Heritage Specialty Care

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to prepare food in accordance with professional standards for food safety to reduce the risk of food borne illness. The facility reported a census of 127 residents.

Inspectors wroteBased on clinical record review, facility document review, and staff interview, the facility failed to notify the Long-Term Care Ombudsman of a discharge for 3 of 6 residents reviewed (Resident #13, Resident #122, and Resident #126). The facility reported a census of 127 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to complete the Minimum Data Set (MDS) assessments to accurately reflect resident condition for a feeding tube, and to accurately reflect Preadmission Screening and Resident Review Level II for 2 of 4 residents reviewed (Resident #3 and Resident #105). The facility reported a census of 127 residents. Findings Include:1. The Minimum Data Set (MDS) assessment for Resident #3 dated 8/23/25 showed Resident #3 was not considered by the state level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. The MDS listed diagnoses of depression and Post Traumatic Stress Disorder (PTSD). Resident #3's chart held the Notice of PASRR Level Il Outcome dated 3/27/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure post dialysis assessments and fistula assessments were consistently completed in accordance with physician orders, facility policy, and the comprehensive care plan for 1 of 2 residents reviewed for dialysis (Resident #84). The facility reported a census of 127 residents.

Inspectors wroteBased on observation, clinical record review, and interviews the facility failed to address trauma history, PTSD triggers, signs of distress, non-pharmacological interventions, or medication in assessments and care plans for 1 of 1 residents reviewed for Post Traumatic Stress Disorder (PTSD) (Resident #112). The facility reported a census of 127 residents.

Inspectors wroteBased on interviews, record review, and policy review the facility failed to maintain documentation of staff screening and education regarding COVID vaccination, or maintain records of staff vaccination status. The facility reported a census of 127 residents.

Inspectors wroteBased on clinical record review, facility policy review, staff and resident interviews, the facility failed to provide baths for 3 of 9 residents sampled (Resident #2, Resident #3, and Resident #4). The facility reported a census of 123.

Inspectors wroteBased on observations, clinical record reviews, facility policy review, provider interview, staff and resident interviews, the facility failed to complete wound care as ordered, and failed to assure a resident attended schedule appointments for 1 of 9 sampled residents (Resident #4). The facility reported a census of 123 residents.

Inspectors wroteBased on observations, clinical record review, review of food temperature logs, resident and staff interviews, the facility failed to provide food that is palatable for 1 of 9 sampled residents (Resident #4). The facility reported a census of 123 residents.

Inspectors wroteBased on clinical record review, observations, staff and resident interview and facility policy review the facility failed to provide safe transfers for 3 of 4 residents reviewed (Residents #1, #6, #7). The facility reported a census of 115 residents.

Inspectors wroteBased on observation, clinical record review, staff and resident interviews, and facility policy, the facility failed to ensure each resident had the call light accessible for Resident #3, Resident #6, and for multiple residents observed in resident rooms. The facility reported a census of 118 residents.

Inspectors wroteBased on observation, maintenance record review, staff interviews, and facility policy review, the facility failed to provide a clean and homelike environment. The facility reported a census of 118 residents.

Inspectors wroteBased on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies form, the facility Quality Assurance and Performance Improvement (QAPI) Plan, and staff interview the facility failed to carry out Quality Assurance activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence. The facility reported a census of 118 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, observations and policy review the facility failed to administer medications as ordered for one of three residents reviewed (Resident #8). The facility reported a census of 118 residents.

Inspectors wroteBased on observation, staff and resident interviews, and clinical record review the facility failed to offer toileting assistance for one of three residents reviewed. (Resident #3). The facility reported a census of 118 residents.

Inspectors wroteBased on observation, record review, resident, family and staff interview, the facility failed to administer medications as ordered for two of three residents reviewed (Residents #2 and #3). The facility reported a census of 118 residents.

Inspectors wroteBased on record review, family and staff interview, and facility policy review, the facility failed to properly assess and intervene after administration of a rapid acting insulin (without consuming the meal) to 1 of 3 residents reviewed with orders for insulin (Resident #1). This resulted in the resident becoming unresponsive with a blood glucose of 25 and being sent to the hospital. The facility reported a census of 118 residents.

Inspectors wroteBased on observation, record review, resident, family and staff interview, the facility failed to administer medications as ordered for two of three residents reviewed (Residents #2 and #3). The facility reported a census of 118 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to consistently monitor the functioning of the dishwasher and failed to ensure adequate kitchen sanitation for 2 of 2 kitchen observations. The facility reported a census of 118 residents.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to change oxygen tubing on 1 out of 1 concentrator for residents with physician orders for oxygen (Resident #14). The facility reported a census of 118 residents.

Inspectors wroteBased on observation, clinical record review, menu review, and staff interview, the facility failed to ensure residents on a pureed diet received the correct portion sizes and food items in accordance with the menu for 1 of 1 meal observed. The facility reported a census of 118 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview the facility failed to follow the Center for Disease Control and Prevention (CDC) 2025 Adult Immunization Schedule for pneumococcal vaccination for 1 of 5 residents sampled (Resident #41). The facility identified a census of 118 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and resident and staff interviews, the facility failed to assess and document follow up skin assessments for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 131 residents.

Inspectors wroteBased on observation, clinical record review, staff, resident, and family interviews, and policy review, the facility failed to provide a safe transfer for 1 of 4 residents reviewed (Resident #10). The facility failed to utilize a gait belt during a 2 person transfer as directed by the Care Plan. The facility reported a census of 131 residents.

Inspectors wroteBased on observation, record review, staff and family interviews, and policy review the facility failed to complete pain assessments as directed, update Narcotic Records with changes in medication prescriptions, and complete follow up assessments when pain interventions were ineffective for 1 of 3 residents reviewed (Resident #10). The facility reported a census of 131 residents.

Inspectors wroteBased on record reviews, interviews, policy reviews, and observations the facility failed to maintain a clean, homelike, and safe environment. The facility reported a census of 134 residents. Observations on 2/3/25 at 9:05 am with Staff A-LPN revealed the following: a. Observation at 9:10 am revealed 15 4-person tables and 1-6 person table with black metal bases, each table base revealed dust accumulation and dried food particles splattered on the bases of each table. b. Observation at 9:20 am revealed at the entrance of the skilled unit across from the nurses station, the base of the North pillar had exposed insulation material with approximately 1/2 of the original wood covering noted to be missing. c. Observation at 9:30 am revealed the bottom of the wall directly next to the janitors closet on 3-B Hall revealed a hole in the wall behind and directly above the rubber baseboard. [...]

Inspectors wroteBased on clinical record review, staff and resident interviews, observations, and policy review, the facility failed to follow physician's orders for wound treatments for 1 of 4 residents reviewed (Resident #4). The facility reported a census of 134 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, and observations the facility failed to send a resident's medications for an off campus appointment for 1 of 8 residents reviewed (Resident #2). The facility reported a census of 144 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews and observations, the facility failed to provide adequate oxygen services for 1 of 8 residents reviewed (Resident #2). The facility reports a census of 144 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, and observations the facility failed to follow a physician's order for wound treatment for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 143 residents.

Inspectors wroteBased on clinical record review, staff and resident interviews, and observations the facility failed to answer resident call lights within 15 minutes of activation for 2 of 6 residents reviewed (Residents #4 and #10). The facility reported a census of 143 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pain medication when scheduled for 1 of 1 residents that wore a Fentanyl patch (opioid medication) (Resident #109), resulting in this resident reporting being in severe pain. This resident was to have a Fentanyl patch applied on 8/19/24 at 1800. It was not applied until the morning of 8/21/24. The facility reported a census of 140 residents.

Inspectors wroteBased on observation, clinical record review, document review, and staff interview, the facility failed to maintain a clean, homelike environment. The facility reported a census of 140 residents.

Inspectors wroteBased on observation, clinical record review, policy review, resident and staff interviews, the facility failed to follow physician orders for 1 of 1 resident's reviewed for catheter care (Resident #71). The facility identified a census of 140 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to do weekly measurements and assessments on 1 of 2 residents with pressure ulcers (Resident #37). Resident #37 did not receive the weekly assessments between 7/10/24 when he was seen at a wound clinic to 8/20/24 when an assessment was done at the facility. The facility reported a census of 140 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were smoking in approved areas for 1 of 1 resident reviewed (Resident #184). Resident #184 was observed smoking on facility grounds. The facility was a smoke free campus. The facility reported a census of 140 residents.

Inspectors wroteBased on observation, clinical record review, document review, resident and staff interviews, the facility failed to honor resident choice of meal items for 1 of 1 resident sampled (Resident #113). The facility identified a census of 140 residents.

Inspectors wroteBased on facility document review, staff interview, and policy review, the facility failed to comply with all applicable Federal Regulations regarding Medicare requirements governing billing practices by failing to serve Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) forms 48 hours before the resident ended skilled services for 2 of 3 residents reviewed for liability and appeal notices (Residents #112 and #122). The facility identified a census of 140 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility to follow Physician Orders for one of three residents reviewed (Resident #10). The facility reported a census of 139. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 11/16/2023 revealed Resident #10 with no cognitive impairment, relied on staff assistance for transfers from one surface to another and had a history of falls. The resident had diagnoses including closed fractures of the right tibia and left femur, diabetes and congestive heart failure. The Care Plan directed staff to transfer the resident using a Hoyer mechanical lift with two person assistance. The resident admitted to the facility 11/12/2023 from the hospital. The resident's Discharge Instructions included a scheduled follow-up appointment for the resident to see the Orthopedic Physician on Friday, 11/17/2023 at 1:00 p.m. [...]

Inspectors wroteBased on clinical record review, observations and staff interviews, the facility failed to adequately provide supervision to keep two of three residents reviewed free from a resident to resident altercation. (Residents #7 and #8). The facility reported a census of 139 residents. Findings Include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #8 failed to complete the Brief Interview for Mental Status (BIMS) indicating cognitive impairment and ambulated with supervision. The MDS reported the resident had no behaviors during the look back period and had diagnoses including dementia and hypertension. On 11/20/2023 the Care Plan added: observe for the potential that the resident may try to redirect other residents himself and remind him to allow staff to do so. On 11/26/23 the Care Plan documented the resident struck another resident in his room. [...]

Inspectors wroteBased on record review and staff interview the facility failed to have a properly certified nutrition professional and/or director who met the required qualifications in the time frame allowed. The facility reported a census of 138 residents. Findings Include: A document titled Continuing Education from a local college with a transaction date of 10/30/23 documented Staff H, Food Service Director, was enrolled in a Dietary Manager certification program beginning 1/08/2024. During an interview with Staff H on 10/30/23 at 9:49 AM he indicated he did not have a current Dietary Manager certification, had enrolled in the Certified Dietary Manager (CDM) course, and would start his training in January. He stated the Dietician came to the facility one day per week. [...]

Inspectors wroteBased on observation, facility policy review, and staff interview the facility failed to prepare foods under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 138 residents. Findings Include: 1. The initial kitchen observation on 10/30/23 at 9:24 AM revealed the following: a. The Handwashing sink did not have paper towels, and the sink basin contained a wet wash rag, a wrapper, and a Styrofoam cup. b. The food preparation area lacked filled sanitizer buckets. Food was wiped from surfaces with dry rags. A green food product was noted under breadstick pans placed on the surface after they were cleaned. c. The dishwasher chemical did not read on the test strip. Staff H, Food Service Director, was not able to determine how long the chemical had been missing from the cycle. The temperature gauge read between 148 and 150 degrees. d. [...]

Inspectors wroteBased on record review, staff interviews and the facility's Quality Assurance Performance Improvement (QAPI) Plan the facility failed to implement a successful QAPI program for six repeated citations. The facility reported a census of 138 residents. Findings Include: 1. Review of the Statements of Deficiencies and Plan of Correction dated 5/6/22, identified the following deficiencies: F550 - Dignity. F698 - Dialysis. F812 - Kitchen Cleanliness F880 - Infection Control. The Plan of Correction reflected the QAPI to monitor for compliance and address addition intervention as indicated. 2. The Statements of Deficiencies and Plan of Correction dated 10/5/22, identified deficiencies as follows: F677 - Activities of Daily Living (ADL). F812 - Kitchen Cleanliness. F880 - Infection Control. The Plan of Correction identified the QAPI team to monitor for compliance. 3. [...]

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review, the facility failed to provide privacy and dignity with dressing (Resident #55) and failed to ensure privacy of a urinary bag by omitting a dignity cover (Resident #4) for 2 out of 5 residents reviewed for dignity. The facility reported a census of 138 residents.

Inspectors wroteBased on clinical record review, observation, resident, family and staff interviews the facility failed to assist a resident to shave and failed to provide appropriate peri-care for 1 of 4 residents reviewed for activities of daily living (ADLs) (Resident #25). The facility identified a census of 138 residents. Findings Include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive loss. The resident required extensive assistance of two staff for bed mobility, transfer, dressing, toileting and personal hygiene. The MDS documented Resident #25 as frequently incontinence of bowel and bladder. The MDS listed a diagnosis of Non-Alzheimer's Dementia. The ADL Care Plan revised 3/15/23 detailed Resident #25 required assistance for ADL's and mobility. [...]