Heatherdowns Rehab & Residential Care Center

In the surveyor’s words

From the most serious findings on record at Heatherdowns Rehab & Residential Care Center, in the surveyor’s own words.

• Actual harm, isolatedF627Sep 18, 2025

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff, resident, health insurance provider and waiver service provider interviews, review of an Emergency Medical Services (EMS) run report, review of hospital documents, and review of facility policy, the facility failed to ensure a safe resident discharge to home. This resulted in Actual Harm on 07/24/25 at approximately 10:44 A.M. when Resident #62, who was dependent on others for care and required the use of a mechanical lift for transfers, was discharged to home without the needed equipment and services to meet her care needs. […]

• Actual harm, isolatedF689Nov 16, 2023

  Based on medical record review, resident interview, staff interview, hospital documentation review, review of an incident report, review of witness statements, review of a facility policy, and review of facility corrective action, the facility failed to ensure resident transferring equipment was maintained and utilized in a safe and appropriate manner to ensure proper checks and safety measures were taken when assisting a resident with a mechanical lift transfer resulting in a fall. This resulted in actual harm when Resident #21 was transferred by a Hoyer (mechanical) lift while staff members utilized a lift pad that was known to be defective by previous shift staff members. […]

• No harm, potential for more than minimal, widespreadF607Jul 13, 2026

  Based on review of personnel files, staff interview and policy review, the facility failed to implement their policy to ensure all newly hired staff were checked on the nurse aide registry (NAR) to verify eligibility for employment prior to working with residents. This had the potential to affect all residents in the facility. The facility census was 82. Findings include:Review of the personnel file for the Administrator revealed a hire date of 03/09/26. Further review revealed no evidence the Administrator was checked on the NAR for findings of abuse, neglect, exploitation, or misappropriation of property prior to working in the facility.Interview on 07/08/26 at 4:30 P.M. […]

• No harm, potential for more than minimal, widespreadF812Feb 10, 2025

  Based on observation, staff interview, review of the dishwasher monitoring logs and review of facility policy, the facility failed to practice proper hand hygiene during meal service. Additionally, the facility failed to label and date food items in the resident refrigerators. Lastly, the facility failed to test and monitor proper sanitation of the dishwasher. This had the potential to affect all residents in the facility except one (#137) resident identified by the facility as receiving no nutrition by mouth. The facility census was 71. Findings include: 1. Observation on 02/03/25 at approximately 12:25 P.M. in the dining room revealed Certified Nursing Assistant (CNA) #611 providing assistance to Resident #237 who stood up from his wheelchair at the table. […]

• No harm, potential for more than minimal, widespreadF880Dec 11, 2023

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure staff practiced proper infection control practices when entering and exiting rooms under transmission based precautions. This had the potential to affect all 75 residents residing in the facility. The facility census was 75. Findings include: Observation on 12/11/23 at 8:58 A.M. revealed State tested Nurse Aide (STNA) #101 donned an isolation gown to enter Resident #71's room, who was positive for COVID-19. STNA #101 was wearing an N95 respirator and goggles. […]