Heather Health Care Center

In the surveyor’s words

From the most serious findings on record at Heather Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 13, 2026

  Based on interview and record review, the facility failed to provide adequate supervision and maintain a safe environment for one resident that had a diagnosis of schizophrenia, anxiety, and depression, with a documented history of self-harming behaviors and exit-seeking behavior. The facility failed to prevent the resident from accessing a fire extinguisher, which was used to break a second-floor window and exit the building without staff knowledge. This affected one of three residents (R162) reviewed for supervision. As a result, R162 exited through the second-floor window, landed face down outside the facility, and sustained a left leg [NAME] fracture, a severe fracture involving the distal tibia. […]

• Immediate jeopardy, isolatedF600Apr 18, 2024

  Based on observations, interviews, and record review the facility failed to protect a cognitively and visually impaired resident's (R1) right to be free from physical abuse from another resident (R2) with known history of aggressive behavior for 1 (R1) of 3 residents reviewed for abuse in a sample of 10. This failure resulted in R1 being physically assaulted by R2. The Immediate Jeopardy began on [DATE] at 04:10 AM when R2 physically assaulted R1 which resulted in R1's emergent hospitalization . V1 (Administrator) was notified on [DATE] at 11:14 AM of the Immediate Jeopardy. The facility presented an acceptable removal plan, and the immediacy was removed on [DATE]. The surveyor conducted onsite investigation on [DATE] to confirm the removal plan was implemented. Findings include: 1. […]

• Immediate jeopardy, isolatedF689Apr 18, 2024

  Based on observation, interviews and record reviews, the facility failed to provide adequate supervision and monitoring on a resident assessed to be at risk for elopement due to history of elopement from previous nursing home; failed to ensure the resident did not leave facility without staff knowledge or supervision; and failed to follow elopement policy on procedures and reporting. These failures affected one (R5) of three residents in a sample of 10 reviewed for elopement risk and supervision. These failures resulted in R5 able to eloped from facility. R5 experienced harm by walking to emergency room without shoes on and having to cross a high-volume traffic intersection at night, while allegedly experiencing chest pain. […]

• Actual harm, isolatedF686Apr 9, 2026

  Based on observation, interview, and record review the facility failed to follow policy procedures, failed to transcribe physician's orders, failed to follow physician orders, failed to notify the wound care director of resident's skin integrity impairment, failed to ensure that staff were aware of required LALM (Low Air Loss Mattress) settings, failed to ensure that the LALM was on the right setting (while in use), failed to ensure that the LALM was on (while in use), failed to implement preventive interventions, and/or failed to ensure that treatments were administered for two of three residents (R1, R2) reviewed for pressure ulcers. […]

• Actual harm, isolatedF692Apr 9, 2026

  Based on observation, interview, and record review the facility failed to follow policy procedures, failed to document meal intake, failed to provide meal within reach, and/or failed to provide required feeding assistance for two of three dependent residents (R1, R2) reviewed for nutrition. These failures resulted in R2's significant weight loss (-15.6% within 1 month) and R1's significant weight loss (-7.9% within 1 month).Findings include:1.) R2's diagnoses include obesity, dementia, transient ischemic attack and cerebral infarction.R2's (3/3/26) functional assessment affirms substantial/maximal assistance is required for eating.R2's (9/29/22) care plan states resident has an ADL (Activities of Daily Living) self-care performance deficit related to dementia, impaired cognition,… […]