The Heritage Rehabilitation and Health Care Center

Inspectors wroteBased on record review and staff interviews conducted during the Recertification Survey from 05/12/2025 to 05/15/2025, the facility did not ensure that the baseline care plan was completed within 48 hours of a resident's admission. This was evident for 1 (Resident #327) of 1 resident reviewed for Communication out of 20 sampled residents. Specifically, the baseline care plan for Resident #327 was not completed until 04/29/2025 which was four days after admission.

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey from 05/12/2025 to 05/15/2025, the facility did not ensure that based on the comprehensive assessment of a resident, and consistent with the resident's needs and choices, communication including language was provided. This was evident for 1 (Resident #327) of 1 resident reviewed for Communication out of 20 sampled residents. Specifically, Resident #327 whose primary language is Cantonese was not provided with interpretation services during the admission nutrition assessment.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 08/10/2023 to 08/17/2023, the facility did not ensure that menus were followed. This was evident for 1 (Resident #9) of 3 residents reviewed for food out of 20 total sampled residents. Specifically, Resident # 9 did not receive items listed on their tray ticket during mealtimes.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility failed to ensure each resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility failed to provide ongoing re-evaluation for the need of the restraint used and attempts to use the least restrictive alternative for the least amount of time. Specifically, residents were observed with restraints in place without 1) adequate assessment and re-evaluation, 2) physician's orders for the restraint, and 3) release from restraints at least every 2 hours per the physician's orders. Resident #2 was observed in the wheelchair on multiple occasions with seatbelt and pommel cushion in place with legs dangling. [...]

Inspectors wroteBased on observation, record review, and interview during the Recertification and Extended Survey from 11/16/2021 to 11/26/2021, the facility did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the QAA committee which is composed of the Administrator, Medical Director, Director of Nursing (DON) Et. Al. was aware of the identified concern of physical restraint/side rail use via Certification and Survey Provider Enhanced Reporting (Casper) and the plans of action implemented in June 2021 were shown to be ineffective resulting in both deficiency and immediate jeopardy during this recertification survey. The finding is. [...]

Inspectors wroteBased on observation, Interview, and record review conducted during the recertification survey, the facility did not ensure that infection control standards were maintained. Specifically, 1) a facility entertainer was observed without a face covering; and, 2) multiple staff were observed without the necessary Personal Protective Equipment (PPE) interacting with a Resident #123 on contact/droplet precautions (CDP). This was evident for 1 of 2 units and 1 of 4 residents reviewed for Transmission Based Precautions (TBP) in the infection control task.

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey, the facility did not ensure that a safe, functional, sanitary, and comfortable environment for residents was provided. Specifically, a patio exit door, situated in the 1st floor resident dining room was not secured with a properly functioning alarm or door hardware to secure and prevent residents from exiting unattended.

Inspectors wroteBased on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure a resident's right to a dignified existence were respected. Specifically, a photograph and identifying information of Resident #48 were posted in a public area visible to other residents, staff, and visitors. This was evident for 1 of 1 residents reviewed in the area of Dignity.

Inspectors wroteBased on observation, record review, and interview during the recertification survey completed [DATE], the facility did not ensure a resident's wishes for Advance Directives were ordered and correctly identified. Specifically, the facility did not ensure that Resident #220 Physician's orders for Advance Directives, were updated and consistent with the resident's MOLST (Medical Orders for Life Sustaining Treatment). This was evident for 1 of residents reviewed for Advance Directives (Resident #220).

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not ensure that a safe, clean, comfortable, and homelike environment was provided to residents. Specifically, 2 resident rooms were observed with dirty and sticky floors not swept, torn wallpaper and paper blind, and stained toilet door for multiple observations over several days. This was evident for 1 of 2 resident units observed for Environmental Observations (Floors 1).

Inspectors wroteBased on observations, interviews and record review conducted during the recertification survey, the facility did not ensure that all alleged violations of of abuse and neglect, including injuries of unknown source were thoroughly investigated. Specifically, the facility did not initiate an investigation after a resident was found with a large ecchymosis, with swelling, warm to touch over her left upper arm and elbow. This was evident for 1 of 1 resident reviewed for Abuse (Resident #11).

Inspectors wroteBased on record review and interviews conducted during the Recertification and Extended Survey, the facility did not ensure, to the extent practicable, that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 2 of 2 residents reviewed for Participation in Care Planningout of a sample of 44 residents. (Resident #69 and #38)

Inspectors wroteBased on observations, interview, and record review conducted during the recertification survey, the facility did not ensure appropriate equipment to maintain or improve mobility. Specifically, Resident #16 was at risk for contracture and was observed on multiple occasions without the Physician ordered (MDO) handroll in place. This was evident for 1 of 2 residents reviewed for Position/Mobility.

Inspectors wroteBased on observation, interview and record review conducted during the Recertification and Extended Survey from 11/16/2021 to 11/26/2021, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. Specifically, there was no documented evidence of an assessment and review of physical restraint use for 2 residents with seat belts and four (4) side rails. This was evident for 2 of 4 residents reviewed for physical restraint out of a sample of 44 residents. (Resident # 13 & # 2).