Heritage Gardens Rehabilitation and Healthcare

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 3 of 4 hallways (200 Hall, 300 Hall, and 400 Hall) reviewed for accidents and hazards. The facility failed to ensure 3 of 3 mechanical lifts on 3 Halls (200 Hall, 300 Hall and 400 Hall) were locked and secured when not in use. This failure could place residents, at risk of falls and/or injuriesFindings include:Observation of the 200 Hall on 04/14/26 at 1:13 PM revealed 1 unlocked and unsecured mechanical lift parked on the 200 Hall parked in between room [ROOM NUMBER] and room [ROOM NUMBER]. Observation of the 400 Hall on 04/14/26 at 1:27 PM revealed 1 unlocked and unsecured mechanical lift parked on the 400 Hall parked outside of room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to secure the resident had the right to personal privacy and confidentiality of his or her personal and medical records for two staff reviewed for privacy and confidentiality of records. The facility failed to ensure LVN A locked and secured her laptop which contained private healthcare and confidential information for residents on the 100 Hall on 04/14/26. This failure could place residents at risk of exposure of their personal and medical information disclosed to unauthorized individuals including visitors and other residents, causing embarrassment, frustration, loss of dignity, decreased privacy and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse on 01/25/2026 when Resident #2 touched Resident #1 between her legs over her pants. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 resident (Resident #1) reviewed for abuse reporting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an alleged violation involving abuse was investigated for 1 (Resident #1) of 6 residents reviewed. The facility's Abuse Coordinator failed to investigate Resident #1's sexual abuse allegation that occurred on 01/25/2026. This failure could place residents at risk of abuse, neglect, and/or exploitation.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program to the maximum extent practicable for one of five residents (Resident #25) reviewed for PASARR requirements. The facility failed to identify and screen Resident #25 as having a serious mental illness and failed to complete a new PASRR Level I screening and referral for further evaluation when there was evidence of mental illness. This failure placed residents at risk of not being appropriately identified, screened, and referred for PASRR evaluation and determination of the need for specialized services.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one Resident (Resident #44) of four Resident reviewed for medication administration. The facility failed to ensure proper storage and disposal of Resident #44's Albuterol Sulfate HFA (expired on 1/10/2026). This failures could place residents at risk of medication error, reduced therapeutic effectiveness, and potential adverse and administration of expired medication. Review of Resident #44's Quarterly MDS Assessment, dated 12/26/25, reflected Resident #44 is a [AGE] year-old female admitted on [DATE], she had a BIMs score of 8 indicated moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 2 medication carts (hall 300 Nurses cart and 100 hall medication Aide cart) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure proper storage and disposal Resident #83's Albuterol Sulfate HFA (Resident discharged [DATE]), acidophilus 1 billion which required refrigeration per manufacturer's guidelines was observed stored unrefrigerated. These failures could place residents at risk of medication error, reduced therapeutic effectiveness, and potential adverse outcome due to improper storage. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (Resident #17) of three residents, reviewed for infection control. The facility failed to ensure CNA C changed gloves and performed hand hygiene during incontinence care for Resident #17. This failure placed residents at risk for healthcare associated cross contamination and infections. Review of Resident #17's Quarterly MDS Assessment, dated 01/03/26, reflected the resident was [AGE] year-old male admitted [DATE] who had a BIMs score of 00 indicated severe cognitive impairment. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from abuse when Resident #1 punched him on 06/21/25, causing Resident #2 to have a laceration to his top lip. This failure could place residents at risk for severe and long-lasting impact for physical, psychological and emotional wellbeing.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents, reviewed for infection control. 1. The facility failed to ensure CNA A changed gloves and performed hand hygiene during incontinence care for Resident #1. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 Nurse Aides (NA A and NA B) of four nurse aides reviewed for proficiency of nurse aides. The facility failed to ensure NA A and NA B were CNAs after four months of being hired 06/03/24. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to exercise his or her rights as a resident of the facility and a citizen or resident of the United States for 5 of 8 residents (5 confidential residents) reviewed for resident rights. The facility failed to ensure the five confidential residents had the right to be able to vote in the current election cycle. This deficient practice could affect dependent residents and their families and contribute to feelings of shame and loss of dignity.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 7 of 61 days (11/05/23, 11/11/23, 11/12/23, 11/19/23, 12/10/23, 12/24/23, and 12/31/23) reviewed for staffing. The facility failed to have an RN for at least 8 consecutive hours for the following 7 days: 11/05/23, 11/11/23, 11/12/23, 11/19/23, 12/10/23, 12/24/23, and 12/31/23. This failure placed all residents at risk of not receiving adequate medical care and supervision of an RN.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 5 of 8 residents (5 confidential residents) reviewed for medically related social services. The facility failed to obtain needed services from outside entities, including absentee ballots, to ensure 5 confidential residents had the right to be able to vote in the current election cycle. This deficient practice could place residents at risk for their mental and psychosocial needs not being met and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs. The facility failed to prepare and serve pureed rosemary roast pork and pureed corn as a pudding consistency for residents who required pureed diets. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to dissatisfaction, poor intake, choking, and/or weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #41 and #46) reviewed for infection control. 1. The facility failed to ensure LVN L put on appropriate PPE (gown) before entering Resident #46's room to administer medications via gastronomy tube to Resident #46, who was on enhanced barrier precautions. 2. The facility failed to ensure LVN D changed soiled gloves and performed hand hygiene during wound care for Resident #41. These failures placed residents at risk of cross contamination and the spread of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for 1 (Residents #1) of 4 residents reviewed for tube feeding management. The facility failed to ensure Resident #1's Piston syringe for G tube flushing was changed daily. (A piston syringe is a small, cylindrical piece that fits inside the barrel of a syringe. It is typically made of plastic or metal and moves back and forth within the barrel to draw in or expel fluids for tube feedings.) These failures could place residents at risk un-sanitized treatment and infections.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #1) of three residents reviewed for baseline care plan. Resident #1s baseline care plan was missing information related to dialysis. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who require dialysis services, receive services consistent with professional standards of practice, the person-centered care plan and the resident's goals and preferences for one (Resident #1) of three residents, reviewed for in-house dialysis. The facility failed to ensure that Resident #1 was dialyzed Monday-Friday as ordered by the physician. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 10/03/23 at 9:34 AM revealed: - 3 tomatoes withered and 1 tomato with white spots - 2 heads of cabbage with black spots. Observation of the facility's freezer storage on 10/03/23 at 9:37 AM revealed: -1 box of country fried beef steak open and exposed to air - 1 bag of chicken undated; and -1 bag of fries undated. Observation of the facility's prep table on 10/03/23 at 9:40 AM revealed: -1 white onion with black spots. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest for one (Hall 300) of four halls. The facility failed to treat the facility flies for Hall 300. This failure could affect all residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteResident #54 FTag Initiation Based on observation, interview and record review the facility failed to provide the necessary services to maintain grooming and personal care for two (Resident #34 and Resident #54) of four residents reviewed for ADL care in that: Resident # 34 was not provided supervision with a razor for grooming and personal care. The facility failed to provide adequate supervision to Resident #54 while toileting. These failures could place residents requiring supervision with personal care, grooming, and toileting at risk of low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for one (Resident #217) of eight residents observed for indwelling urinary catheters. The facility failed to ensure Resident #217's foley catheter drainage bag was not on the floor, and not full beyond capacity. This failure could place residents with urinary catheters at risk for urethral tears, dislodging of the catheter, and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe environment for residents who utilized 1(Shower Room A) of 2 shower rooms reviewed. The facility failed to ensure the water temperature was at a comfortable tempetature. This failure could place the residents at risk for an unsafe and uncomfortable environment.