Heritage Gardens Health and Rehabilitation Center

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to consistently provide activities on the weekends, the facility identified 28 residents with moderately impaired or severely impaired cognition. This deficient practice had the risk of a decline in physical, mental, and psychosocial well-being and independence for these residents.

Inspectors wroteThe facility identified a census of 54 residents, eight residents on a puree-textured diet. Based on observation, record review, and interviews, the facility failed to follow nutritionally approved recipes during the preparation of the facility's puree-based meals. This deficient practice placed eight residents at risk for complications related to nutritional impairment.

Inspectors wroteThe facility identified a census of 46 residents. The facility identified seven residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure Resident (R) 9 and R36 nasal cannulas and BIPAP masks were stored in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 46 residents. The sample included 14 residents, with five reviewed for immunization status. Based on record review and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial infections) pneumococcal (type of bacterial infection) vaccination for Residents (R) 36, R2, R35, and R21. This placed the residents at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents, with two for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a written notice of transfer/discharge as soon as practicable, and the facility also failed to provide a bed hold notice with the required information for Resident (R) 38. This deficient practice placed R38 at risk of uninformed choices and miscommunication regarding her care needs and at risk for impaired ability to return to the facility or her same room.

Inspectors wroteThe facility identified a census of 46 residents. The sample included 14 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to consistently follow a physician's order for daily weights for Resident (R) 9. This deficient practice placed R9 at risk for delay in treatment and untreated illness.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents, with three reviewed for pressure ulcer prevention (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on interviews, record reviews, and observations, the facility failed to provide a pressure redistribution cushion for Resident (R) 35's wheelchair. This deficient practice places R35 at risk for preventable skin breakdown and pressure ulcers. Findings Included: [...]

Inspectors wrote- R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of multiple sclerosis (MS - progressive disease of the nerve fibers of the brain and spinal cord), epilepsy (brain disorder characterized by repeated seizures), convulsions (involuntary series of contractions of a group of muscles), and transient ischemic attack (TIA - temporary episode of inadequate blood supply to the brain). The admission Minimum Data Set (MDS) dated 12/08/24 documented a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The MDS documented R28 had limitations in bilateral upper and lower extremities of range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). The MDS documented R28 was dependent on staff assistance for dressing. [...]

Inspectors wroteThe facility identified a census of 46 residents. The sample included 14 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 9's bilevel positive airway pressure (BIPAP - non-invasive ventilation device that provides two different levels of air pressure to assist with breathing) mask and nasal cannula were stored in a sanitary manner. This placed R9 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents, with three reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion). Based on interviews, record reviews, and observations, the facility failed to provide consistent dementia-related care services for Resident (R) 35 to promote his highest practicable level of well-being. This deficient practice placed the residents at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: [...]

Inspectors wroteThe facility identified a census of 50 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to provide adequate supervision and failed to identify and implement interventions to address elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) risk and attempts for Resident (R)1, who had exit seeking behavior and actual attempts to elope from the facility. This placed the resident at risk for elopement and other preventable accident hazards.

Inspectors wroteThe facility identified a census of 52 residents. Based on observation, record review, and interviews, the facility failed to post the pertinent state agencies and advocacy groups in a manner that was accessible and clearly visible to residents and/or their representatives. This placed the residents at risk for impaired access to resident advocacy groups and agencies.

Inspectors wroteThe facility had a census of 52 residents. The sample included 15 residents and five Certified Nurse Aide's (CNA) were reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had received yearly performance evaluations and had the required 12 hours of in-service education per year. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 52 residents. Based on observation, record review, and interviews, the facility to ensure staff practiced standard infection control practices regarding appropriate hand hygiene during wound care. The facility also failed to ensure staff disinfected resident's items after dirty items were placed on bedside table where the resident ate her meals. The facility failed to ensure the Infection Preventionist tracked and trended infections within the facility. This had the potential to increase the residents' risk for transmission of infectious disease.

Inspectors wroteThe facility identified a census of 52 residents. The sample include 15 residents. Based on observation, record review, and interviews, the facility failed to promote a safe, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings Included: - On 09/18/23 at 07:05AM walkthrough of the facility revealed a heavy urine smell in the southwest hall and the southeast hallway. On 09/18/23 at 09:23AM an inspection of Resident (R)27's bathroom revealed missing tiles around her toilet. On 09/19/23 at 11:00AM Maintenance Staff U was on the secured unit fixing the wall tiles in the unit. She stated the facility was getting around to completing some minor repairs around the facility. [...]

Inspectors wroteThe facility had a census of 52 residents. The sample included 15 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview the facility failed to secure rooms containing hazardous materials to keep out of reach of 12 cognitively impaired /independently mobile residents. This deficient practice placed the 12 residents at risk for preventable injuries and accidents. Findings Included: - On 09/18/23 at 07:34AM, an inspection of an unsecured utility closet in the north-east hall revealed a sprayer bottle of Shurguard Plus cleaning solution in the lower cabinet. The bottle contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. [...]

Inspectors wroteThe facility identified a census of 52 residents. The sample included 15 residents with two residents reviewed for dignity. Based on observation, interview and record review, the facility failed to ensure a dignified care environment for Resident (R)1. This deficient practice placed R1 at risk unnecessary embarrassment and decreased psychosocial wellbeing. Findings Included: - The Medical Diagnosis section within R1's Electronic Medical Records (EMR) included diagnoses of schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), major depressive disorder (major mood disorder), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and insomnia (difficulty sleeping). [...]

Inspectors wroteThe facility identified a census of 52 residents with 15 residents included in the sample. The facility identified 26 residents who discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) for Resident (R) 11 and failed to ensure the SNF ABN form 10055 and the Notification of Medicare Non-Coverage (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) form 10123 was provided within the required timeframes for R16. This failure placed the residents at risk for decreased autonomy and impaired right to appeal.

Inspectors wroteThe facility identified a census of 52 residents. The sample included 15 residents with five residents reviewed for care planning. Based on observation, record review, and interviews, the facility failed identify the level of care assistance needed for activities of daily living (ADLs) on Resident (R)44's care plan. This deficient practice placed R44 at risk for ineffective treatment and preventable accidents due to uncommunicated care needs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 52 residents. The sample included 15 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Resident (R)44 and R33. This deficient practice placed both residents at risk for infections and skin breakdown. Findings Included: [...]

Inspectors wroteThe facility identified a census of 52 residents. The sample included 15 residents with two residents reviewed for treatment/services to prevent/heal pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to implement preventive measures to prevent possible skin breakdown for Resident (R) 33 who was at risk for development of pressure ulcers. The facility failed to ensure weekly wound assessments were completed for R4 who had a pressure ulcer. These deficient practices placed these residents at risk of development or worsening pressure ulcers.

Inspectors wroteThe facility identified a census of 52 residents. The sample included 15 residents with three residents reviewed for increase/prevent decrease in range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to provide services to prevent a potential decrease in ROM/mobility and/or development of contractures (abnormal fixation of a joint or muscle) for Resident (R) 19 when staff failed to provide his left-hand splint to prevent contractures. The deficient practices placed the resident at risk of loss of ability to perform activities of daily living (ADLs) and development or worsening of contractures.

Inspectors wroteThe facility identified a census of 52 residents. The sample included 15 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to implement individualized interventions to improve/maintain R44's bowel and bladder incontinence. This deficient practice placed R44 at risk for complications related to incontinence. Findings Included: [...]

Inspectors wroteThe facility identified a census of 52 residents. The sample included 15 residents with two residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to provide dementia care and services for Resident (R)27's dementia related behaviors. This deficient practiced placed the residents at risk for unmet care needs to maintain their highest practicable level of functioning. Findings Included: -The Medical Diagnosis section within R27's Electronic Medical Records (EMR) included diagnoses of dementia, visual hallucinations (sensing things while awake that appear to be real, but the mind created), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and major depressive disorder (major mood disorder). [...]

Inspectors wroteThe facility had a census of 52 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to ensure the number of nursing (licensed and unlicensed) staff and actual hours worked was posted for all three days of the onsite survey.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility staff failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to conduct a complete COVID (acute respiratory infection) screening process for visitors and staff prior to entering the facility. The facility failed to utilize aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) technique when providing tracheotomy (trach-opening though the neck into the trachea through which an indwelling tube may be inserted) care failed to ensure staff performed appropriate hand hygiene when provided care to R13, R16 and R27. This placed the residents at increased risk for infections.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to have a surety bond or otherwise provide satisfactory assurance to guarentee the security of all personal funds of the residents deposited with the facility. This placed the residents at risk for impaired psychosocial well-being and loss of personal funds.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide personal privacy for phone calls for residents in the Special Care Unit (SCU) who did not have a personal phone. This placed the residents at risk for lack of privacy during phone calls.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide a safe, clean, homelike atmosphere in the Special Care Unit (SCU- a special care unit for memory related issues is specifically designed to accommodate the unique needs of dementia patients) and the two shower rooms on the main halls of the facility. This placed the residents at risk for an non-homelike environment.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide an environment free of accident hazards for Resident (R) 23 when the facilty failed to secure a wobbly grab bar on her bed. The facility failed to ensure a safe, accident free environment when staff left an unlocked treatment cart containing medications unsupervised and left medications unsupervised at the bedside of R14 on the south hall. These deficient practices placed residents at risk for accidents.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to date Resident (R) 22, R15, R35 and R17's insulin (medication that lowers the level of glucose [a type of sugar] in the blood) vials when they were opened in one of two medication carts. The facility failed to ensure medication carts did not contain expired medications. The facility also failed to lock an unsupervised treatment carts. This placed the residents at risk for receiving an ineffective insulin medication and risk due to unintended access to unsupervised medications.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure staff treated three residents who required assistance with dignity during meals, Resident (R) 17, R37, and R16. The facility failed to provide R16 with his meal at the same time as other residents at his table. This placed the residents at risk for an undignified experience.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to notify Resident (R) 34 that she was getting a new roommate. This placed the resident at risk for impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents with three reviewed for Beneficiary Liability Notices. Based on interview and record review, the facility failed to ensure Resident (R)17 and R5 received notice of the discontinuation of Medicare Part A services in a timely manner and failed to ensure R5's notice contained the appropriate appeal information. This placed the residents at risk to make uninformed decisions about their skilled services.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents, with one reviewed for dental. Based on observation, record review, and interview, the facility failed to accurately assess one of 17 sampled residents on the Minimum Data Set (MDS), Resident (R) 34. This placed the resident at risk for an inaccurate care plan.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents, with one reviewed for constipation. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan that included Resident (R) 34's history of constipation (difficulty in emptying the bowels) and interventions to prevent constipation. This placed the resident at risk for complications related to constipation including impaction (the condition of being or process of becoming impacted, especially of feces in the intestine).

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to review and revise R17's care plan to include the transfer assistance required, placing R17 at risk for injury during transfers.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents, with one resident sampled for constipation. Based on observation, record review, and interview, the facility failed to provide interventions for lack of bowel movements for one sampled resident, who had a history of impaction (the condition of being or process of becoming impacted, especially of feces in the intestine) and constipation (difficulty in emptying the bowels), Resident, (R) 34. This placed the resident at risk for impaction.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents with two reviewed for restorative services. Based on observation, record review, and interview, the facility failed to provide range of motion for Resident (R) 16, who had contracted (abnormal permanent fixation of a joint) left hand fingers. This placed the resident at risk for further decrease in range of motion.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being for Resident (R) 20. This placed R20 at risk for decline.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for one sampled resident, Resident (R) 36. This placed the resident at risk for complication related to constipation.

Inspectors wroteThe facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 32's and R21's medication administration was free from significant errors when staff crushed extended release medications prior to administration. This placed both residents at risk for unecessary complications related to immediate release of a medication intended for extended release.