South Heritage Health & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to seek medical services outside the facility, resulting in delayed emergent care and services for one resident (#5) of two residents sampled.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure nail care was provided to one resident (#4) out of three resident reviewed for total assistance with activities of daily living (ADLs).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure diet-related physician orders were implemented for one resident (#4) out of three resident reviewed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to to ensure the medication error rate was less than 5.00%. Twenty-two medication administration opportunities were observed, and fifteen errors were identified for two residents (#3 and #2) of two residents observed. These errors constituted a 68.18% medication error rate. Failure to ensure the accurate administration of medications has the potential to greatly affect the effectiveness of the medication and jeopardize the health and safety of the resident.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement an effective infection control program related to ensuring one of one observed needle attached to an insulin syringe was appropriately sheathed, staff failed to provide a barrier between an insulin syringe and an over bed table, failed to clean hands in between residents and handling random resident equipment stored in hallway, failed to don gloves prior to the administration of eye drops for one (#2) of one resident receiving this type of medication, and failed to ensure two (B & C) of three direct care nurses fingernails had the ability to be cleaned thoroughly and adequately to prevent the transmission of microbes. [...]

Inspectors wroteBased on observations, interviews and review of the facility policy, the facility did not ensure a sanitary and home-like environment was provided in the main shower room and in two shared bathrooms (100/102 and 129/131) out of thirteen rooms with shared bathrooms.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect for one resident (#1) out of seven sampled residents. Resident #1 sustained an unwitnessed fall on 08/21/25 and was not assessed after the fall. Resident #1 complained of hip pain on 08/23/25, an X-ray was obtained on 08/24/25 and Resident #1 was transferred to a higher level of care due to a right hip fracture on 08/24/25 and required surgical intervention.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of three sampled residents, was provided transfer assistance in accordance with the resident's ability, care plan, facility policy, and/or the mechanical lifts manufacturer's recommendation, resulting in harm to Resident #1.

Inspectors wroteBased on record review and interviews, the facility did not ensure a Registered Nurse (RN) was providing services for eight consecutive hours a day, seven days a week, for the period of 4/6/25 to 4/12/25.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide nursing staff with the competencies and skills to provide appropriate nursing services to one resident (#1) of three sampled residents related to 1.) not providing a safe mechanical lift transfer which resulted in a severe bodily injury, 2.) not accurately documenting the administrations of controlled medications, and 3.) failed to notify the emergency contact of the resident requiring a transfer to an acute care facility following a fall.

Inspectors wroteBased on record review and interviews, the facility did not ensure the designated representative/emergency contact was notified regarding a change in condition, related to an accident resulting in hospitalization, for one resident (#1) of three residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain an accurate accounting of narcotic medication for one resident (#1) of one resident sampled for the administration of pain medication.

Inspectors wroteBased on observation staff interview and facility record review, the facility failed to ensure the kitchen dish washing machine was operating at optimum levels, to include excessive concentration with the chemical sanitizer delivery, in one of one facility kitchen, during one (2/11/25) of three days observed.

Inspectors wroteBased on observations, interviews and facility record review, the facility failed to ensure resident spaces and equipment were maintained in a sanitary manner in two of two units (Main, West), during three of three days observed (2/11/2025, 2/12/2025, and 2/13/2025).

Inspectors wroteBased on observation interview and record review, the facility did not ensure prompt efforts were made to resolve grievances for two (#33 and #13) of six residents sampled.

Inspectors wroteBased on observation interview and policy review, facility did not ensure medication was stored appropriately on three out of three units in the facility related to medication in resident rooms on the north and main units, unsecured medication is an office on the central unit, and improperly stored medication in two medication carts on the north and central units.

Inspectors wroteBased on record review and interviews the facility did not ensure Preadmission Screening and Resident Review (PASARR) Level I screens were completed accurately for three residents (#64, #65, and #40) out of sixteen sampled residents.

Inspectors wroteBased on observation interview and record review, the facility failed to develop a contracture management splinting care plan with goals and interventions for one (#45) of thirty-two sampled residents.

Inspectors wroteBased on observation interviews and record review, the facility failed to ensure nail care was provided to a resident who needed assistance for one (#55) of three residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to provide enteral nutrition per physician orders for one (#220) out of five residents with enteral nutrition orders.

Inspectors wroteBased on record review and interviews the facility did not ensure pharmacy recommendations were implemented for two residents (#64 and #2) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure the medication error rate was less than 5.0%. Thirty medications opportunities were observed, and three medication errors were identified for three residents (#32, #36, #11) of three residents observed. These errors constituted a 10.0% medication error rate.

Inspectors wroteBased on observation, interview and record review facility did not ensure proper infection control practices for one resident (#64) out of sixteen sampled residents related to scabies treatment.

Inspectors wroteBased on observations, interviews, and policy review the facility did not ensure a safe, clean, and homelike environment in nine resident rooms (108, 117, 116, 119, 123, 124, 126, 127, and 121) out of 34 rooms and four bathrooms (110, 123, 124 & 125, and 126 & 127) out of 22 bathrooms, one hall (Main) out of three halls, and one patio (dining area) out of two patios observed.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to ensure care and services were provided in accordance with professional standards of practice for facility acquired pressure injuries for one resident (#1) by not seeking surgical intervention in a timely manner and for not ensuring orders were in place and followed for wound care for two residents (#30 and #7) of a total of three residents sampled.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure medications were administered without irregularities and followed as ordered for one resident (#1) out of five residents sampled as evidenced by failing to follow blood pressure parameters.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to provide timely notification to the physician for one resident (#17) out of two residents, who were dependent on staff for total enteral nutritional support by way of a gastrostomy tube and enteral feedings, related to a significant weight loss of 38.6 pounds within a 26 day period.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal privacy was maintained for one resident (#34) out of 22 residents sampled.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain kitchen equipment in a clean manner by not ensuring three drip trips were free from grease for one of one stove in one of one kitchen.

Inspectors wroteBased on observation, interview, and medical record review the facility failed to collaborate with the hospice agency related to current plans of care for one resident (#8) out of one resident sampled with hospice services.

Inspectors wroteBased on observation, interview and record & policy review, the facility failed to identify and provide wound care effectively for tunneling or undermining wounds for one (#8) of three sampled residents with identified pressure sores; failed to ensure wound care visits were completed as ordered; and failed to identify a special air loss mattress was set in accordance with Resident #8's wound care needs, impacting the healing potential for the only resident with worsening wounds. Findings Included: Review of the facility CMS form 672, Resident Census & Conditions of Residents, revealed one resident, Resident #8, with worsened pressure ulcers. Review of Resident's #8's medical record did not reflect any wound care or physician notes. Review of the electronic record did not reveal any of the physician notes for wound care or from the facility physician related to wound care. [...]