Heritage Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure narcotic medications were free from theft of an employee for 1 of 3 residents reviewed for misappropriation of property. (Resident B) The deficient practice was corrected on 2/10/2026, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were labeled with the date received, the reach-in refrigerator was maintained at a safe temperature, and temperature logs were up to date. This deficient practice had the potential to affect 68 of 69 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pureed foods were prepared according to the recipe to ensure the nutritive value, flavor, and appearance were conserved for 5 of 5 residents reviewed for a pureed diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility and resident rooms were maintained for 8 of 33 rooms reviewed for environment. (room [ROOM NUMBER], 16, 23, 18, 21, 32, 36, 103).

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and resident's representative received notification in writing of the facility's bed hold policy and the reason for the resident's transfer and discharge to the hospital for 1 of 2 residents reviewed for hospitalization. (Resident 3)

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level I was completed on or prior to admission for 1 of 3 residents reviewed for PASARR. (Resident 10)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were followed related to medications hold parameters for 1 of 5 residents reviewed for quality of care. (Resident 5)

Inspectors wroteBased on record review and interview, the facility failed to ensure smoking evaluations were completed quarterly to evaluate the resident's capabilities and deficits for 1 of 6 residents reviewed for accident hazards. (Resident 23)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who did not experience a change in payor source was given the choice/opportunity to remain in his room for 1 of 1 resident reviewed for room transfers. (Resident C)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications administered orally were separated from topical medications and eye drops, to store cleaning supplies separately from medications, correctly label OTC (over the counter) medications, date opened medications, and routinely dispose of medications after the date of expiration for 4 of 4 medication carts reviewed. (medication cart 1, medication cart 2, medication cart 3, and medication cart 4)

Inspectors wroteBased on interview and record review, the facility failed to submit a discharge MDS (Minimum Data Set) assessment upon discharge, making the assessment greater than 120 days since the last submitted assessment for 1 of 2 residents reviewed for resident assessments. (Resident 67)

Inspectors wroteBased on interview and record review, the facility failed to resubmit a PASARR (Preadmission Screening and Record Review) for a resident after a new mental health diagnosis and medication were added for 1 of 3 residents reviewed for PASARR. (Resident 70)

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician of blood glucose levels out of the physician's parameters and to follow-up on a hospice order for a Broda chair (chair which helps accommodate residents with impaired mobility) for 3 of 3 residents reviewed for quality of care. (Resident L, C and 136)

Inspectors wroteBased on observation, interview and record review, the facility failed to turn and reposition a resident every 2 hours as ordered to promote healing and to prevent future pressure injuries for 1 of 4 residents reviewed for pressure ulcers. (Resident 50)

Inspectors wrote2. During an observation, on 7/08/24, Resident H was in the hallway in her wheelchair with her foley catheter in a dignity bag. The clinical record for Resident H was reviewed on 7/10/24 at 9:50 a.m. The diagnoses included, but were not limited to, peripheral vascular disease, retention of urine, polyneuropathy, acquired absence of left leg above the knee, restless legs syndrome, cerebral infarction without residual deficits, and obstructive and reflux uropathy. A physician's order, dated 2/2/24, indicated indwelling catheter to straight drainage. Size: 18 Fr Bulb: 30 cc. Change for infection, obstruction, or when the closed system was compromised as needed. A progress note, dated 4/3/24 at 4:47 p.m., indicated the resident complained the Foley catheter was leaking. The nurse deflated the balloon, advanced the catheter and re-inflated the balloon. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure transportation was available for dialysis for 1 of 1 resident reviewed for dialysis. (Resident 18)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an order for side rails was obtained and an assessment for side rails was completed prior to the use of side rails for 1 of 3 residents reviewed for accident hazards. (Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to address an annual gradual dose reduction (GDR) for an anti-depressant and an antipsychotic for 1 of 5 residents reviewed for unnecessary medications. (Resident J)

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of a staff member working while impaired and the potential residents' physical or emotional suffering from the impaired staff member's interactions for 1 of 1 staff member reviewed for allegation of abuse. (CNA 12)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired food was discarded, the refrigerator did not contain employee lunches and the dishwasher was washing at the recommended temperature. The deficient practice had the potential to affect 67 of 68 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident hallways and a bathroom were clean and in good repair for 2 of 4 hallways and 1 of 10 bathrooms observed for the environment. ([NAME] and Ross Hall)

Inspectors wroteBased on record review and interview, the facility failed to ensure a MDS (Minimum Data Set) assessment was accurate for 1 of 1 resident reviewed for resident assessments. (Resident 42)

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with congestive heart failure received daily weights and the physician was notified of a weight gain as ordered for 1 of 3 residents reviewed for quality of care. (Resident 33)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the controlled substance record used was provided by the pharmacy and not altered by facility staff for 1 of 3 medication carts observed for medication storage. (Ross Hall)