Heather Hill Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689May 20, 2026

  Based on observations, interviews, and record review, the facility failed to ensure monitoring and supervision for the safety of one resident (#1) out of three sampled residents. Resident #1 suffered a fall with major injury requiring transfer to a higher level of care for treatment. Findings included: Review of the report titled incidents by incident type for 1/1/2026 to 5/20/2026 showed Resident #1 as having an unwitnessed fall on 1/11/2026, 2/10/2026, 3/9/2026, and 4/12/2026. Review of Resident #1's progress notes revealed:4/12/2026 at 11:40 p.m. Resident returned back to facility from the hospital with a comminuted left humeral head fracture with surgical neck involvement and displacement of the greater tuberosity (meaning: a severe, multi-part break near the shoulder joint. […]

• No harm, potential for more than minimal, patternF645Jun 6, 2024

  Based on interviews and record reviews, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon having a qualifying mental health diagnosis for 7 of 20 residents sampled (Residents #80, #54, #19, #62, #22, #52, and #33). Findings included: 1. Review of the Admission Record showed Resident #54 was admitted on [DATE] with diagnoses of Major Depressive Disorder, Dementia, psychosis, anxiety, pseudobulbar affect, and other comorbidities. Review of Resident #54's PASRR Level I Assessment, dated 4/30/2021 did not reveal a qualifying mental health diagnosis marked in section I A. Section 6 was marked yes for dementia with a suspected mental illness although a level II PASRR was not completed. […]

• No harm, potential for more than minimal, patternF684Jun 6, 2024

  Based on observations, interviews and record reviews, the facility did not ensure care was provided in accordance with professional standards by failing to ensure Hospice care coordination was in place for 2 (#12 and #52) of 4 residents with a Hospice diagnosis and did not ensure one resident ( #5) out of 5 residents received appropriate care and services related to behaviors. Findings included: 1. On 06/03/24 at 01:32 p.m., Resident #12 was observed in bed sleeping. The resident did not respond to the interview. An immediate interview was conducted with the Responsible Party who was visiting. She stated the resident was on Hospice. She stated the resident had declined significantly and she occasionally expressed pain. […]

• No harm, potential for more than minimal, patternF725Jun 6, 2024

  Based on observations and interview, the facility failed to ensure sufficient staff to meet the needs of 30 residents on one (400 - secure) of four units during mealtime and for 30 residents on one (400 - secure) of four units for activities over three (06/03/2024, 06/04/2024 and 06/06/2024) out of four days observed. Findings included: An observation was conducted on 6/3/24 at 10:50 a.m. of Resident #17 sitting in the dining room on the 400 unit. No staff were interacting with the resident, she had nothing at the table to do, and there were no activities going on. The resident remained in the same spot at 1:48 p.m. No staff interacted with the resident or provided any stimulation. No activities were observed throughout the day on 6/3/24. […]

• No harm, potential for more than minimal, patternF847Jun 6, 2024

  Based on interviews and record review, the facility did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#342, #22 and #87) of three residents sampled. Findings included: 1. During an observation and interview conducted on 06/05/24 at 03:03 p.m., Resident #342 stated she had signed the arbitration agreement during orientation. She stated a young man came to the room the other day with a stack of papers and had her sign all kinds of paperwork. She said, To be honest I don't know what that is. Everything was mumbo jumbo (meaning confusing or meaningless). I told my husband to listen to him. The resident and surveyor reviewed the Arbitration Agreement with her signature dated 06/03/24. She said, Yes that is my signature. […]