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.

• Actual harm, isolatedF600Aug 15, 2024

  Based on review of facility documents, facility policy, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect for one of two residents (Resident R1), which resulted in actual harm of a dislocated shoulder for Resident R1. Findings include: Review of facility policy Abuse and Neglect- Clinical Protocol, review date undetermined, indicated that neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• Actual harm, isolatedF689Aug 15, 2024

  Based on review of facility documents, clinical records, resident interview, and staff interviews, it was determined that the facility failed to provide appropriate assistance with an appropriate device to prevent falls for one of two residents (Resident R1), which resulted in actual harm of a dislocated shoulder for Resident R1. Findings include: Review of the facility job description for Certified Nursing Assistant, indicated that the purpose of the job position is to provide each resident with routine daily nursing care and services in accordance with the resident's assessment and care plan and as may be directed by your supervisor in accordance with the requirements of the policies and procedures of this facility in accordance with current federal, state, and local standards governing… […]

• Actual harm, isolatedF689Jan 12, 2023

  Based on review of facility policies, clinical records, incident reports, employee statements and staff interview, it was determined that the facility failed to make certain a resident received adequate supervision and assistance to prevent accident which resulted in actual physical harm (multiple hematomas, redness to multiple areas, and a fractured left arm that was later diagnosed as no definitive fracture and a radial head contusion of left elbow) for one of five residents (Resident R72). Findings include: Review of the facility policy Falls Care During and After, dated March 2022, indicated all residents experiencing a fall will receive appropriate care and investigation of the cause. […]

• Actual harm, isolatedF600Jan 28, 2022

  Based on review of facility policy, reports submitted to the State, clinical records, and staff interviews it was determined that the facility failed to make certain that a resident was free from neglect by not providing proper bed mobility which resulted in a small abrasion to the left upper buttocks and transfer assistance with a hoyer lift which resulted in a resident's right toenail being removed, causing actual harm to two out of eight sampled residents (Resident R11 and R33). Findings include: The facility Abuse policy, dated 10/31/19 and last reviewed on 2/14/21, indicated that the nursing facility prohibit all forms of abuse and strive to provide an environment and culture that treats every resident with dignity and respect. […]

• Actual harm, isolatedF689Jan 28, 2022

  Based on review of facility policy, resident clinical records, facility documentation, hospital documentation, and staff interviews it was determined the facility failed to provide adequate supervision, interventions, and assistive devices to prevent accidents and falls that resulted in abrasions, loss of toe nail, fractured bones, and knee cap displacement for four of four residents (Residents R9, R11, R33 and R38). Findings include: Review of facility policy titled Resident Falls - Evaluation, Re-Evaluation and Documentation revised in April, 2019, and last reviewed 2/14/21, indicated it is the policy of UPMC Senior Communities to make reasonable efforts to identify residents who are at risk to fall so that appropriate preventative measures can be implemented to minimize the risk of harm… […]