Heritage Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 17, 2026

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #7), who had a history of elopement at prior facilities, was provided adequate supervision, when staff did not confirm the resident's whereabouts for at least 4.5 hours (from 2:30 P.M. to approximately 7:00 P.M.) on 01/12/26. Review of the resident's record showed the resident had a legal guardian and diagnoses which included schizoaffective disorder (a chronic mental health condition of schizophrenia symptoms (such as hallucinations, delusions, or disorganized thinking), bipolar type (involves alternating 'poles' of intense, elevated, or irritable mania/hypomania and profound, low energy depressive episodes that severely disrupt life), lack of coordination and muscle weakness. […]

• Immediate jeopardy, isolatedF689Apr 25, 2025

  Please see deficiency cited at F689 in Event ID 533H12. This citation is uncorrected. See the narrative at Event ID 533H11. This deficiency is uncorrected. For previous examples, please see the Statement of Deficiencies dated 3/14/25.

• Immediate jeopardy, isolatedF689Mar 14, 2025

  Based on interview and record review, the facility failed to ensure one resident (Resident #1), with a known history of suicidal ideation, high risk of suicide and frequent self-harming behavior received adequate supervision. The facility determined the resident required close supervision, defined as supervision from three to five feet, to ensure the resident's safety and well-being. Per the resident's care plan, the resident was to receive 1:1 monitoring. On 3/3/25, staff assigned to provide 1:1 supervision for the resident were reassigned to other duties and left the resident unsupervised in his/her room with the door closed. The resident broke the window in his/her room and used the glass to cut himself/herself resulting in multiple deep cuts requiring medical intervention. […]

• Immediate jeopardy, isolatedF689Feb 3, 2025

  See the narrative at event ID WGJ612 Based on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated [DATE], for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on [DATE], staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on [DATE]. The sample was 10. The census was 110.

• Immediate jeopardy, isolatedF689Dec 26, 2024

  Based on interview and record review, the facility failed to ensure staff served a resident, who required supervision, the correct diet ordered by the physician. (Resident #7). The resident had a diet order, dated [DATE], for mechanical soft texture (food is altered to be soft and easy to chew) foods. During lunch, on [DATE], staff served the resident a regular textured ham sandwich. The resident began to choke. Staff intervened and were unsuccessful with completely clearing the resident's airway. Staff performed life saving measures until emergency medical staff arrived; who eventually were able to dislodge several pieces of regular textured thinly sliced meat. The resident was hospitalized and expired on [DATE]. The sample was 10. […]