Heartway at Heritage Village Health and Rehab

In the surveyor’s words

From the most serious findings on record at Heartway at Heritage Village Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Nov 1, 2024

  On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to assess a resident with new onset respiratory changes for Res #72. Res #72 expired on [DATE]. A progress note, dated [DATE] at 6:44 a.m., documented Res #72 was having shortness of breath and wheezing. The note documented the physician was contacted and a breathing treatment was ordered. The note documented the Res #72 coughed up green sputum. The note did not document an assessment of the resident's lung sounds. A MAR, dated [DATE], documented the breathing treatment was administered as ordered at 6:46 a.m. The vital signs were documented as oxygen saturation 87%, heart rate 117, and irregular. There was no respiration rate documented. […]

• No harm, potential for more than minimal, widespreadF727Jan 8, 2026

  Based on record review and interview, the facility failed to ensure RN coverage eight consecutive hours seven days per week.The administrator identified 84 residents resided in the facility. Findings:Time card reports for RN coverage were reviewed July 2025 through January 2026. There was no RN coverage for eight consecutive hours for the following days:a. 08/03/25,b. 08/17/25,c. 10/04/25, d. 10/18/25, e. 11/29/25,f. 12/27/25, andg. 01/04/26.On 01/07/26 at 4:05 p.m., the administrator stated they had an agency RN scheduled for the dates above, but nobody showed up, nor did anybody notify the administrator.

• No harm, potential for more than minimal, patternF656Nov 1, 2024

  Based on observation, record review and interview, the facility failed to ensure comprehensive care plans were developed for two (#50 and #46) of 17 residents reviewed for care plans. The DON identified 68 residents resided in the facility. Findings: 1. Res #50 was admitted to facility with diagnoses which included COPD, acute and chronic respiratory failure with hypoxia, and malignant neoplasm of upper lobe. A review of the resident's care plan contained no documentation related to COPD On 10/31/24 at 11:49 a.m., MDS Coordinator #1 stated COPD should have been care planned. 33097 2. […]

• No harm, potential for more than minimal, patternF812Nov 1, 2024

  Based on observation and interview, the facility failed to ensure food was stored in accordance with the professional standards for food service safety. The DON identified 68 residents resided in the facility. Findings: On 10/28/24 at 8:22 a.m., during a tour of the kitchen there were 10 plastic cups covered with clear wrap. Three cups had yellow liquid, four had red liquid, one had pink liquid, one with white liquid, and one with dark brown liquid. There was no label or date. On 10/28/24 at 8:35 a.m, [NAME] #1 was asked what was the policy for labeling and dating food. They stated everything was supposed to be labeled and dated for the date you made it.

• No harm, potential for more than minimal, patternF921Nov 1, 2024

  Based on observation and interview, the facility failed to ensure chemicals were locked away from residents and shower rooms were clean and safe. The administrator identified 38 residents who resided in the facility. Findings: On 10/28/24 at 8:36 a.m., the shower room on hall six was observed with plastic draping taped to two of three walls from approximately three feet down to floor and secured with duct tape. A grey, black, and white fuzzy substance was observed on the ceiling where the walls met and on inside of the door jamb and frame. On 10/28/24 at 2:29 p.m., an observation of the janitor closet on the Southwest resident hall was conducted. The door was without a lock on the knob to secure the closet. […]