Village Creek Nursing & Rehabilitation

Penalties

• Jul 11, 2024 — Fine ($10,842)
• May 25, 2024 — Fine ($8,167)

Inspection findings

1. Jul 2, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Jul 3, 2026 · CMS health inspection

2. Dec 3, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

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

     Corrected Dec 4, 2025 · CMS health inspection

3. Aug 14, 2025 Health · 7 findings
   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Aug 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected Aug 15, 2025 · 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 Aug 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Aug 15, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Aug 13, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Aug 13, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0711 Miscellaneous Deficiencies

     Provide a written emergency evacuation plan.

     Corrected Aug 13, 2025 · CMS fire safety

4. Jul 11, 2024 Fire Safety · 25 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0007 Emergency Preparedness Deficiencies

     Address patient/client population and determine types of services needed.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0009 Emergency Preparedness Deficiencies

     Include a process for Emergency Preparedness collaboration.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0018 Emergency Preparedness Deficiencies

     Establish procedures for tracking staff and patients during an emergency.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0024 Emergency Preparedness Deficiencies

     Establish policies and procedures for volunteers.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0032 Emergency Preparedness Deficiencies

     Provide primary/alternate means for communication.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Jul 12, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected May 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Aug 31, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

     Corrected Jul 15, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

     Provide safe, appropriate dialysis care/services for a resident who requires such services.

     Corrected Jul 12, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Aug 16, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0914 Environmental Deficiencies

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

     Corrected Jul 12, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Aug 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Aug 23, 2024 · CMS fire safety

5. May 25, 2024 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 26, 2024 · CMS health inspection

6. Jun 15, 2023 Health · 9 findings
   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jun 16, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

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

     Corrected Jun 16, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0727 Nursing and Physician Services Deficiencies

     Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

     Corrected Jun 16, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Jun 16, 2023 · CMS health inspection

   • Not serious Scope/severity E

     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 Jun 16, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 16, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 10, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jun 15, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected Jun 15, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• GARETZ, DAVID — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• GURWITZ, SOLOMON — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 06/26/2025
• HAGINS, ELIZABETH — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/09/2025
• KAPLAN, ESTHER — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 06/26/2025
• KAPLAN, MORDECHAI — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/09/2025
• LEWIS, ADOLPHUS — adp of the snf, NOT APPLICABLE, since 01/01/1989
• MINDLE, ADAM — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/09/2025
• OSBORNE, GLORIA — adp of the snf, NOT APPLICABLE, since 01/01/2024
• RUFF, MICHAEL — corporate officer, NOT APPLICABLE, since 01/01/2024
• UNGER, JEFFREY — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 06/26/2025
• 3825 VILLAGE CREEK ROAD, LLC — adp of the snf, NOT APPLICABLE, since 01/01/2024
• ALTITUDE REALTY HOLDINGS, LLC — adp of the snf, NOT APPLICABLE, since 01/01/2024
• CONTINUUM REHAB GROUP LLC — adp of the snf, NOT APPLICABLE, since 01/01/2024
• FRIO HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 01/01/2024
• GIBRALTAR TRUST — adp of the snf, NOT APPLICABLE, since 01/01/2024
• LARCHMONT REALTY, LLC — adp of the snf, NOT APPLICABLE, since 01/01/2024
• MONTGOMERY SKY TRUST — adp of the snf, NOT APPLICABLE, since 01/01/2024
• OPCO CA SKILLED MGMT INC. — adp of the snf, NOT APPLICABLE, since 01/01/2024
• OPCO TEXAS SKILLED MGMT LLC — adp of the snf, NOT APPLICABLE, since 01/01/2024
• VILLAGE CREEK NURSING & REHABILITATION LLC — operational/managerial control, NOT APPLICABLE, since 01/01/2024