Heritage Health Care Center

Inspectors wroteBased on medical record review, observation, staff interview, review of hospital records, review of the National Pressure Injury Advisory Panel (NPIAP) guidelines and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure necessary and effective interventions were in place to prevent the development and/or worsening of pressure ulcers for Resident #5 and to ensure wound treatments were completed as ordered for Resident #3. This affected two residents (#3 and #5) of three residents reviewed for pressure ulcers. The facility census was 30. [...]

Inspectors wroteBased on review of the Facility Assessment, review of the Payroll Based Journal (PBJ), policy review, and interview, the facility failed to ensure Registered Nurse (RN) staffing coverage of at least eight consecutive hours per day, and the facility had a one-star rating on the PBJ for the second quarter of 2026. This finding had the potential to affect all 30 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to ensure proper infection control procedures were implemented related to glucometer use, respiratory equipment storage and sanitation of the laundry room. This affected Resident #4 and #8 and had the potential to affect all 30 residents in the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to maintain a clean and sanitary resident environment that was also in good repair. This affected 10 residents (#11, #13, #14, #15, #21, #23, #26, #27, #28, and #31) and had the potential to affect all residents residing in the facility. The facility census was 30.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure call lights were in reach of residents. This affected two residents (#2 and #28) reviewed for access to call lights. The facility census was 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate Resident #28's preference for arising. This affected one Resident (#28) of one resident reviewed for preferences. The facility census was 30.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure Resident #37's medical records were provided per the family request. This finding affected one (Resident #37) of one resident reviewed for medical record requests. The facility census was 30.

Inspectors wroteBased on record review, interview, policy review, and review of the witness statements for a facility self-reported incident (SRI), the facility did not ensure Resident #24 was free from resident-to-resident sexual abuse by Resident #26. This affected one (Resident #24) of two residents reviewed for abuse. The facility census was 30.

Inspectors wroteBased on record review, interview, and review of the facility Self-Reported Incident (SRI) #261861, and policy review, the facility failed to ensure a complete and accurate investigation was completed for an allegation of resident-resident physical abuse between Residents #3 and #36. This affected two residents (Residents #3 and #36) of four residents reviewed for abuse and had the potential to affect all residents in the facility. The facility census was 30.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure required transfer and discharge procedures were completed for Residents #3, #36, and #38. The facility failed to provide bed hold notices and notify the Long Term Care (LTC) Ombudsman for residents transferred to the hospital, failed to provide required transfer documentation, and failed to complete a discharge summary/recapitulation upon resident discharge. This affected three (Residents #3, #36, and #38) of three residents reviewed for discharge. The facility census was 30.

Inspectors wroteBased on record reviews, staff interviews, and review of the facility policy and procedure, the facility failed to ensure care conferences were completed as required and/or included the required attendees. This affected two residents (#5 and #38) of three residents reviewed for care conferences. The facility census was 30.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide adequate nail care for Resident #21. This affected one Resident (#21) of four residents reviewed for activities of daily living. The facility census was 30.

Inspectors wroteBased on record review and interview, the facility failed to ensure notification of a change in condition to the resident's responsible party affecting Resident #5. The facility also failed to timely address a change in condition affecting Resident #38. This affected two residents (#5 and #38) of two residents reviewed for change in condition. The facility census was 30.

Inspectors wroteBased on open and closed record review, policy review, and interview, the facility failed to ensure appropriate supervision levels were provided to residents while smoking and residents did not have access to smoking materials in their room. This affected one resident (Resident #36) of five residents reviewed for accidents and one resident (Resident #37) of three residents reviewed for discharge. The facility also failed to ensure residents didn't exit the facility without staff knowledge/supervision. This affected one resident (Resident #7) of five residents reviewed for accidents. The facility census was 30.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure Residents #18 and #27 received timely incontinence care. This finding affected two (Residents #18 and #27) of three residents reviewed for incontinence care. The facility census was 30.

Inspectors wroteBased on record review and interview, the facility failed to ensure psychiatric services were provided timely and per orders This finding affected one (Residents #5) of two residents reviewed for psychiatric services. The facility census was 30.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure pharmacy recommendation were acted on timely. This affected one Resident (#28) of five residents reviewed for unnecessary mediations. The facility census was 30.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure staff did not administer two doses of aspirin (anticoagulant) daily to Resident #4. This finding affected one (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 30.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Resident #27's Depakote (antiseizure and mood stabilizer) was discontinued as ordered. This finding affected one (Resident #27) of five residents reviewed for unnecessary medications. The facility census was 30.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure physician appointments were attended. This affected one Resident (#27) of one resident reviewed for appointments. The facility census was 30.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure Resident #15's meals were provided as ordered and per the approved facility menu. This finding affected one (Resident #15) of two residents reviewed for food. The facility census was 30.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure staff performed hand hygiene to prevent cross contamination of germs during medication administration. This affected two residents (#8 and #21) out of five residents observed for medication administration. The facility census was 32.

Inspectors wroteBased on observation, interview, review of narcotic count sheets and review of facility policy the facility failed to ensure the shift to shift narcotic count forms were signed by the on coming and off going nurses as required. This had potential to affect nine residents (#2, #7, #10, #16, #19, #20, #22, #25 and #31) of nine residents the facility identified as receiving narcotic medications . The facility census was 32.

Inspectors wroteBased on observation and interview the facility failed to ensure the refrigerator and microwave located in the lounge area was kept clean and sanitary. This affected seven Residents (#4, #5, #6, #7, #9, #17, and #23) of 32 residents living in the facility. The facility census was 32.

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary environment for residents. This affected Residents #15 and #38 and had the potential to affect all 41 residents residing in the facility.

Inspectors wroteBased observation and interview the facility failed to ensure residents had appropriate bed linens. This affected four residents randomly observed, Residents #8, #9, #14, and #18. Facility census was 41.

Inspectors wroteBased on record review and interview the facility failed to complete quarterly smoking assessments as care planned to identify and to the extent possible eliminate foreseeable smoking hazards. This affected one (Resident #7) of three residents reviewed for smoking.

Inspectors wroteBased on record review, observations and interview the facility failed to ensure Resident #23 was provide nail care. This affected one (Resident #23) of three residents observed for activities of daily living. The census was 41.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure all residents were given opportunities to engage in activities and have opportunities for social interaction other than routine activities of daily living. This affected one (Resident #2) of seven residents observed for quality of life.

Inspectors wroteBased on record review, interview, and review of the facility policy the facility failed to prevent an incident of resident abuse involving Resident #37. This affected one resident (#37) of three residents reviewed for abuse. The facility census was 42.

Inspectors wroteBased on record review, interview, and review of the facility policy the facility failed to ensure an incident of physical abuse involving Resident #37 was reported to the State agency as required. This affected one resident (#37) of three residents reviewed for abuse. The facility census was 42.

Inspectors wroteBased on record review, interview, and review of the facility policy the facility failed to thoroughly investigate an incident of physical abuse involving Resident #37. This affected one resident (#37) of three residents reviewed for abuse. The facility census was 42.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility self-reported incident (SRI) and investigation review, staff interview, facility policy and procedure review, and review of facility corrective action, the facility failed to prevent resident to resident abuse and failed to ensure Resident #20 was free from visitor-to-resident physical abuse. Actual harm occurred on 01/03/24 when during a resident-to resident-altercation involving Resident #20 and Resident #39 in Resident #39's room, a visitor in Resident #39's room, began swinging a dust mop in an attempt to get Resident #20 away from Resident #39 and struck Resident #20 on the head. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure eight hours of Registered Nurse (RN) coverage as required. This affected all 38 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented related to handwashing with medication pass, proper personal protective equipment (PPE) before entering a COVID-19 positive room, and did not fully develop and implement a comprehensive water management program to prevent Legionella. This had the potential to affect all residents. The facility census was 38.

Inspectors wroteBased on observation, interview, and record review ,the facility failed to ensure a clean, sanitary, and well maintained environment in good repair. This affected five residents (#4, #30, #33, #34, and #38) of seven residents reviewed for physical environment. The facility census was 38.

Inspectors wroteBased on record review and interview the facility failed to ensure the do not resuscitate comfort care (DNRCC) order form was timely signed as required by the physician. This affected one resident (#33) of one resident reviewed for advance directives. The facility census was 38.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide necessary services to maintain personal hygiene and grooming for two residents (Resident #12 and #18) out of two residents reviewed for activities of daily living. The facility census was 38.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to have a comprehensive system in place for communication and collaboration with the dialysis facility. This affected one resident (Resident #97) of one resident reviewed for dialysis. The facility census was 38 residents.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure monitoring for medication effects and potential adverse consequences was completed for residents who were receiving psychotropic medications. The facility also failed to document a rationale for extending an as-needed (PRN) anti-anxiety medication. This affected two residents (Residents #21 and #24) out of five residents reviewed for unnecessary medications. The facility census was 38 residents. Findings Include: 1. Review of Resident #24's medical record revealed an admission date of 10/07/16 and diagnoses including depression, dementia, hypertension and COVID-19. Review of a plan of care dated 10/19/16 for Resident #24's potential for adverse side effects of psychotropic drug use - anti-depressant daily for depression revealed interventions of document side effects of medication: [...]

Inspectors wroteBased on observation and interview the facility did not ensure a working call system was in place for Resident #17. This affected one resident (Resident #17) of one resident whose call light was not working. The facility census was 38.

Inspectors wroteBased on record review and interview, the facility failed to develop a care plan for antipsychotic use for Resident #34. This affected one (#34) of three residents reviewed. The census was 39.

Inspectors wroteBased on record review and interview, the facility failed to ensure orders for antipsychotic medications to be administered as needed (PRN) were limited to 14 days for Resident #34. This affected one (#34) of three residents reviewed. The census was 39.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #33 and Resident #34's medical record was accurate and complete. This affected two residents (Resident #33 and Resident #34) of three residents reviewed for medical records.

Inspectors wroteBased on interview and review of personnel files, the facility failed to have evidence State Tested Nurse Aides (STNA) had annual performance reviews for three STNA's (#315, #417 and #461). This had the potential to affect all 44 residents.

Inspectors wroteBased on observation, record review, interview and review of Centers for Disease Control (CDC) Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated 04/27/21, the facility failed to provide adequate care and positioning of Resident #18's urinary catheter drainage tubing to prevent infection. This affected one resident (Resident #94) of three residents (Resident's #6, #8 and #94) reviewed for indwelling urinary catheter use; the facility failed to provide adequate care of Resident #94's oxygen tubing to prevent contamination. This affected one resident (Resident #94) of two residents (Resident's #5 and #94) reviewed for oxygen. [...]

Inspectors wroteBased on interview and review of personnel files, the facility failed to ensure State Tested Nurse Aides (STNA) received no less than 12 hours of in-service education to ensure continued competence per year. This affected three of three STNA's (#315, #417 and #461) with the potential to affect all 44 residents.

Inspectors wroteBased on interview, review of resident funds and policy, the facility failed to notify each resident that receives Medicaid benefits when the amount in the account reached $200.00 less than the resource limit and failed to disperse funds within 30 days of a resident's death. This affected ten residents (Resident's #9, #11, #22, #23, #24, #25, #29, #30, #38 and #39) of 32 resident accounts managed by the facility and one (Resident #47) of two (Resident's #47 and #48) residents that expired. The facility census was 44.

Inspectors wroteBased on interview, review of the medical record and review of beneficiary notices, the facility failed to inform residents/representatives orally and in writing of changes in services. This affected two residents (Resident's #23 and #27) of three residents (Resident's #23, #27 and #46) reviewed for Notices of Medicare Non-Coverage (NOMNC). The facility census was 44.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to maintain Resident #94's dignity by not providing a urinary catheter drainage bag cover and Resident #41 for not providing preferred colostomy supplies. This affected two residents (Residents #94 and #41) of three residents reviewed. The facility census was 44.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Resident #24 with nail care and feed him according to speech therapy recommendations for safe swallowing. This affected one (Resident #24) of seven (Resident's #8, #14, #21, #24, #41, #42 and #144) reviewed for activities of daily living. The facility census was 44.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure skin assessments and documentation accurately reflected the status of resident's non-pressure wounds and pressure wounds. This affected two (Resident's #8 and #42) of three (Resident's #8, #25 and #42) reviewed for pressure wounds. The facility census was 44.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide an ordered treatment for Resident #24 to increase range of motion/mobility or prevent further decrease in range of motion/mobility. This affected one resident reviewed for range of motion/positioning of 44 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure Resident #6 was provided with timely incontinence care. This affected one resident (Resident #6) of four residents (Resident's #6, #195, #15 and #8) reviewed for incontinence care and one resident (Resident #6) of four residents (Resident's #8, #6, #94 and #42) reviewed for catheter (sterile tube inserted into the bladder to drain urine) care. The facility census was 44.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician/prescriber acted upon pharmacy identified irregularities for Resident #6. This affected one of six residents (Resident's #5, #6, #14, #27, #42 and #96) reviewed for unnecessary medications. The facility census was 44.