Heritage Care And Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Heritage Care And Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 20, 2024

  Based on observations, interviews and record review, the facility failed to provide follow-up assessments and interventions for 1 of 3 residents reviewed (Resident #1 ). Resident #1 had an unwitnessed fall. Resident #1 stated he hit his head and had 2 abrasions on his head. Staff A, the covering Licensed Practical Nurse (LPN), documented she completed 8 neurological assessments (neuro checks) on Resident #1. This facility's video footage and staff interviews revealed that Staff A only did the initial assessment, with no further assessments to follow. The facility reported a census of 51. Findings include: Resident #1's Minimum Data Set (MDS) dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. […]

• Actual harm, isolatedF686Apr 4, 2022

  Based on record review, staff interviews, and observations, the facility failed to ensure skin care to prevent the development and worsening condition of pressure ulcers, and the facility failed to ensure timely notification of family members regarding the skin condition for 1 of 2 residents (Resident #3) in the sample reviewed for pressure ulcers. The facility reported a census of 55 residents at the time of the survey. Findings include: The Significant Change Minimum Data Set (MDS) dated [DATE], indicated on 12/2/21, Resident # 3 re-entered the facility from an acute hospital. The MDS listed Resident #3's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Dec 17, 2021

  Based on observation, clinical record review, staff, family and a Physician Assistant (PA) interview and facility policy review, the facility failed to ensure staff maintained a safe and secure environment for 1 of 4 residents reviewed, (Resident #2) The facility identified a census of 57 residents. Findings include: A State of Iowa, Iowa Department of Public Health Certificate of Death form filed 7/13/21 documented Resident #2 passed away on 7/7/21 at 12:43 p.m. with the immediate cause of death documented as a pulmonary embolism as a consequence of a right [CONDITION(S)] from a fall with an underlying cause of dementia. […]

• No harm, potential for more than minimal, patternF804Aug 14, 2025

  Based on observations, resident interviews, and food temperatures during food services, the facility failed to serve food within the appropriate temperature ranges throughout the observed meal service. The interviewed residents reported the food temperature as not satisfactory. The facility identified a census of 61 residents.Findings include:On 8/13/25 from 11:30 AM to 1:20 PM, observed Staff L, Cook, and Staff N, Cook, serve the facility residents their meal. Prior to service of the meal, Staff L, took the temperature of the turkey burger, French fries, cauliflower, cauliflower soup, ground turkey, mashed potatoes, puree cauliflower, puree turkey burger, macaroni and cheese and oatmeal. Staff N took the temperature of the last tray. […]

• No harm, potential for more than minimal, patternF812Aug 14, 2025

  Based on observations, resident interviews, and food temperatures during food services, the facility failed follow infection control practices while preparing the residents' meal. During the kitchen observation, the staff didn't remove their gloves after touching non-food items before touching food items while wearing the same gloves. The facility reported a census of 61 residents. Findings include:On 8/13/25 at 11:30 AM Staff L, Cook, completed hand hygiene, then applied gloves to the right hand. With their gloved hand, Staff L grabbed the hamburger bun sack and reached in to grab a bun, placed the bun on the plate, opened the bun, grabbed the tongs, and placed the turkey burger on the bottom bun. […]