded mattress, bedside tables, wheelchairs, a leg rest, large cloth garbage containers, a blanket, curtains, window blinds, and a piece of therapy equipment, alongside the dumpsters in the facility's designated disposal area. The Dietary Director acknowledged that the area was not well maintained or cleaned and clarified that the items originated from maintenance, not dietary services. The Maintenance Director confirmed that the debris had been present for over a week and admitted to delaying pickup until the pile became larger, also stating unfamiliarity with the facility's policy and recognizing that the area was not clean or tidy. Review of the facility's Environmental Management policy revealed that there was an established process and schedule for inspecting, maintaining, and cleaning grounds, including areas around dumpsters, to keep them free of debris.
Survey Results Not Accessible on Secured Unit
Penalty
Summary
The facility failed to ensure that state survey results were available and accessible to residents residing on the secured unit. During a resident council interview, five residents on the secured unit reported they were unaware of where to find the state survey results. Observations confirmed that while the most recent survey results from 2023 were available in the facility lobby, they were not present on the locked unit. An orange binder labeled 'State Survey' behind the nurse's desk on the secured unit was found to be dusty and only contained outdated results from 2019, missing the 2021 and 2023 re-certification surveys. Multiple staff interviews, including with the Administrator, Recreation Director, DON, and Scheduler, revealed uncertainty and lack of knowledge regarding the location and requirement for survey results on each floor, with none able to confirm their presence on the secured unit.
Medication Room Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in two of three medication storage rooms, as observed during interviews and inspections. On the 4th floor, the medication room floor was found dirty with dried spilled liquids and debris, and expired hemoccult cards and developer were present in a cabinet drawer. The LPN interviewed stated that housekeeping was responsible for cleaning the medication room floor, but acknowledged that it was not cleaned frequently. The Director of Facilities Housekeeping confirmed that housekeeping staff were responsible for daily cleaning, including dusting, mopping, and cleaning fixtures in the medication rooms. On the 3rd floor, the medication room had a soiled tile floor with a build-up of dust and debris, and several tiles near the medication cart were broken, crumbling, and cracked. The sink and faucet had white build-up and the base of the sink was dirty with splashes of liquid and debris. The Director of Facilities Housekeeping was aware of the broken tiles and the condition of the sink but could not specify how long these issues had existed. The unit maintenance book did not show that these problems had been reported, and the LPN was unable to confirm when or if they had been reported. Facility policies required daily cleaning and maintenance of medication rooms and their fixtures, which was not followed.
Resident Fracture Due to Inadequate Assistance During Bed Linen Change
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, generalized muscle weakness, and difficulty walking was not provided adequate assistance during a bed linen change, resulting in the resident rolling out of bed and sustaining a left hip fracture. The resident was assessed as having severely impaired cognition, was non-ambulatory, always incontinent, and required maximal assistance with bed mobility and total care for activities of daily living. The care plan specified the use of two upper quarter side rails for bed mobility and directed total care with the assistance of one staff member for bed mobility and incontinent care. On the night of the incident, a nurse aide was performing a bed change with the resident lying on their right side, gripping the side rails. The bed was in a high position, and the aide was standing on the left side of the bed. While tucking in the clean sheets, the aide released their hold on the resident's waist to secure the sheets, at which point the resident rolled out of bed onto the floor. Both upper quarter side rails were up, and the resident had their hands on them, but the aide believed the resident could grip the rails. The aide reported that the resident's left leg's weight contributed to the fall when the sheets were pulled. Following the fall, the resident initially showed no signs of injury or pain, but later began to complain of left hip pain and exhibited guarding of the hip and pelvic area. An x-ray revealed an acute fracture of the left femur with mild displacement, and the resident was subsequently transferred to the hospital for evaluation. The incident was documented as unwitnessed by some staff, but the nurse aide involved reported witnessing the fall during care.
Failure to Supervise Wandering Resident Results in Sexual Abuse Incident
Penalty
Summary
A deficiency occurred when the facility failed to adequately supervise a resident with known wandering behaviors, resulting in an incident of sexual abuse involving another resident. The resident with Alzheimer's disease and generalized anxiety disorder exhibited ongoing agitation, anxiety, and frequent wandering into other residents' rooms, as documented in multiple clinical notes and staff interviews. Despite these behaviors being well-documented, the resident was not consistently redirected or supervised to prevent entry into other residents' rooms. The care plan for the resident identified interventions such as redirection and removal from overstimulating environments, but staff notes repeatedly described the resident as being unable to be redirected at times and requiring frequent intervention. On the day of the incident, staff observed the resident pacing the hallways and entering other residents' rooms. At one point, the resident was not visible in the hallway, prompting a staff member to search for them. The resident was found in another resident's room, engaging in inappropriate sexual contact with a resident who was dependent for activities of daily living and had severely impaired cognition. Interviews with staff confirmed that the resident's wandering and entry into other rooms were known behaviors, and that frequent redirection was required. The Director of Nursing stated she was unaware of the extent of the wandering behavior prior to the incident and that no care plan was in place specifically addressing this risk. The facility's policy required prevention of harm from resident-to-resident contact, but the lack of supervision and specific interventions for the wandering resident led to the incident of sexual abuse.
Failure to Develop and Implement Pressure Injury Prevention Care Plan for High-Risk Resident
Penalty
Summary
A resident with multiple sclerosis, Guillain-Barre syndrome, and generalized muscle weakness was identified as being at high risk for developing pressure injuries upon admission, as documented in the nursing assessment and Braden Scale. Despite this high-risk status, there was no evidence that a comprehensive care plan with specific interventions to prevent skin breakdown was developed and implemented at the time of admission. The care plan addressing the risk for pressure injuries was not created until after the resident developed a blister on the left heel, which was later assessed as a deep tissue injury. Facility documentation and interviews confirmed that while standard practices such as offloading heels and turning every two hours were reportedly in place, there was no documentation to support that a comprehensive care plan had been developed or implemented prior to the identification of the pressure injury. The facility's policy requires the interdisciplinary team to create a person-centered care plan addressing high-risk factors upon admission, but this was not done for the resident until after the injury occurred.
Failure to Revise Care Plan for Resident Wandering and Behavioral Issues
Penalty
Summary
The facility failed to review and revise the care plan for a resident with Alzheimer's disease and generalized anxiety disorder who was repeatedly observed wandering into other residents' rooms. Multiple nursing notes documented the resident's behaviors, including pacing, agitation, anxiety, and entering other residents' rooms, with some instances where the resident could not be redirected and required multiple interventions, including PRN medication and 1:1 observation. Staff interviews confirmed that the resident's baseline behaviors included frequent pacing and wandering into other rooms, requiring frequent redirection. Despite these ongoing behaviors, the resident's care plan did not address the specific issue of wandering into other residents' rooms until after a significant incident occurred, where the resident was found in another resident's room engaging in inappropriate physical contact. The Director of Nursing was unaware of the extent of the resident's wandering behaviors prior to this incident, and the care plan was not updated to reflect these behaviors as required by facility policy. The deficiency was identified due to the lack of timely care plan review and revision in response to the resident's documented behaviors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 103 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Milford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Candlewood Rehabilitation And Healthcare Center | 1 mi | — | 1 | 0 |
| The Grand Rehabilitation And Nursing At Pawling | 9.3 mi | — | 0 | 0 |
| Bethel Health Care Center | 11 mi | — | 0 | 0 |
| Springs At East Hill, The | 11 mi | — | 0 | 0 |
| Pomperaug Woods Health Center | 11.6 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Village Crest Center For Health & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.