The Village at Heritage Oaks

In the surveyor’s words

From the most serious findings on record at The Village at Heritage Oaks, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Dec 1, 2022

  Based on observation, interview and record review, the facility failed to ensure that the resident was free from any significant medication errors for (Resident #1) of 5 residents reviewed. This facility failed to administer insulin medication for (Resident #1) according to the doctor's order. Resident #1 was administered a long- acting insulin (released over time), the resident should have been administered short acting insulin (taken daily before meals). This failure could place residents at risk of jeopardizing their health by not receiving medications as ordered. The noncompliance was identified as PNC (Past non-compliance). The non-compliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. […]

• No harm, potential for more than minimal, widespreadF868Jul 26, 2023

  Based on interview and record review, the facility failed to ensure that the facility's Medical Director attended the QAA/QAPI Committee meetings, for 3 of 3 quarterly meetings ( July, August, September 2022, October, November, December 2022 and January,February, March 2023), reviewed for QAA/QAPI. The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of July 2022 through March 2023. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented, and no appropriate guidance developed. […]

• No harm, potential for more than minimal, patternF583Dec 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and clinical records for 15 (Resident #1, Resident # 2, Resident #3, #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14 and Resident #15) out of 15 residents on 200 Hall of the facility. A. The personal health information of 15 residents was left unlocked and displayed on the charting kiosk's screen on the hallway wall by CNA L. This failure could result in fifteen residents' personal information being exposed to unauthorized individuals. The findings included:Observation on 12/09/2025 at 9:35 a.m. […]

• No harm, potential for more than minimal, patternF584Sep 18, 2024

  Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for hall 300, 400 and room [ROOM NUMBER]. The facility failed to ensure the carpet in the hallway between room [ROOM NUMBER] and 304, was in good repair. The facility failed to ensure the carpet in the doorway to room [ROOM NUMBER] was in good repair. The facility failed to ensure the flooring in the doorway into room [ROOM NUMBER] was in good repair. The facility failed to ensure the flooring on 400 hallway was kept in good repair. […]

• No harm, potential for more than minimal, patternF925Sep 18, 2024

  Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for four of four halls (Halls 100, 200, 300, and 400) and the nurse's station, conference room, lobby, and main dining room reviewed for pest control program. The facility had live flies and gnats in areas of the facility including the nurse's station, Halls 100, 200, 300, 400, nurse's station, conference room, lobby, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings included: An observation on 09/16/24 at 9:00 a.m., revealed in the front lobby there were three gnats flying around the front door. […]