Heritage Convalescent Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 18 residents (Resident #15) reviewed for accommodation of needs in that:Resident #15 was not being provided with the correct size of adult brief. This failure could place residents at risk of not having met their needs and a decline in their quality of care and life.

Inspectors wroteBased on interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 5 of 7 anonymous residents. The facility failed to address a grievance put forth by the resident council regarding sheets not being changed on beds. This failure could lead to residents feeling unheard and unvalued in their place of residence. Findings Included:During a resident council meeting on 12/03/25 at 2:00 PM 5 of 7 attendees complained that their bed sheets were not being changed weekly while they were getting their showers, which was what was supposed to happened. One of the anonymous residents stated that she was a new admit and had only resided in the facility for one month. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer, and pantry items were properly stored, labeled, and dated. This failure could place residents at risk of food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #24) of 24 residents reviewed for advanced directives. Resident #24 had a DNR in her record that was signed incorrectly by the witnesses. The facility's failure to ensure the accuracy of a residents advanced directive could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents the right to a safe, clean, comfortable, and homelike environment including clean bed linens for 2 (Resident #12 and Resident #78) of 18 residents reviewed for environment.1. The facility failed to ensure Resident #12 had clean sheets.2. The facility failed to ensure Resident #78 had clean sheets and a clean, sanitary room. These failures could lead to residents feeling neglected and/or to infection control issues. Findings Included:1. Record review of Resident #12's admission record dated 12/03/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to cognitive communication deficit (difficulty with one or more of the following: [...]

Inspectors wroteBased observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #1 and Resident #24) of 18 residents reviewed for comprehensive care plans.1. The facility failed to include Resident #1's oxygen therapy in her care plan.2. The facility failed to include Resident #24's skin lesion in her care plan. These failures could lead to residents not receiving necessary care and/or treatment or receiving inaccurate care/and or treatment. Findings Included:1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 (Resident #11) of 18 residents reviewed for accident hazards. The facility failed to ensure Resident #11 did not have a tube of medicated cream and an aerosol can of sanitizing spray in her room. This failure could lead to harm if a resident was to ingest the cream and/or spray their skin with the sanitizing spray. Findings Included:Record review of Resident #11's admission record dated 12/03/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for respiratory care. -Resident #1 was receiving oxygen with no orders for her therapy. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated and freezer items were properly stored, labeled, and dated. This failure could place residents at risk of food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 (Resident #1) of 6 residents reviewed for medical records. The facility failed to document wound care had been completed on 6 days of the previous 90 days that were reviewed. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from misappropriation of property from 1 of 1 (LVN A) nurses reviewed. The facility did not prevent LVN A from taking narcotics from multiple unidentified residents. This failure could place residents at risk of continued misappropriation of property, increased pain, and lost trust in facility staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. Cooks C, D, and E failed to perform hand hygiene appropriately when preparing foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 1 of 7 staff (RN J) reviewed for nursing services. The facility failed to ensure the following: -RN J used proper hand hygiene when administering medications -RN J observed resident consume their medications at time of administration. -RN J used proper hand hygiene while assisting an unidentified resident with eating their midday meal. -RN J locked and secured medication cart during medication administration. -RN J used proper hand hygiene or donning of gloves before breaking a pill with her hands for Resident #57. [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (Hall 100 medication cart and Hall 400 medication cart) of 3 medication carts reviewed for medication storage. -Hall 100 medication cart left unlocked and unattended. -Hall 100 medication cart revealed 4.5 lose pills in the bottom of medication drawers. -Hall 100 medication cart had insulin for Resident #41 with no open date on her Humulin N insulin. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communication diseases and infections for 3 (Resident #15, Resident #22, and Resident #57) of 17 Residents. The facility failed to ensure the following: -RN J used proper hand hygiene while assisting an unidentified resident with eating their midday meal. -RN J used hand hygiene and donning of gloves before breaking a pill with her hands for Resident #57. -CNA H perform hand hygiene during incontinent care of Resident #15. -CNA I perform hand hygiene during incontinent care of Resident #22. [...]

Inspectors wroteBased on observations, interviews, and record reviews, it was determined the facility failed to ensure each resident was provided the right to a dignified existence, self-determination, for 1 of 20 residents reviewed for Resident rights (Resident #15). -The facility failed to provide dignity and respect for Resident #15 by providing a privacy bag for her foley catheter. The facility's failure to ensure that each resident was treated with respect, dignity, and care in a manner that protects and promotes the rights of the residents.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #10) of 20 residents reviewed for advanced directives. Resident #10 had a DNR in her record with no date for the physician signature. The facility's failure to ensure accuracy of resident medical records for advanced directives such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical and nursing needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #50) of 19 residents reviewed for care plans. The facility failed to update the wound care orders in Resident #50's care plan. This failure could put residents at risk of not receiving necessary care and treatment.

Inspectors wroteBased observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive, person-centered care plan, and the resident's choices for 1 (Resident # 50) of 20 residents reviewed for quality of care. The facility failed to provide wound care for Resident #50 as ordered. This failure could place residents at risk of poor healing, worsening infection, and increased pain. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #6) of 5 residents reviewed for unnecessary medication. Facility failed to ensure Resident #6's PRN order for psychotropic medication was limited to 14 days. This failure could place residents at risk of oversedation which could lead to falls and/or injuries as well as affect their quality of life. Findings Included: Record review of Resident #6's admission record dated 10/01/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes (insufficient production of insulin, causing high blood sugar), depression, and anxiety disorder. Record review of Resident #6's care plan completed 09/09/24 revealed she used antianxiety medications for anxiety disorder. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 (Resident #18 and Resident #60) of 20 residents reviewed for environment and 2 of 2 resident refrigerators. The facility failed to remove expired and rotten food from both resident refrigerators and failed to maintain them in sanitary condition. This failure could place residents at risk of contracting foodborne illness and/or feeling uncomfortable or degraded in their living environment. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for physician orders for treatments. The facility failed to follow physician orders and perform wound treatments as ordered for Resident #1. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition.

Inspectors wroteBased on interviews and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing on a full-time basis for the care and treatment of 65 of 65 residents. The facility failed to employ a DON from November 14, 2023, to present day. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care and disasters such as with flooding, power outage, tornado, fire, etc.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments for 2 of 2 medications. -Medication bubble pack was left unattended on medication cart on Hall 400 -Medication discovered was left on bedside table for Resident #1 These failures could place all residents at risk for obtaining medications that could cause adverse reactions.

Inspectors wroteBased on observation, record review, and interview the facility failed to post in a form and manner accessible to residents, resident representatives contact information including telephone numbers for the Long-Term Care Ombudsman program for 2 of 4 residents interviewed in a confidential group interview. The facility failed to ensure the Ombudsman Program information was posted in an area accessible for residents or resident representatives to see. This failure placed residents at risk of not being informed about the Ombudsman Program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure dented cans were not in circulation. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. 4. The facility failed to ensure the pantry was free from bugs. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 of 3 medication carts (Rehabilitation Hall Cart) reviewed for medication storage. The Rehabilitation Hall Medication Cart contained an insulin pen that had no markings for which resident it was being used for and no date of when it was opened/accessed and when it would expire. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.