Heritage Health Services

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and served in a sanitary manner. This practice had the potential to affect all 25 residents residing in the facility. The kitchen cooler and dry storage area contained multiple open and undated food items. Staff did not follow appropriate hand hygiene procedures in the kitchen and while serving food.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect all 25 residents residing in the facility. The facility did not maintain infection surveillance logs to assist with the recognition of trends and patterns of infection. In addition, the facility did not monitor residents for signs and symptoms of infection. Hand hygiene was not offered or completed for residents prior to dining. Licensed Practical Nurse (LPN)-E did not complete appropriate hand hygiene during wound care for R1.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly. This practice had the potential to affect more than 4 of the 25 residents residing in the facility. The facility did not ensure the required members of the QAPI committee met at least quarterly from March 2024 through February 2025.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were offered or administered for 5 residents (R) (R1, R5, R7, R19, and R21) of 5 sampled residents. The facility did not offer R1, R5, R7, R19, or R21 the PCV20® vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R1) of 3 sampled residents with a Guardian when the resident's nursing home stay exceeded ninety days. R1 was admitted to the facility on [DATE] with the consent of a legal Guardian. The facility did not pursue protective placement when the resident's stay exceeded ninety days.

Inspectors wroteBased on staff, resident, resident representative interview and record review, the facility did not ensure 2 residents (R) (R5 and R14) of 2 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R5 was transferred to the hospital on 2/21/25. Neither R5 or R5's Guardian received a written transfer notice. R14 was transferred to the hospital on [DATE], 1/8/25, and 2/14/25. R14 did not receive a written transfer notice for any of the transfers.

Inspectors wroteBased on staff, resident, resident representative interview and record review, the facility did not ensure a bed hold notice was provided for 2 residents (R) (R5 and R14) of 2 sampled residents. R5 was transferred to the hospital on 2/21/25. Neither R5 or R5's Guardian received a bed hold notice. R14 was transferred to the hospital on [DATE], 1/8/25, and 2/14/25. R14 did not receive a bed hold notice for any of the transfers.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary care and treatment to promote healing and/or prevent impaired skin integrity for 1 resident (R) (R1) of 15 sampled residents. R1 was diagnosed with a rare skin condition. R1's care plan indicated staff should not use incontinence briefs for R1. During an observation of care on 3/11/25, staff removed an incontinence brief from R1 and applied a clean brief.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R1 and R2) of 5 residents observed during the provision of cares. R1 was on enhanced barrier precautions (EBP). On 12/4/24 and 12/5/24, staff did not wear personal protective equipment (PPE) during the provision of care for R1. In addition, staff did not complete appropriate hand hygiene during a dressing change on 12/5/24. On 12/4/24 and 12/5/24, R1 and R2's uncovered catheter drainage bags were in contact with the floor.

Inspectors wroteBased on staff interview and record review, the facility did not have a licensed nurse on duty to meet the needs of residents for approximately 2.5 hours on the [DATE] PM shift. This had the potential to affect 23 of 23 residents (R) residing in the facility. On [DATE], an agency nurse who worked the AM shift left the facility without licensed nurse coverage for the PM shift. The facility was without a nurse for approximately 2.5 hours. Due to not having a licensed nurse on duty, 3 residents (R10, R16, and R7) did not receive blood glucose monitoring in accordance with physician orders. Fourteen residents (R8, R9, R10, R11, R12, R5, R1, R13, R14, R15, R16, R7, R3, and R17) did not receive medication in accordance with physician orders. One resident (R5) was transported by ambulance to the emergency room (ER) without a nurse assessment. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of neglect was reported to the State Agency (SA) when the facility was without a licensed nurse for approximately 2.5 hours on 4/14/24. This had the potential to affect 14 of 23 residents. On 4/14/24, the facility was without a licensed nurse on the PM shift from approximately 3:02 PM until 5:35 PM. Three residents (R10, R16, and R7) did not receive blood glucose monitoring in accordance with physician orders. Fourteen residents (R1, R3, R5, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17) did not receive medication in accordance with physician orders or the facility's policy. One resident (R5) was transported by ambulance to the emergency room (ER) without a nurse assessment to determine R5's medical needs.

Inspectors wroteBased on staff interview and record review, the facility did not implement their written policies and procedures that prohibit and prevent abuse for 3 of 8 facility and contracted staff reviewed for caregiver background checks. The facility did not ensure a thorough and timely background check was completed for Licensed Practical Nurse (LPN)-K, LPN-I, and Certified Nursing Assistant (CNA)-L.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the accurate acquiring, receiving, dispensing, and/or administering of drugs and biologicals to meet the needs of 1 resident (R) (R2) of 1 sampled resident. R2 did not have a physician's order for alprazolam (a sedative medication used to treat anxiety) from 8/30/24 to 9/3/24. R2 received alprazolam 6 times during that time period.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the nurse staffing posting accurately reflected the number of nursing staff working in the facility. This had the potential to affect all 23 residents who resided in the facility on 4/14/24. The nurse staffing posting and payroll record did not accurately reflect the actual nursing staff who worked on 4/14/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a Registered Nurse (RN) was scheduled for at least 8 consecutive hours a day 7 days per week. This had the potential to affect all 25 residents residing in the facility. The facility did not have a RN on duty for 8 consecutive hours on 8/29/23, 10/4/23, 10/6/23, and 10/7/23.

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associate's or higher level degree in food service management or hospitality. This had the potential to affect all 25 residents residing in the facility.

Inspectors wroteBased on observation, staff interview and record review, the facility did not ensure food was stored and served in a safe and sanitary manner. This practice had the potential to affect 25 of 25 residents residing in the facility. The kitchen cooler and dry storage area contained multiple open, undated, unclearly dated, and expired food items. Staff did not follow appropriate hand hygiene procedures when food was prepared and served. Kitchen equipment and food services areas were not in a clean and sanitary condition. Staff used an unsanitary practice when processing dishes.

Inspectors wroteBased on staff interview and record review, the facility did not ensure it completed mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 25 residents residing in the facility. Staffing information for fiscal quarter, date range: Quarter 1 (October 1-December 31), Quarter 2 (January 1-March 31), Quarter 3 (April 1-June 30), and Quarter 4 (July 1-September 30) of the Payroll Based Journal (PBJ) were not correctly submitted to CMS.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy for 3 Residents (R) (R3, R11 and R17) of 25 sampled residents with the potential to affect multiple other residents. On 2/4/25, Surveyor observed an unattended and unlocked medication cart on multiple occasions. On 2/5/24, Surveyor observed an open and undated eye drop medication for R11 in the unit 3 medication cart. On 2/5/24, Surveyor observed an open and undated inhaler for R17 in the unit 3 medication cart. On 2/5/25, Surveyor observed an open and undated medication bottle for R3 in the unit 3 medication storage room.

Inspectors wroteBased on observation and resident and staff interview, the facility did not maintain dignity for 2 Residents (R) (R10 and R12) of 12 sampled residents. R10 and R12 required feeding assistance. During the lunch meal on 2/5/24, staff did not sit down while feeding R10 and R12.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 3 Residents (R) (R3, R16, and R1) of 3 sampled residents. R3's medical record indicated R3 had a legal guardian upon admission and had court-ordered guardianship paperwork. R3's medical record did not contain protective placement documentation. R16's medical record indicated R16 had a legal guardian upon admission and court-ordered guardianship paperwork. R16's medical record did not contain protective placement documentation. R1's medical record indicated R1 had a legal guardian, but did not contain court-ordered determination of guardianship or protective placement documentation.

Inspectors wroteBased on staff and Power of Attorney (POA) interview and record review, the facility did not notify the POA for 1 Resident (R) (R25) of 2 sampled residents when the resident returned from the hospital. R25 was transferred to the hospital following a seizure and returned to the facility on [DATE]. R25's POA was not notified when R25 returned to the facility.

Inspectors wroteBased on staff interview and record review, the facility did not ensure written notification of financial liability via an Advanced Beneficiary Notice (ABN) was provided for 1 Resident (R) (R228) of 3 sampled residents. The facility did not provide an ABN to R228 when R228's Medicare Part A benefits ended on 11/21/23. R228 discharged home from the facility on 11/29/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse consequences of high-risk medications for 1 Resident (R) (R5) of 5 residents reviewed for unnecessary medications. R5 was prescribed gabapentin and divalproex (high-risk medications in the anticonvulsant class used to treat seizures). R5's care plan did not contain monitoring for adverse consequences of gabapentin or divalproex.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 26 opportunities which resulted in a 7.69% medication error rate that affected 2 Residents (R) (R14 and R12 ) of 7 residents observed during medication pass. R14 was administered 10 units of insulin lispro (use to treat diabetes) injection solution 100 units/ml (milliliter) via insulin pen. Staff did not prime the insulin pen prior to administration. Staff did not check R12's heart rate and blood pressure prior to administering a diltiazem (Tiadylt) (used to treat high blood pressure and chest pain) extended release (ER) 300 milligram (mg) capsule.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a resident or their representative was provided a written transfer notice and did not ensure the State Long Term Care Ombudsman was notified when 2 Residents (R) (R10 and R17) of 2 residents transferred to the hospital. R10 was transferred to the hospital on 1/9/24. The facility did not provide R10 or R10's representative with a written transfer notice and did not notify the Ombudsman of R10's transfer. R17 was transferred to the hospital on 4/21/23, 6/29/23, and 10/5/23. The facility did not provide R17 or R17's representative with a written transfer notice and did not notify the Ombudsman of R17's transfers.

Inspectors wroteBased on staff interview and record review, the facility did not ensure written bedhold policy information was provided for 2 Residents (R) (R10 and R17) of 2 residents who transferred to the hospital. R10 was transferred to the hospital on 1/9/24. The facility did not provide R10 or R10's representative with a written bedhold notice. R17 was transferred to the hospital on 4/21/23, 6/29/23, and 10/5/23. The facility did not provide R17 or R17's representative with a written bedhold notice.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services to maintain the highest practical physical well being related to nursing assessment and a change in condition for 1 Resident (R) (R25) of 14 sampled residents. On [DATE], R25 returned from the hospital following a seizure at the facility on [DATE]. Staff did not assess R25 for over 12 hours after R25 returned.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate a fall to ensure the environment was as free of accident hazards as possible for 1 Resident (R) (R1) of 5 sampled residents. R1 was overheard by a nurse reporting a fall to a family member on 8/18/23. The facility did not complete a thorough investigation to determine a root cause analysis or complete staff education to minimize the likelihood of future falls.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure the resident representative (RR) was notified timely of a fall for 1 (R173) of 1 resident reviewed for notification of change.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to revise the comprehensive care plan to address a resident's ability to safely smoke without supervision for 1 (R9) of 1 sampled resident reviewed for smoking.

Inspectors wroteBased on observations, interview, record review, and facility policy review, it was determined that the facility failed to ensure a medication error rate of less than 5% for 2 (Residents #3 and #13) of 4 residents observed for medication administration. Specifically, there were two errors out of 31 opportunities, which yielded a medication error rate of 6.45%.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed between dirty and clean tasks during catheter care to prevent potential infection for 1 (R1) of 2 sampled residents reviewed for urinary catheters/urinary tract infection.