Country Village Care

Penalties

• Sep 23, 2025 — Fine ($29,803)
• Feb 7, 2025 — Fine ($15,575)

Inspection findings

1. Jan 9, 2026 Health · 10 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jan 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jan 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 10, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Jan 10, 2026 · CMS fire safety

2. Nov 26, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Nov 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Nov 27, 2025 · CMS health inspection

3. Sep 23, 2025 Health · 1 finding
   • Serious Scope/severity K Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Oct 9, 2025 · CMS health inspection

4. Aug 25, 2025 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Aug 27, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Aug 27, 2025 · CMS health inspection

5. Feb 7, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 8, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Feb 8, 2025 · CMS health inspection

6. Oct 25, 2024 Health · 10 findings
   • Not serious Scope/severity D Complaint

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Nov 1, 2024 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 1, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Oct 19, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Oct 18, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Oct 20, 2024 · CMS fire safety

7. Sep 8, 2023 Health · 7 findings
   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Sep 25, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Sep 22, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0914 Environmental Deficiencies

     Provide bedrooms that don't allow residents to see each other when privacy is needed.

     Corrected Oct 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 22, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Sep 22, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Sep 22, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BESS, EDWARD — managing control - governing body, NOT APPLICABLE, since 05/01/2026
• BESS, EDWARD — adp of the snf, NOT APPLICABLE, since 05/01/2026
• BESS, EDWARD — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 05/01/2026
• KAKULAVAR, PALLAVI — adp of the snf, NOT APPLICABLE, since 05/01/2026
• KAKULAVAR, PALLAVI — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• KAKULAVAR, PALLAVI — managing control - governing body, NOT APPLICABLE, since 05/01/2026
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• NEWTON, ELIZABETH — corporate director, NOT APPLICABLE, since 05/01/2026
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 02/13/2026
• NEW HIGHLAND HEALTHCARE LLC — adp of the snf, NOT APPLICABLE, since 05/05/2026
• NEW HIGHLAND HEALTHCARE LLC — operational/managerial control, NOT APPLICABLE, since 05/01/2026
• STANDARD BEARER HEALTHCARE OP, LP — adp of the snf, NOT APPLICABLE, since 05/01/2026
• THE ENSIGN GROUP INC — adp of the snf, NOT APPLICABLE, since 05/01/2026
• WEST MULBERRY HEALTH HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 05/01/2026