Country Villa Wellness & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Country Villa Wellness & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 3, 2026

  Based on interview and record review, the facility failed to ensure one resident (Resident #9), assessed to have swallowing problems per the speech therapist after choking on medication on the day shift, was provided supervision during the evening meal. The day staff failed to notify the evening staff the resident had been assessed with swallowing difficulties, and no interventions were put in place to protect the resident during the evening, while further tests were pending. The resident, who was not supervised by staff during dinner, choked on a cheeseburger, requiring staff to attempt to perform the Heimlich maneuver (emergency action to reverse choking), initiate cardiopulmonary resuscitation (CPR), call 911 and send the resident to the hospital. […]

• Actual harm, isolatedF689Feb 4, 2025

  Based on interview and record review, facility staff failed to keep residents free from accidents when staff failed to use safe, professional standards of care when transferring two residents (Residents #1 and #2) using a Hoyer lift (a mechanical device that helps people with limited mobility move from one place to another, such as from bed to a wheelchair). This failure caused an injury requiring hospitalization and surgery for one resident (Resident #1). The facility also failed to investigate two improper Hoyer transfers involving one resident (Resident #2) and did not put corrective measures in place to prevent further injuries to both residents. The sample was three. […]

• Actual harm, isolatedF684Feb 23, 2022

  Based on interview and record review, the facility failed to follow their policy for observing, recording, and reporting one resident's condition change that included a change in level of consciousness, change in respirations, and a change in oxygen saturation levels. Staff observed the resident's changes in condition, but failed to adequately assess, monitor, and document the changes in condition, and failed to promptly notify facility management and the resident's physician until the resident was found unresponsive on [DATE]. Six residents were sampled and problems were found with one (Resident #1). […]

• No harm, potential for more than minimal, patternF568Jun 3, 2026

  Based on interview and record review, the facility failed to maintain a system of full and complete accounting of funds and to ensure residents were refunded upon transfer to another facility for four residents (Residents #10, #11, #12, and #13). The sample size 18. The census was 79. Review of the facility's Resident Funds - Handling and Recording policy, revised August 2020 showed:-Objective of policy is to provide a means to protect resident funds managed by the facility. Provide for an individual and confidential accounting of funds received and disbursed on the resident's behalf;-Procedure: Residents may elect to have the facility act as a fiduciary of their funds and hold, safeguard, and manage his or her personal funds;-Depositing resident funds with the facility:--If the resident… […]

• No harm, potential for more than minimal, patternF658Feb 26, 2026

  Based on interview and record review, the facility failed to ensure services provided met professional standards of practice when staff failed to administer physician-ordered medications to 10 residents (Resident #8, #6, #4, #7, #17, #5, #9, #10, #2, and #3). The sample was 17. The census was 80.Review of the facility's Physician Orders policy, revised 6/2020, showed: -Purpose: This will ensure that all physician orders are complete and accurate;-Policy: The Medical Records Department will verify that physician orders are complete, accurate and clarified as necessary;-Procedure:--Medication/treatment orders will be transcribed onto the appropriate resident administration record. […]