Heritage Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jul 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents admitted without pressure ulcers were provided effective interventions to prevent the development of an unstageable pressure ulcer on the spine for 1 of 5 residents who met the criteria for review of pressure ulcers. (Resident B) Finding includes: During an observation on 6/27/22 at 10:25 A.M., Resident B was observed laying in bed on Resident's back with blankets covering Resident B's shoulders. During an observation on 6/28/22 at 8:24 A.M., Resident B was observed laying in bed on Resident's back with blankets covering Resident B's shoulders. During an observation on 6/30/22 at 11:34 A.M., Resident B's dressing was changed. […]

• Actual harm, isolatedF689Jul 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent falls for 2 of 5 residents reviewed for falls, both residents received fractured femurs from their falls. Resident 41 had five additional falls after the fracture one resulting in a major injury. (Resident 41, Resident 76) Findings include: 1. On 7/1/22 at 10:51 A.M., Resident 41's clinical record was reviewed. Diagnoses included, but were not limited to, nontraumatic [CONDITION(S)] and dementia. The most recent admission MDS (minimum data set) Assessment, dated 4/7/22, indicated Resident 41 had a severe cognitive impairment, and required assistance of 1 (one) staff for all ADLs (activities of daily living). […]

• No harm, potential for more than minimal, patternF657Apr 25, 2025

  Based on interview and record review, the facility failed to ensure care plan conferences were completed quarterly for 13 of 25 residents admitted reviewed for care plans. (Resident 1, Resident 16, Resident 14, Resident 22, Resident 17, Resident 26, Resident 42, Resident 45, Resident 49, Resident 75, Resident 99, Resident 105, Resident 115) Findings include: 1. On 4/22/25 at 9:03 A.M., Resident 26 indicated that the facility did not involve her in reviewing her care plan and that she did not attend care plan conference meetings quarterly. On 4/23/25 at 9:27 A.M., Resident 26's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF761Apr 25, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe and secure storage of all medications for 2 of 5 medication carts and 3 of 3 medication rooms observed. Medication refrigerator temperature logs were not filled out, loose pills were observed in medication carts, and medication carts were observed unlocked. (Horizons Unit, Harbor Unit, Wellsprings Unit) Findings include: 1. On 4/21/25 at 8:56 A.M., the Horizons Unit medication storage room was observed. A temperature log dated February 2025 and included a small fridge, small locked fridge, and large fridge, had temperatures listed for 2/1/25, and 2/16/25 through 2/18/25. All other dates were blank. The same form, dated April 2025, had temperatures listed for 4/16/25 through 4/18/25. […]

• No harm, potential for more than minimal, patternF880Apr 25, 2025

  Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for all residents. Hand washing was not adequately performed during medication administration, cups were handled by the rims during a meal observation, clean linen was not handled appropriately, and activity items were not washed after use. (Wellsprings Unit, Registered Nurse (RN) 42, Resident 89) Findings include: 1. During a medication pass on 4/24/25 at 7:52 A.M., RN 42 was observed to enter Resident 236's room with a medication cup of pills. RN 42 placed the medication cup on the bedside table, assisted the resident to put on her pants and shoes, then washed her hands for 11 seconds. […]