Frederick Villa Healthcare

In the surveyor’s words

From the most serious findings on record at Frederick Villa Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF697May 6, 2026

  Based on resident interviews, record review, reviews of other pertinent documentation, and staff interviews, it was determined that the facility failed to treat a resident who complained of severe pain resulting in harm to the resident. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey.The findings include:In an interview with Resident #1 and a family member on 05/04/26 at 11:07 am, Resident #1 complained of pain in the groin area. Resident #1 moaned in pain with any movement while seated during the interview. […]

• No harm, potential for more than minimal, widespreadF882Aug 28, 2025

  Based on facility documentation and an interview, it was determined that the facility failed to have a qualified Infection Preventionist (IP). This failure has the potential to affect all residents in the facility.The findings include:An Infection Preventionist is responsible for assessing, developing, implementing, and monitoring a facility's Infection Prevention and Control Program to prevent and control infections.During an interview with the Director of Nursing (DON) on 8/26/25 at 12:38 PM, the DON stated that Staff #29 (regional Assistant Director of Nursing and Infection Preventionist) was collaborating as the IP for the facility. […]

• No harm, potential for more than minimal, widespreadF925Aug 28, 2025

  Based on review of complaint 337259 and the facility's pest problem logs and interview with facility staff, it was determined that the facility failed to maintain an effective pest control program. This deficient practice had the potential to impact all residents.The findings include:Review of complaint 337259 on 8/25/25 at 12:13 PM revealed that the facility was infested with roaches and rodents.The surveyor requested the facility's pest logs from 2025 on 8/27/25 at 7:42 AM. Review of the Pest Problem Log on 8/27/25 at 9:42 AM revealed the following entries in patient care areas:11/13/24 room [ROOM NUMBER]: roaches, mice11/13/24 room [ROOM NUMBER]: roaches, mice1/21/25 room [ROOM NUMBER]: roaches2/6/25 Medication room [ROOM NUMBER], 2, 3: ants, roaches, mice, mice droppings4/21/25 Rooms… […]

• No harm, potential for more than minimal, widespreadF812Apr 13, 2023

  Based on observation and interview it was determined that the facility staff failed to store and serve food according to professional standards. This deficient practice has the potential to affect the residents with meal service within the Candlelight Dining Room. The findings include: On 04/04/23 at 8:04 am, during the initial walk-through of the kitchen with the Certified Dietary Manager #5 there was an outdated container of lunch meat dated 02/28/23 and a box of Zucchini that was spoiled in the freezer. On 04/04/23 at 12:20 PM, during a dining observation during lunch in the Candlelight Dining Room, the staff were observed serving drinks and plates of food without gloves on their hands. The surveyor observed four staff serving the residents. […]

• No harm, potential for more than minimal, patternF609Aug 28, 2025

  Based on review of facility reported incidents (Intake #2578127, # 337212 and #337236), record review, and interview, it was determined that the facility failed to ensure that all alleged resident violations were reported in a timely manner, including: abuse, neglect, exploitation or mistreatment. This was evident for 6 (Resident #86, # 143, #71 #101, #2, and #140) of 76 Residents that were part of the survey sample.The findings included: 1) On 08/19/2025 at 9:04 AM, during the initial screening phase of the survey, Resident #86 alleged to the surveyor that “on the last Sunday night shift (8/17/2025) a nurse was very mean and rough with the resident during care and when her attitude was brought to her attention by Resident #86, she just left the room and never came back. […]