Heritage House Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #1) residents reviewed for assistive devices. CNA A operated the Hoyer (mechanical) lift independently while lowering Resident #1 into bed on 3/24/2026. This failure placed residents at risk for accidents and injuries.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 3 of 3 confidential residents interviewed for grievances.1. The facility failed to notify residents in writing of the findings and actions of the grievances they filed. 2. The facility failed to have prominent postings of who the grievance official was.3. The facility failed to inform residents and their family groups of how to file an anonymous grievance. This failure could affect resident's right to file an anonymous grievance and receive a written decision regarding the resolution of their grievance.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed. 1. The facility failed to properly label and/or date food items.2. The facility failed to dispose of expired food items. 3. The facility failed to correctly seal food items. 4. The facility failed to discard spoiled food items. These practices could cause foodborne illness or choking, particularly in a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to refer all level I residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 3 of 3 residents (Resident #3, #24 and #29) assessments reviewed for PASARR evaluations. The facility failed to demonstrate a PASRR I was completed on Resident #03 and failed to refer her to the appropriate, State-designated authority when she was diagnosed with bipolar disorder. The facility failed to refer Resident #24 to the appropriate, State-designated authority when he was diagnosed with Major Depressive Disorder and Unspecified Psychosis. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 (Resident #4, Resident # 28) of 8 residents reviewed for care plans. The facility failed to ensure Resident #4)comprehensive care plan was updated when he quit smoking. The facility failed to ensure Resident # 28's comprehensive care plan reflected current physician orders for weights . These failures could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure a resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 8 (Residents # 4,8,9,13,25,27,28 and 30) of 31 residents reviewed for consistent review of weight variances. The facility failed to ensure accurate resident weights for 8 (Residents # 4,8,9,13,25,27,28 and 30) of 31 Residents reviewed which resulted in significant weight variance. The facility failed to consistently monitor that effective interventions were put in place for residents with significant and/ or severe weight loss which resulted in weight variances. [...]

Inspectors wroteBased on observation, interview, 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 transmission of communicable diseases and infections for 4 of 4 resident (Residents# 8, 14, 26, and 186) reviewed for infection control. The facility failed to ensure MA performed proper hand hygiene and sanitized equipment properly during medication pass on 4 residents (Residents# 8, 14, 26, and 186). This failure could place residents at risk for development of communicable diseases and infections.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure that the resident environment was as free of accident hazards as possible for one resident (Resident #3) out of five residents. The facility failed to ensure that the temperature of the coffee was safe for consumption and handling by Resident #3, resulting in a coffee burn. The failure could result in residents being burned due to the temperature of the coffee being too hot.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and a received adequate supervision and assistance devices to prevent accidents for (Resident #1) one resident reviewed for transfers. The facility failed to ensure Resident #1 was transferred properly as stated in the resident's care plan and MDS. An IJ was identified on 01/30/2024. The IJ Template was provided to the facility on [DATE] at 06:16 p.m. While the facility was removed on 01/31/2024, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure may put resident at risk for falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 of three (3) medication/treatment carts reviewed for medication storage. The facility failed to prevent the treatment cart at the nurse's station from being unattended and unlocked. This failure could place residents, unauthorized staff and visitors access to medications that could cause physical harm and decreased quality of life.