Heritage Living Center

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's(s') right to be free from neglect for one (Resident #1) of six residents reviewed for neglect. Specifically, the facility failed to ensure a cumulative effect of individual staff failures in the provision of care and services did not lead to an environment promoting neglect, when on 07/09/2026: - At or about 8:55 AM, CNA #1 performed a one-person pivot transfer of Resident #1 to the shower chair, in direct deviation from the resident's established care plan, which required two staff members and a mechanical lift for all transfers. Resident #1 reported to staff she heard a cracking sound and experienced pain in her leg. Cross-Reference - F689: Please refer to F689 for additional information related to this incident. [...]

Inspectors wroteBased on interviews, record review, and facility document review, the facility failed to ensure staff followed the Care Plan for one (Resident #1) of six residents reviewed. This failed practice led to an avoidable accident in which the resident obtained a fracture of the right distal femur.

Inspectors wroteBased on interviews and facility document review, the facility failed to utilize the Facility Assessment to ensure the minimum weekend staffing needs were met a total of 8 out of 26 weekend days, for the residents during April, May, and June of 2025, based on the Facility Assessment staffing requirements.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, record review and facility policy review, the facility failed to ensure the ice machine was maintained in a clean and sanitary condition.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, the facility failed to ensure a nurse performed hand sanitation during medication administration for one (Resident #111) of one resident and failed to ensure staff followed Enhance Barrier Precautions (EBP) during care of an indwelling urinary catheter for one (Resident #16) of one resident observed for indwelling urinary catheter care.

Inspectors wroteBased on observations, interviews, record review, and facility document review, it was determined that the facility failed to protect resident rights that promote individuality and dignity for 1 (Resident #76) out of 2 residents reviewed for Resident rights. This failed practice resulted in actual harm to Resident #76 who sustained devastating psychosocial harm when the resident's hair was cut without Resident #76's permission. Based on interviews, record review, and facility policy review, it was determined that the facility failed to protect resident rights that promote individuality and dignity for 1 (Resident #76) out of 2 residents reviewed for Resident rights. [...]

Inspectors wroteBased on observations, record review, interview, facility document review, and facility policy review, it was determined that the facility failed to ensure behavioral health services were provided to meet the needs of a resident with a history of suicide and a family history of suicide. Specifically, the admission nurse did not include the resident’s suicide history in the Care Plan, and facility staff were not trained to identify or respond to behavioral health needs for one (Resident #1) of one sampled resident reviewed for death.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen; Hot food items were not maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 127 residents who received meals from the Kitchen.

Inspectors wroteBased on observations, interviews, facility document review, and facility policy review it was determined that the facility failed to ensure that a nurses wound treatment cart remained locked when left in the hallway without licensed staff remaining with the cart.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observations, interviews, record review, facility document review, and facility policy review it was determined the facility failed to secure residents private health information on facility tablet to prevent unauthorized sharing of electronic medical record (EMR), while leaving the EMR open in the hallway without staff around for 1 (Resident #330) of 1 Resident reviewed for protection on electronic medical record.

Inspectors wroteBased on observations, interviews, facility document review, and facility policy review it was determined the facility failed to ensure that portable oxygen cylinders were stored securely when not in use for the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that bathroom call lights had pull strings in place to accommodate the residents needs to call for help while in the bathroom for 4 of 15 resident bathrooms observed for call lights.

Inspectors wroteBased on record review, and interview, the facility failed to ensure the physician and family were notified after a resident had a change in condition, resulting in injury, for 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to report an incident with injury involving 1 (Resident #1) of 3 (Residents #1, #2 and #3) sampled resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that the foods stored in the freezer were covered and sealed to minimize the potential for food-borne illness for the residents who their received meals from 1 of 1 kitchen, dietary staff washed their hands between dirty and clean tasks, and before they handled clean equipment or food items to prevent potential for cross contamination. These failed practices had the potential to affect 127 residents who received meals from the kitchen (total census: 127), as documented on a list provided by Dietary Supervisor on 05/10/23 at 10:55 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that meals were served in a method that maintained the appearance of cold products and temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 22 residents who received meal trays in their rooms on the 100 Hall, 10 residents who received meal trays in their room on the 200 Hall, 18 residents who received meal trays on the 300 Hall, 21 residents who received meal trays in their room on the 400 hall, 7 residents who received meal trays in their room on the 500 Hall, and 16 residents who received meal trays in their room on the 600 Hall, as documented on a list provided by the Dietary Supervisor on 05/10/23 at 10:55 AM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper placement of a gastrostomy tube was checked per Physicians' Orders prior to use for 1 (Resident #112) of 3 (#63, #93, and #112) sampled residents.