Heritage Hall Nursing Center

Inspectors wroteBased on interview and record review facility staff failed to document treatments as ordered by the physician for four residents (Resident #1, #2, #3 and #4). The facility census was 40.1. Review of the facilities Wound Treatment Management policy, revised 11/07/25, showed the purpose of the policy is to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Treatments will be documented on the Treatment Administration Record or in the electronic health record.2. Review of Resident #1's Quarterly Minimum Data Set, dated [DATE], a federally mandated assessment tool, showed staff assessed the resident with moderate cognitive impairment and diagnoses of gluteal cleft wound. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement appropriate infection control procedures to prevent the spread of communicable diseases when staff failed to screen seven staff (Certified Medication Technician (CMT) B, [NAME] D, Certified Nurse Aide (CNA) E, CNA F, Licensed Practical Nurse (LPN) G, Homemaker H and the Employee Experience Coordinator) out of 10 staff for tuberculosis (TB), a contagious, air-borne bacterial infection primarily affecting the lungs, in accordance with facility policy. The facility census was 38. 1. Review of the facility's policy titled TB Testing Policy, dated January 2025, showed: [...]

Inspectors wroteBased on interview, and record review, facility staff failed to maintain a system that assured full, complete, and separate accounting of each resident's personal funds to preclude the commingling of resident funds with facility funds for three residents (Residents #23, #49 and #50) out of 102 sampled residents. The facility census was 38. 1. Review of the facility's policy titled Resident Personal Fund, revised [DATE], showed: [...]

Inspectors wroteBased on record review and interview, facility staff failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment tool, when staff did not accurately code medications administered for six residents (Resident #9, # 15, #26, #29, #30 and #39) out of 14 sampled residents. The facility census was 38.1. Review of the facility's policy titled MDS 3.0 Completion, dated 11/05/24, showed staff are directed to assess residents, using a comprehensive assessment process, to identify care needs and to develop an interdisciplinary care plan. According to federal regulations the facility conducts initially and periodically a comprehensive, accurate and standardized of each resident's functional compacity. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed to ensure outdoor waste containers remained covered when not in actual use. This failure has the potential to affect all residents. The facility census was 38.1. Review of the facility provided policies from 08/11/25 through 08/14/25, showed did not contain a policy related to maintenance of outside waste containers. Review of the United States Food and Drug Administration Food Code, 2022 edition, 5-501.15, showed Receptacles and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 87. 1. Review of the facility provided policies, showed the records did not contain a policy related to the qualifications for Director of Food and Nutrition Services. Review of the dietary manager's (DM) personnel records showed a hire date for the DM position listed as 04/20/23. Review showed a certificate of completion for a food protection manager course, which showed a start date of 02/21/24 and a completion date of 05/07/24. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to thaw frozen meat using approved methods to prevent the growth of food-borne pathogens. Facility staff failed to store food in a manner to prevent contamination and out-dated use. Facility staff failed to reheat pureed food in accordance with the standardized recipes to prevent the growth of food-borne pathogens and potential for food-borne illness. These failures have the potential to affect all residents. The facility census was 41. 1. Review of the facility's Food Storage (Dry, Refrigerated and Frozen) policy, dated 2020, showed Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Review showed the policy did not contain instruction to staff on approved methods for thawing frozen foods. Observation on 06/11/24 from 9:50 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure residents who are unable to complete their own Activities of Daily Living (ADLs) received necessary care and services to maintain good personal hygiene two residents (Resident #13 and #17) out of 14 sampled residents, when staff failed to assist with facial hair grooming, clothing changes and showers. The facility census was 41. 1. Review of the facility's policy titled Activities of Daily Living, dated 2023, showed care and services will be provided for the following ADL's: -Bathing, dressing, grooming, toileting and oral care; -Transfer and ambulation; -Eating to include meals and snacks; -A resident who is unable to carry out ADL's will receive the necessary services to maintain good nutrition, grooming, and personal or oral hygiene; -The facility will maintain individual objectives on the care plan. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide residents with a written response to grievances. The facility census was 37. 1. Review of the facility's Resident and Family Grievances policy, dated 1/23/23, showed staff were directed as follows: - The grievance officer is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the residents; and coordinating with state and federal agencies as necessary in light of specific allegations; - Upon request, the facility will give a copy of this grievance policy of the resident; [...]