Heritage Gardens Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured and administered in accordance with the facility's medication administration policy and procedure (P&P) for one (1) of three (3) sampled residents(Resident 3), when a License Vocational Nurse (LVN 1) left a medication cup containing four (4) tablets unattended on Resident 3's beside table. This failure had the potential to cause medication errors, accidental ingestion and intentional misuse, which jeopardized the health and safety of Resident 3, who had severe cognitive impairment (a person has lost their ability to think, remember, or make decisions so much that they cannot live independently) or any person who could access Resident 3's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and maintained in sanitary conditions when on May 4, 2026 the following was observed:1. Multiple pieces of cooking equipment had significant accumulations of grease, grime, burnt on residue, rust, food debris, discoloration.2. Several food items were stored on the floor. These failures had the potential to facilitate the growth of harmful microorganisms (tiny living organisms too small to be seen with the naked eye, requiring a microscope for viewing), including bacteria, viruses, and fungi significantly increasing the risk for cross-contamination and development of food-borne illnesses, potentially affecting 93 medically vulnerable residents who rely on meals prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when a cockroach was observed by surveyors in the facility's conference room, multiple staff interviews indicated ongoing sightings of cockroaches on multiple occasions, and the facility's pest control report indicated ongoing, active cockroach activity in the facility's dining area, resident rooms, and boiler room. This failure had the potential for compromising resident health and safety by exposing residents to disease-carrying pests, contamination of food surfaces, and increased risk of infection in a vulnerable population of 98 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the facility's policy and procedure (P&P) for three of six residents (Residents 14, 30, and 73) reviewed for advance directives (a written document that tells your health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself) when:1. Resident 14 was not provided advance directive information on admission.2. Resident 30's medical record had discrepant information regarding if Resident 30 had an advance directive or not. Additionally, there was no evidence the facility requested or attempted to obtain a copy of Resident 30 advance directive.3. [...]

Inspectors wroteBased on observation and interview, the facility failed to help maintain dignity for one of three residents (Resident 115) reviewed for urinary catheters (a thin, flexible tube inserted through the an opening which leads into the bladder allowing urine drainage into an external collection bag) when Resident 115's urinary collection bag (bag connected to a catheter by a tube and is used to collect urine) was left uncovered and urine was visible to individuals entering the resident's room and people passing in the hallway. This failure had the potential to compromise Resident 115's dignity, cause embarrassment, humiliation, and diminish the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of one resident (Resident 52) when Resident 52, who had a known history of verbal aggressive behaviors, was observed to be verbally abusing Resident 56 on May 7, 2026. This failure had the potential to place Resident 56 at risk for physical injury, fear, emotional distress, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a Minimum Data Set (MDS - a computerized clinical assessment) Significant Change in Status Assessment (SCSA) within 14 days for one of five residents (Resident 53), who were reviewed for accidents when Resident 53 experienced a fall with a fracture on April 9, 2026. This failure had the potential to delay identification and implementation of necessary interventions to address the residents' care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for one of two residents (Resident 30) reviewed for behavior and emotional mood, when the Resident 30's RAI-MDS dated [DATE], did not indicate Resident 30 was experiencing hallucinations. This failure had the potential to result in unmet care needs for Resident 30 which can potentially jeopardize the residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for medication administration for 1 of 14 sampled residents (Resident 116) when Licensed Vocational Nurse 1 (LVN 1) did not to administer Cholecalciferol (a vitamin to treat Vitamin D deficiency) as ordered by the physician. This failure had the potential to result in ineffective treatment, and adverse health outcomes for Resident 116.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff monitored the indwelling foley catheter (a thin, flexible tube inserted through an opening into the bladder allowing continuous urine drainage into an external collection bag) for one of three residents (Resident 115) reviewed for urinary catheters when the tubing for Resident 115's urinary collection bag (bag connected to a catheter by a tube and is used to collect urine) was observed to be touching the floor and documentation of observation and monitoring of Resident 115's catheter was not documented as being performed as ordered by the physician. This failure exposed Resident 115 to increased risk of urinary tract infection and the spread of microorganisms (cross contamination), from the floor to his indwelling foley catheter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that allows residents' to communicate with nursing staff when they need assistance) was within resident reach for one of five sampled residents (Resident 91 ) when Resident 91 call light was wedged/stuck between the mattress and the side bed rail and not accessible to Resident 91. This failure had the potential to place Resident 91 at risk for their safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents the results of the most recent survey of the facility. This failure had the potential to prevent residents, family members, and legal representatives from being informed about the facility's compliance with state and federal requirements, which could limit their ability to make fully informed decisions regarding the residents' care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect, kindness, and dignity, when a Certified Nursing Assistant (CNA 1) engaged in a verbal altercation with Resident 1. This failure resulted in Resident 1 ' s basic right to be violated, which had the potential for Resident 1 to feel disrespected and unsafe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice scoop used for the kitchen's ice machine was stored in a clean and sanitary manner as required by the facility's policy. This failure posed potential risk for contamination of ice, which could lead to foodborne illness (food poisoning, is a sickness caused by eating food or drinking water that is contaminated with harmful bacteria, viruses, parasites, or chemicals.) and negatively impact the health and safety of 96 of 96 vulnerable residents who received food and beverages from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were being followed for six of 25 sampled residents (Residents 44, 33, 65, 4, 484 and 47) when: 1. Resident 44's Central Venous Catheter (CVC- thin, flexible tube inserted into a vein to provide access to the heart) dressing was not changed in accordance with facility policy. 2. Resident 44's Intravenous tubing (IV- flexible tube used to give fluids, medicine, or nutrients through a vein) was not dated in accordance with facility policy. 3. Resident 33's oxygen tubing (flexible plastic tube that is used to deliver oxygen from an oxygen supply to a person who needs extra oxygen) was not changed in accordance with facility policy. 4. Resident 65's oxygen tubing was not dated in accordance with facility policy 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Significant Change of Status Assessments (SCSA- comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline) Minimum Data Set (MDS- a computerized assessment instrument) were completed within 14 days for one of two residents (Resident 5) reviewed for hospice (services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care.). This failure resulted on Resident 5's care plan not being updated and revised to reflect her current status, and had the potential to delay identification and implementation of the resident's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately for two of two residents (Residents 9 and 19) reviewed for insulin (hormone that helps the body use sugar and starches for energy or store them for later use) and antibiotic (medication used to treat bacterial infections) use when: 1. Resident 9's insulin injections were not coded on the MDS assessment. 2. Resident 19's antibiotic therapy was not coded on the MDS assessment. These failures had the potential to cause inaccuracy in identifying Residents 9 and 19's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order was carried out timely for one of two residents (Resident 62) reviewed for hospice (services to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care) when Resident 62's order for a Speech Therapy (ST- assessment and treatment of communication problems and speech disorders) evaluation was not communicated with the hospice provider. This failure had the potential to place Resident 62 at risk for aspiration (when food, liquid, or other material is accidentally inhaled into the lungs), weight loss and further nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services to ensure activities of daily living were being provided for two of four residents (Residents 44 and 54) reviewed for position and mobility when: 1. Resident 44's Restorative Nursing Program (RNP- planned healthcare approach within long-term care facilities that aims to help residents maintain or regain their independence by providing targeted interventions to improve their functional abilities) recommendation from the Physical Therapist (PT- healthcare provider who helps you improve how your body performs physical movements) was not implemented. 2. Resident 54's RNP recommendation from the PT and Occupational Therapist (OT- healthcare provider who helps you improve your ability to perform daily tasks) were not implemented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen therapy (administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of decreased perfusion of oxygen to the tissues) was obtained for one of three residents (Resident 33) reviewed for oxygen. This failure had the potential for Resident 33 to develop oxygen toxicity (conditions that occurs when someone breaths too much oxygen, damaging lungs and potential for death) from the lack of monitoring from a physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure their professional staff maintained an active and current license (legal permit that allows a person to practice nursing) when a Licensed Vocational Nurse (LVN 2) worked with an expired license on [DATE], through [DATE]. This failure had the potential to place 101 highly vulnerable residents whose health conditions are already compromised at risk of receiving care from an unqualified nurse with an expired license, which could have affected and altered their health and well-being.

Inspectors wroteBased on , interviews, and record reviews, the facility failed to implement its policy for blood glucose monitoring, when one of four sampled residents (Resident 1) was not checked at the scheduled time, which potentially resulted in a change in Resident 1's condition leading to being transferred to a general acute hospital for evaluation and treatment. This failure had the potential to jeopardize the health and well-being of Resident 1 who is medically compromised. During a review of Resident's 1 admission Record (document containing clinical and demographic data), it indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis which included type 2 diabetes mellitus (a condition where the body doesn't use insulin [ a hormone that helps sugar from food to get into the cells for energy] properly, causing blood sugar levels to get too high ). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure for activities of daily living (ADL) to ensure the proper maintenance of grooming and personal hygiene services for one of the three sampled residents. This failure had the potential to put clinically compromised resident (Resident 1) at risk for infection when Resident 1 ' s unclean and untrimmed fingernails were not adequately maintained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy and procedure for restraints, for one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA 1) wrapped Resident 1 ' s waist and legs in linen sheets on April 15, 2024. This failure had the potential to place Resident 1 at risk for decreased mobility, circulation, psychological harm and even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was treated with respect, and dignity when Certified Nursing Assistant 1 (CNA1) used profanity around Resident 1. This failure compromised Resident's 1 dignity and violated her rights to respect, which had the potential for Resident 1 to experience psychosocial harm (mental harm and suffering).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure immediate protective measure was put into place to provide protections to one of three sampled resident (Resident 3) when a Certified Nurse Assistant (CNA) was not suspended immediately after an alleged abuse to Resident 3 was reported. This failure had the potential for further abuse, neglect, exploitation, or mistreatment in a vulnerable population of 94 residents as the alleged perpetrator, CNA, continued to have access to the alleged victim, Resident 3, and to other residents while the investigation was still in process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect 92 clinically compromised residents when the treatment cart was left unlocked and unattended by a licensed nurse. This failure had the potential for a vulnerable population of 92 residents to gain direct access to harmful chemicals, placing them at risk for ingestion of harmful chemicals, which could lead to poisoning and even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when A Certified Nursing Assistant (CNA 1) and A License Vocational Nurse (LVN 2) did not perform COVID-19 (a highly contagious illness caused by a virus) precautions upon entry into Covid positive room on September 19, 2023, in accordance with the facility's policy and procedure. This failure increased the risk of the transmission of Covid 19 to a compromised resident (Resident 1).

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient numbers of staff when three out of 12 sampled days (August 5, 2023, August 6, 2023, and August 20, 2023) had less than 3.5 direct care service hours per patient day (DHPPD- the total number of hours worked per patient day divided by the average daily number of residents in the facility). This failure had the potential to result in unmet needs, such as psychosocial and physical needs, and safety concerns for 101 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The ice machine was not kept in sanitary condition. 2. The microwave had food residue. 3. Seven out of seven shelves in the walk-in refrigerator had dust and grime, and the floor inside walk-in refrigerator had old food, black grime, and trash. 4. The reach in refrigerators #1 and # 2 had sticky handles. The gaskets had black grime. The ventilation fans were dusty with black debris. 5. The food warmer had food crumbs and residue on bottom shelves. 6. The shelf storing the spices had dust. 7. The area behind the stove had dust, grease build-up and black grime. 8. In the dry storage room, four lid covers for thickener, flour, sugar, and brown sugar had dust. 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services for 86 medically compromised residents when: 1. Outdated medications were observed stored and was available for resident use: 1.a. For Resident 634, a syringe of outdated ABHR gel (mixed medication containing Ativan/Benadryl/Haldol/Reglan; medication used for nausea and vomiting or agitation), with an expiration date of [DATE], was observed stored in the Medication Room refrigerator. 1.b. For Resident 36, four (4) bags of outdated Vancomycin (antibiotic), with an expiration date of [DATE], was observed stored in the Medication Room refrigerator. 1.c. For Resident 34, a vial of outdated Nitroglycerin (medication to treat chest pain), with an expiration date of [DATE], was observed stored in the Medication Cart 300. 1.d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food textures were provided for 12 of 12 residents (Residents 1, 8, 14, 20, 39, 46, 47, 57, 74, 82, 534, and 635) with puree textured diet (a diet with smooth food texture like pudding or mashed potatoes designed for someone who has difficulty swallowing and/or chewing) when Residents 1, 8, 14, 20, 39, 46, 47, 57, 74, 82, 534, and 635 received cheese and vegetable lasagna pureed entrée, that was not smooth, for lunch on July 13, 2022. This failure had the potential to place the residents that received this diet at risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for three of three residents (Residents 634, 47, and 8) reviewed for call lights. This failure resulted in Residents 634, 47, and 8 not to have means of contacting the staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard the privacy and confidentiality of personal and medical records for one of six residents (Resident 36) reviewed for medication administration when a licensed nurse used her personal cell phone to text the physician regarding Resident 36's protected health information with the resident's full name in the text message. This failure had the potential for unauthorized individuals to view Resident 36's protected health information on facility's staff personal cell phone.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Resident Assessment Instrument-Minimum Data Set (RAI-MDS - a computerized resident assessment tool) for one of three residents (Resident 48) reviewed for tube feedings (a tube inserted into the stomach used to administer liquid nutrition) when Resident 48's RAI-MDS dated [DATE], did not indicate Resident 48 was receiving enteral nutrition (liquid nutrition) through a feeding tube. This failure had the potential to result in unmet care needs for Resident 48 which can potentially jeopardize the residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 13) reviewed for rehabilitation services was provided physical therapy services (PT services - specially designed exercises and equipment to help patients regain or improve their physical abilities) as ordered by a physician. This failure had the potential for Resident 13 not to obtain services intended to help the resident achieve and maintain his highest level of mobility functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status (nutrition and hydration status) for three of seven residents (Residents 11, 71 and 48) reviewed for nutrition when: 1. Resident 11, who was at risk for weight loss, was not assessed by the Registered Dietitian (RD) upon admission. (RD assessments are essential to determine the overall nutritional status of residents, diagnose malnutrition (lack of proper nutrition), identify underlying issues that could lead to malnutrition, and plan necessary interventions.) 2. Resident 71, who was at risk for weight loss, was not assessed by the RD quarterly, after the facility failed to inform the RD about the resident's refusal to be weighed. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an enteral nutrition bottle (container with liquid nutritional formula administered to a resident through a feeding tube inserted directly into the stomach) for one of three residents (Resident 48) reviewed for tube feeding (a tube inserted directly into the stomach for the administration of liquid nutrition) was labeled with nurse initials and date (when the feeding was started) in accordance with the facility's policy and procedure. This failure had the potential for the enteral nutrition bottle to exceed the manufacturer's prescribed hang-time (amount of time a feeding is safe to use after opened), and for Resident 48 to not receive the prescribed amount of nutritional calories resulting in weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate respiratory care and treatment for one resident (Resident 9) reviewed for respiratory care when Resident 9 received oxygen therapy (use of oxygen as medical treatment) without a physician's order. This failure had the potential for Resident 9 to receive improper oxygen therapy and potentially missed opportunities to identify Resident 9's significant change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN 1) knew how to properly assess the arterio-venous fistula (AVF- a site on resident's arm used to connect a blood filtering machine) for two residents (Resident 5 and Resident 9) reviewed for hemodialysis (dialysis- a process of purifying the blood of a person whose kidneys are not working normally). This failure increased the potential for staff to have delayed detections, reporting and/or management of complications from the hemodialysis access site for Resident 5 and 9.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate was less than 5%. This occurred when three errors for Resident 55 occurred out of 27 opportunities for a medication administration error rate of 11.1%. This failure had the potential to expose residents to preventable medication errors which could adversely affect their health and safety.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure medications were appropriately labeled in accordance with the facility's policies and procedures and standards of practice when: 1. For Resident 36, two opened and undated insulin (drug used to lower blood sugar) pens were observed stored in the Medication Cart 300. 2. For Resident 484, an opened foil of Budesonide (steroid medication) inhalation pouches observed in the Medication Cart 300 did not have an open date. 3. An incomplete prescription label for a controlled substance (highly regulated medication due to potential for abuse or misuse), Morphine Sulfate (strong pain medication), was observed stored in the Medication Room Refrigerator. It was not labeled with important information such as prescription number and expiration date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their dietary staff had the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services, when three Dietary Aides (Dietary Aides 1, 2, and 3) did not know the manufacturer's guidelines related to the sanitizer testing of the dishwasher. This failure had the potential to cause foodborne illness (illness caused by eating contaminated foods) or food contamination for 84 residents who received foods from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records for five residents (Residents 284, 11, 13, 15, and 29) of 24 sampled residents, were complete and accurately documented when: 1. For Resident 284, a controlled substance (highly regulated medication due to potential for abuse or misuse) pain medication was removed from the drug supply and logged out of the Control Drug Record (CDR - narcotic count sheet) but not documented as administered on the Medication Administration Record (MAR) at the time of removal. This failure had the potential for inadequate controlled substance accountability in the facility or to expose the resident to preventable medication errors. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe infection control program for 86 medically compromised residents when: 1. A licensed nurse did not clean and disinfect the glucometer (devices measures blood sugar values) after using it on Resident 36. 2. Outdated supplies were available for resident use in the Medication Room. These failures had the potential for cross-contamination (unintentional transfer) of blood borne pathogens (microorganisms that cause serious disease present in human blood) due to an improperly cleaned glucometer and/or to be treated with ineffective or deteriorated (reduced quality) supplies which could negatively impact the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their kitchen equipment was maintained in a safe operating condition when: 1. The light for the walk-in freezer and refrigerator was dim. 2. The walk-in freezer was noted with a chunk of ice around the black pipe behind the ventilator fans. 3. The walk-in refrigerator was noted with a copper pipe dripping water behind the ventilator fans. These failures had the potential to negatively affect the quality of food served to 84 medically compromised residents who received food from the kitchen.