Heritage Villa Care & Rehab Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 14, 2025

  Based on record review and interview, the facility failed to ensure a certified nurse aide did not attempt to transfer a resident from a bed to a wheelchair by themselves for a resident that required a two person lift for one (#16) of three sampled residents reviewed for falls. The DON stated there were 19 residents at the facility that required two staff members for transfers. Findings: A facility policy titled Fall Management, read in part, To provide an environment that remains as free of accident hazards as possible. […]

• No harm, potential for more than minimal, widespreadF812Aug 21, 2026

  Based on observation, interview, and facility policy review, the facility failed to maintain clean and sanitary food preparation equipment. Specifically, the kitchen ice machine, convection oven, and deep fryer were observed to be dirty. This deficient practice had the potential to affect all residents of the facility who received nutrition from the kitchen.Findings included: A facility policy titled, Sanitation Inspection, revised 08/25/2025, indicated, Policy: Nutritional services employees shall ensure a clean and sanitary work environment; To promote and protect food safety; and, to maintain compliance with Federal, State, and Local regulations governing food sanitation and safety. […]

• No harm, potential for more than minimal, widespreadF812Apr 28, 2021

  Based on observation, interview, and record review, it was determined the facility failed to ensure the ice machine and scoop bucket were maintained in a sanitary manner. The dietary manager identified 65 residents who received ice from the machine. Findings: The facility's procedure for the ice machine, dated 09/2018, documented, The ice machine, scoop, and storage container will be maintained in a clean and sanitary condition. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once per day. 1. On 04/19/21 at 10:24 a.m., cook #1 was asked to open the locked ice machine. The surveyor used a clean paper towel and wiped across the upper metal housing of the inside of the ice machine. […]

• No harm, potential for more than minimal, widespreadF865Apr 28, 2021

  Based on interview and record review, it was determined the facility failed to ensure the QAPI program made good faith attempts to identify and correct quality deficiencies. The facility identified 65 residents who resided at the facility. Findings: On 04/26/21 at 10:33 a.m., the administrator was asked prior to the survey if the facility had identified and developed a QAA plan for the RAI process. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for the restorative care. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for elopement. He stated, no. He was asked prior to the survey if the facility had identified and developed a QAA plan for ADLs. He stated, no. […]

• No harm, potential for more than minimal, widespreadF883Apr 28, 2021

  Based on interview and record review, it was determined the facility failed to have complete documentation of the seasonal influenza vaccine and the pneumococcal vaccine, for three (#11, #1, and #59) of five residents sampled for immunizations. The facility identified 65 residents resided at the facility. Findings: 1. An influenza vaccine consent form for resident #11 documented the POA refused the vaccine on 9/28/20. The form had a vaccine sticker with lot number TM72J attached to the form. The form included a nurse's signature with a date of 12/08/20. There was no documentation provided regarding the pneumococcal vaccine. 2. […]