Complete Care at Heritage LLC

Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 5 (#5, #4, #2, #1, #14) of 14 residents reviewed during a complaint survey.

Inspectors wroteBased on review of facility documentation and interviews, it was determined the facility staff failed to protect a resident from verbal abuse from facility staff (Resident #8). This was evident for 1 of 11 residents reviewed for abuse during a complaint survey. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 12/5/25.

Inspectors wroteBased on staff and resident interviews, and record review the facility failed to give Resident #12 a shower on Tuesday and Friday as ordered for the month of January 2026 and February of 2026. This was evident for one (Resident #12) of 1 resident reviewed for ADLs during the complaint survey. The Findings Include: An interview was conducted with the responsible party (RP) of Resident #12 on 2/20/26 at approximately 2PM. The RP of Resident # 12 complained that the Resident has had no shower in the last 2 months. An interview was held with Resident #12 on 2/20/26 at 12:30PM who is alert and oriented and can make his/her needs known. Resident #12 also stated he/she has had no shower in the last 2 months and stated he/she wanted a shower. There was one time in [DATE] that the resident refused a shower/bed bath because he/she had diarrhea. [...]

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to administer medications as ordered by the physician (Resident #13). This was evident for 1 of 14 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, and interview, it was determined the facility failed to provide respiratory services in accordance with professional standards of practice (Resident #1 and #13). This was evident for 2 of 3 residents reviewed for respiratory services during a complaint survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to maintain a clean, sanitary and homelike environment for their residents. This was evident for 1) 1 of 2 nursing units in the facility and 2) observation of the laundry room during the recertification/complaint survey.

Inspectors wroteBased on observation, record reviews and staff interviews, it was determined that the facility failed to label oxygen (02) tubing with change dates. This was evident for 7 (#44, #127, #153, #149, #116, #76, #91) of 7 residents reviewed for respiratory care during the recertification/complaint survey.

Inspectors wroteBased on a review of employee files and staff interviews, it was determined that the facility failed to implement a system to ensure newly hired Geriatric Nursing Assistants (GNAs) were competent in their skill sets. This deficiency was evident in four (GNA #15, # 17, 36, and #37) out of five GNA employee files reviewed during the recertification/complaint survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to process linen in such a manner as to prevent infection, evidence by staff not wearing a protective gown to sort dirty linens and having drinks and personal items on the clean folding table next to clean laundry. This was observed during the recertification/complaint survey.

Inspectors wroteBased on surveyor observations and interview with facility staff, it was determined that the facility failed to maintain an effective pest control program. This was observed during the recertification/complaint survey.

Inspectors wroteBased on a review of medical records and interviews, it was determined that facility staff failed to ensure that two physicians' certificates of incapacity were obtained and that Advance Directives were completed in accordance with the Health Care Decisions Act. This was evident for one resident (Resident #1) out of the four residents reviewed for advance directives during the recertification/complaint survey.

Inspectors wroteBased on review of facility records and interview with staff, it was determined the facility staff failed to: 1) immediately report an allegation of suspected resident abuse and 2) timely report allegations of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (Resident #42) of 35 residents reviewed for intakes during the facility's recertification/complaint survey.

Inspectors wroteBased on the matrix, medical record review, and staff interview, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments diagnoses were updated. This was evident for 3 (Residents #82, #113, and #13) residents identified with a diagnosis of COVID on the matrix out of 74 resident records reviewed during the recertification/complaint survey process.

Inspectors wroteBased on interview with family, a review of resident medical records, and interviews with facility staff, it was determined that the facility failed to hold care plan meetings at least quarterly. This was evident for 2 (Resident #13, # 2) out of 4 residents reviewed for care plans during the facility's recertification/complaint survey.

Inspectors wroteBased on interviews with residents, review of medical records, and interviews with facility staff, it was determined that facility nursing staff failed to follow professional standards of nursing practice when documenting medications given to residents. This was evident for 1 (Resident #102) out of 2 residents reviewed for timely medication administration during the recertification/complaint survey.

Inspectors wroteBased on interviews with residents, review of medical records, and interviews with facility staff, it was determined the facility staff failed to provide care and services to maintain or improve a resident's ability to carry out Activities of Daily Living (ADLs). This was evident for 1 (Resident #6) of 2 residents reviewed for rehabilitative or restorative services during the facility's recertification/complaint survey.

Inspectors wroteBased on observations, interviews, and a medical record review, it was determined that facility staff failed to provide personal hygiene services to totally dependent residents. This was evident in 2 (Residents #96 and #42) of the 5 residents reviewed for activities of daily living (ADL) care during the recertification/complaint survey.

Inspectors wroteBased on complaint intake, resident and staff interviews and record reviews, it was determined that the facility failed to provide quality of care services to their resident secondary to a delay in medication administration and wound treatments. This was evident for 2 (Residents #2, #174) of 37 residents reviewed for medication administration and wound treatment during the recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and staff interviews, it was determined that the facility failed to provide adequate fall risk assessments for residents who experienced frequent falls. This was evident in the cases of 3 residents (Resident #15, #16, and # 94) out of the five reviewed for fall risks during the recertification/complaint survey.

Inspectors wroteBased on a review of the resident's medical records and interviews with facility staff, it was determined that the facility failed to address a significant weight loss for a resident. This was evident for one (Resident #9) of 2 residents reviewed for nutrition during the recertification/complaint survey.

Inspectors wroteBased on investigating complaints, medical record review, and staff interview it was determined that the facility failed to provide pain management timely. This was found to be evident for one (Resident #178) out of 10 residents reviewed for pain management during the recertification/complaint survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to properly label and store drugs and biologicals. This was evident in 2 of 4 medication carts observed during the recertification/complaint survey.

Inspectors wroteBased on clinical record review, review of facility report incidents, and staff interview it was determined that the facility staff failed to ensure residents' clinical records were complete and accurate. This was evident for 3 (Residents #4, #137, #190) residents out of the 74 in the survey sample of the recertification/complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to offer pneumococcal vaccine as appropriate for residents. This was evident for 1(Resident #2) of 5 residents reviewed for immunizations during the recertification/complaint survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to offer COVID-19 immunization as required or appropriate for residents. This was evident for 2 (Residents #1 and #2) of 5 residents reviewed for immunizations during the recertification/complaint surveyThe

Inspectors wroteBased on review of employee files and staff interview it was determined that the facility failed to demonstrate the implementation of a process to track nurse aide participation in required training's to ensure all nurses' aides received 12 hours of training that included abuse prevention and Dementia management, annually and addressed areas of weakness as determined in nurse aides' performance reviews. This was evident for 2 (GNA # 16 and #17) of 5 employees' files reviewed during this recertification/complaint survey.

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to post all of the required staffing information on a daily basis and was observed during the recertification/complaint survey.

Inspectors wroteBased on review of a facility reported incident, review of administrative and medical records, and staff interviews, it was determined that the facility failed to ensure a resident was free of a significant medication error when a nurse incorrectly administered the medication Methadone to a resident instead of the prescribed medication Methylphenidate. This was evident for 1 of 1 resident (Resident #1) reviewed for unnecessary medications during a complaint survey. The failure of the facility to ensure that Resident #1 was free of a significant medication error resulted in the determination of an immediate jeopardy situation being identified on February 25, 2025, at 6 PM.

Inspectors wroteBased on observation, medical record reviews, staff, and family interviews, it was determined the facility failed to: 1.) correctly assess a resident for smoking independently to include an accurate account of incidents of past unsafe smoking behaviors; 2) provide increased supervision and safety interventions after multiple unsafe smoking incidents; 3) keep a resident who had multiple smoking-related incidents from igniting flammable materials and safe from self-harm. This was evident for 1 of 4 (#92) residents reviewed for smoking. As a result of the deficient practice, residents were placed at risk for harm/injury causing an immediate jeopardy. The facility also failed to protect a resident who was totally dependent on staff for all aspects of activities of daily living, from an accident with injury (Resident #144). [...]

Inspectors wroteBased on medical records review, facility investigation review and interviews with staff it was determined that the facility failed to protect cognitively impaired residents from physical, sexual, emotional, and verbal abuse which resulted in harm to Resident #144 and Resident #76. This was evident for 3 of 28 residents (Resident #144, #76, #103) reviewed for abuse during the survey. The Findings Include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of resident care. 1. [...]

Inspectors wroteBased on observations and interviews with facility staff, it was determined the facility failed to provide a clean and comfortable environment for residents. This deficient practice has the potential to affect all residents residing at the facility and was found to be evident during the facility's Medicare/ Medicaid recertification survey.

Inspectors wroteBased on administrative record review and interviews with facility staff, it was determined the facility failed to 1.)perform quarterly interdisciplinary care plan meetings for Resident # 92, 2.) update the care plan to the address the specific needs for Resident # 103, a cognitively impaired resident that experienced sexual contact by a cognitively intact resident, and for resident # 166 that was administered Narcan for substance abuse. This was found to be evident for 3 of 90 residents reviewed during the investigation stage of the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on the medical record review and staff interview, it was determined the facility, 1.) failed to ensure that medications were administered to residents (#684, and # 438) as prescribed by the physician, 2.) failed to ensure that psychiatric consultations were done as ordered by the physician for resident (#123 and # 103) and 3.) failed to ensure that a Peripherally Inserted Central Line (PICC) was removed for resident (# 165) prior to discharge. This was evident for 5 residents of 90 residents reviewed during the investigation stage of the facility's annual Medicaid/Medicare survey.

Inspectors wroteBased on review of medical records and interview with staff, it was determined that the facility failed to: 1.) ensure pharmacy recommendations to nursing were addressed during the monthly pharmacy reviews 2.) ensure the monthly reviews were reviewed by the physician and that the physician acted on and addressed irregularities identified by the pharmacist. This was found to be evident for 3 (R#106, #37 and # 10 ) out of the 5 residents sampled for medication regimen review during the facility's Medicare/Medicaid recertification survey.

Inspectors wroteBased on medication administration observation, medical record review, and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5 %. This was evidenced by 6 errors observed during the medication administration of 31 opportunities for errors, that resulted in a medication error rate of 19.35%. This was found to be evident for 3 (R #101, # 99 #55) out of 5 residents observed during the medication administration.

Inspectors wroteBased on administrative record review and interviews with facility staff, it was determined the facility failed to ensure that complete and accurate records were maintained for residents. This was found to be evident for 3 (Resident # 240, # 92, and # 438) of 90 residents reviewed during the investigation stage of the facility's Medicare/Medicaid recertification survey.

Inspectors wroteBased on the record reviews and interviews, it was determined that the facility failed to that ensure 4 Geriatric Nursing Assistants (GNA)s received the required 12 hours of in-service training. This was found to be evident for 4 (GNA #11, #21, # 53, # 56) out of 5 employees reviewed for annual GNA training reviewed during the recertification survey.

Inspectors wroteBased on observation, medical record, administrative review, and interview with facility staff, it was determined that the facility staff failed to: 1.) Promote respect and dignity of a cognitively impaired resident when an employee posted a picture of the resident on a mobile photo-sharing application and social network and 2.) promote care for a resident in a manner and in an environment that maintained or enhanced the resident's dignity and respect. This was found to be true for 2 (R#48 #76) out of 5 residents reviewed for dignity.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to provide a dignified existence to a vulnerable resident. This deficient practice was evidenced in 1 (#92) of 2 residents reviewed for dignity during a Medicare/Medicaid recertification survey.

Inspectors wroteBased on the medical record review and staff interview, it was determined the facility failed to notify the physician of a medication that was not administered to a resident. This was evident for 1 resident (#64) out of 8 residents reviewed at the time of the survey.

Inspectors wroteBased on administrative and medical record review and interviews with facility staff, it was determined the facility failed to ensure that a resident was kept free from physical restraints. This was found to be evident for 1 (Resident # 150) of 28 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on administrative and medical record review and interviews with facility staff, it was determined the facility staff failed to report allegations of abuse to the State Office and Certification Agency. This was found to be evident for 2 (Resident # 103 and Resident # 144) of 28 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to thoroughly investigate abuse allegations. This was found to be evident for 1 Resident # 103 of 28 residents reviewed for abuse during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observation, medical record review, and interviews, it was determined the facility failed to ensure that residents were ordered treatments according to professional nursing standards. This deficient practice was evidenced in 2 residents (#78, #238) of 3 records reviewed for oxygen and/or colostomy orders reviewed during the Medicare/Medicaid recertification survey.

Inspectors wroteBased on record review, staff, and family interview, it was determined that the facility staff failed to follow their own policies and procedures related to the use of siderails Additionally, the facility failed to obtain a physician's order for continued use of the siderails. This was evident for 1 of 1 (resident #144) reviewed for siderails.

Inspectors wroteBased on record review and interviews, it was determined the facility failed to ensure that a Certified Nursing Assistant (CNA) received training to become a Geriatric Nursing Assistant (GNA) within the required 4-month timeframe. This was evidenced in 1 of 5 CNA/GNA employee records reviewed during the annual survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that staffing information was complete and accurate. This deficient practice was discovered during the Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interviews with facility staff, it was determined the facility failed to keep a resident free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #106) of 5 residents reviewed for unnecessary medications during the facility's Medicare/Medicaid recertification survey.

Inspectors wroteBased on medical record review and family and staff interview, it was determined the facility failed to ensure that a resident was free of significant medication error as evidenced by the failure of the nurse to verify the correct dosage and/or medication prior to administration. This was evident for 1 (Resident # 10) of 6 residents reviewed during the annual survey for medications.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to store food and fluids in accordance with professional standards for food service safety, during the annual survey.

Inspectors wroteBased on observation, review of medical records and facility policy, and interviews with facility staff, it was determined that the facility failed to ensure an effective infection control precaution during an outbreak of COVID-19 in the facility. This was evidenced by a nursing staff entering a COVID-19 isolated room without applying adaptable Personal Protective Equipment (PPE).

Inspectors wroteBased on observation and interviews, it was determined the facility failed to maintain effective pest control as evidenced by gnats in the residents rooms. This deficient practice was evidenced in 2 resident rooms (234 & 236) during the annual survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure that annual 12-hour competency training and annual Dementia and Behavioral Health training for geriatric nursing assistants (GNAs) were provided. Additionally, the facility failed to ensure that a computerized educational training program, Relias, was available to their staff to ensure mandatory annual training on abuse, resident neglect, and resident rights, as well as training related to the topics previously mentioned, were kept up to date for all employees. This was evident to be true for 4 (GNA #11, #21, # 53, # 56) out of 5 employees reviewed for annual GNA training. This deficient practice resulted in the facility employing GNAs who were not clinical prepared to care for all types of residents.

Inspectors wroteBased on the record reviews and interviews, it was determined that the facility failed to ensure the behavioral health and dementia training for geriatric nursing assistants (GNAs) were provided. This was evident to be true for 4 (GNA #11, #21, # 53, # 56) out of 5 employees reviewed for annual GNA training.

Inspectors wroteBased on observation and interview while conducting the initial kitchen tour and observation of the walk-in refrigerator, it was determined that the dietary and facility staff failed to maintain the refrigerated food in a clean and sanitary manner.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to maintain a resident's (#105) privacy. This was evident for 1 of 5 residents investigated for dignity.

Inspectors wroteBased on observation and interview it was determined the facility staff failed to honor 2 resident's choices. This was evident for 1 of 5 residents (#131) selected for review for advanced directives and 1 of 4 (#28) resident reviewed for choices.

Inspectors wroteBased on observation and facility policy review, it was determined that the facility failed to provide a safe, clean, comfortable homelike environment.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed staff to provide residents and or their representative (RP) with the proper paper documentation of the facilities bed hold policy. This was evident for 1 (Resident 142) out of 3 residents reviewed for discharge during the investigative portion of the survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to initiate, provide and implement comprehensive care plans for residents. This was evident for 3 (Residents #23, #342 and #13) of 54 residents selected for review during the annual survey process.

Inspectors wroteBased on resident interview, staff interview, and clinical record review it was determined that the facility staff failed to ensure medical appointments were made for the residents (#52). This was true for 1 out of the 1 resident reviewed for communication and sensory issues.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to provide care in the highest practicable manner for Residents (#23 and # 116). This was evident for 2 of 54 residents selected for review during the annual survey process.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure residents were being turned and repositioned as ordered. This was true for 1 out of 4 residents selected to be reviewed for pressure ulcers.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered on Resident #109. This was evident for 1 of 54 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the physician failed to determine the significance and need of an ordered laboratory blood test for Resident #116. This was evident for 1 of 54 residents selected for review during the annual survey process.

Inspectors wroteBased on review of employee files and staff interview, it was determined that the facility failed to provide at least 12 hours of nursing aides' in-services within a year. This was evident for 3 of 5 randomly selected staff members reviewed during an annual recertification survey.

Inspectors wroteBased on review of the medical record, facility policies, and staff interview it was determined that the facility failed to have an effective system in place to ensure pharmacists' review recommendations were addressed and acted on by the physicians in a timely manner. This was found to be evident for 1 (Resident #342) of 3 residents reviewed for drug regimen review during the investigative portion of the survey.

Inspectors wroteBased on review of the medical record, facility policies, and staff interview it was determined that the facility failed to have an effective system in place to ensure residents are free from unnecessary drugs. This was evident for 1 (Resident #342) of 3 residents reviewed for Unnecessary Medications during the survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to obtain a medication error rate less than 5%. This was evident for 1 of 4 residents observed for medication pass and 2 of 25 opportunities for error.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure medications were kept in a locked and secured location (2nd floor). This was evident for 1 out of the 2 facility nursing stations.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to maintain the medical record for a residents (#342 and #13) in the most complete and accurate form. This was evident for 2 of 54 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and resident and staff interviews it was determined the facility staff failed to assess a Resident's (#343) ability to perform their own wound care. This was evident for 1 of 2 residents reviewed for infections.