Complete Care at Heritage LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Heritage LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Feb 26, 2025

  Based on review of a facility reported incident, review of administrative and medical records, and staff interviews, it was determined that the facility failed to ensure a resident was free of a significant medication error when a nurse incorrectly administered the medication Methadone to a resident instead of the prescribed medication Methylphenidate. This was evident for 1 of 1 resident (Resident #1) reviewed for unnecessary medications during a complaint survey. The failure of the facility to ensure that Resident #1 was free of a significant medication error resulted in the determination of an immediate jeopardy situation being identified on February 25, 2025, at 6 PM. […]

• Immediate jeopardy, isolatedF689Aug 22, 2023

  Based on observation, medical record reviews, staff, and family interviews, it was determined the facility failed to: 1.) correctly assess a resident for smoking independently to include an accurate account of incidents of past unsafe smoking behaviors; 2) provide increased supervision and safety interventions after multiple unsafe smoking incidents; 3) keep a resident who had multiple smoking-related incidents from igniting flammable materials and safe from self-harm. This was evident for 1 of 4 (#92) residents reviewed for smoking. As a result of the deficient practice, residents were placed at risk for harm/injury causing an immediate jeopardy. […]

• Actual harm, isolatedF600Aug 22, 2023

  Based on medical records review, facility investigation review and interviews with staff it was determined that the facility failed to protect cognitively impaired residents from physical, sexual, emotional, and verbal abuse which resulted in harm to Resident #144 and Resident #76. This was evident for 3 of 28 residents (Resident #144, #76, #103) reviewed for abuse during the survey. The Findings Include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A care plan is a guide that addresses the unique needs of each resident. […]

• No harm, potential for more than minimal, patternF641Feb 25, 2026

  Based on medical record review and staff interview, it was determined that facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 5 (#5, #4, #2, #1, #14) of 14 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.1) On 2/20/26 at 8:46 AM a review of Resident #5's medical record was… […]

• No harm, potential for more than minimal, patternF584Sep 16, 2025

  Based on observation and staff interviews, it was determined that the facility failed to maintain a clean, sanitary and homelike environment for their residents. This was evident for 1) 1 of 2 nursing units in the facility and 2) observation of the laundry room during the recertification/complaint survey.The findings include:1) On 9/8/25 at 3:31PM during the initial rounding in the facility, the surveyor observed that the bathroom ceiling in room [ROOM NUMBER] was busted inwards where the water sprinkler was located about 10x4 inches long. Further observation of the ceiling on the second-floor hallway by the medication room and janitor's closet were three vents. […]