Heritage Center

In the surveyor’s words

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

• Immediate jeopardy, patternF678May 1, 2024

  Based on observation, medical record review and staff interview the facility failed to ensure the procedures they had in place for verifying a resident's choices Cardiopulmonary Resuscitation (CPR) were able to communicated as soon as possible so that staff know immediately what action to take or not when an emergency arises. The facility used the POST form to document and verify the resident's choices regarding cardiopulmonary resuscitation. The facility failed to ensure the POST form was kept on the medical record in the event of an emergency. This process had the potential to affect all residents in the facility. Facility census: 149. The process of not ensuring POST forms were kept on the medical record in the event of an emergency created an immediate jeopardy situation. […]

• Immediate jeopardy, patternF600Mar 27, 2024

  Based on resident interview, family interview, record review, and staff interview, the facility failed to protect residents from sexual abuse. Resident #208 had a previous history of sexual behaviors toward other residents. The facility failed to protect Resident #15 from unwanted sexual touching by Resident #208. Although Resident #208 had been transferred to another facility by the time of the survey, the State Agency determined the facility's processes that failed to protect Resident #15 placed all residents in the facility in an immediate jeopardy situation. The State Agency notified the Nursing Home Administrator of the immediate jeopardy situation on 03/25/24 at 4:27 PM. The facility submitted a plan of correction (POC) on 03/25/24 at 7:19 PM. […]

• Actual harm, isolatedF689May 20, 2026

  Based on record review, staff interviews, and family interviews, the facility failed to keep the resident environment as free of accident hazards as possible, by not ensuring Resident #157 had assistive devices in place to prevent avoidable accidents. The State Agency (SA) determined that the potential for harm occurred on 12/24/25 when Resident #157 changed rooms and his bed rails did not go with him. Actual harm occurred on 12/26/25 when Resident #157 had a fall from bed resulting in a confirmed brain bleed. The facility was back in compliance on 12/30/25 after the last current staff member had been re-educated. This failed practice was found true for (1) one of (3) residents reviewed for fall prevention safety during the Complaint Survey. Resident identifier: #157. […]

• Actual harm, isolatedF600Apr 21, 2021

  Based on resident interview, medical record review and staff interview, the facility failed to ensure residents were free from abuse and neglect. A facility staff member failed to transfer Resident #72 as directed by the care plan resulting in the actual harm of a fracture of the left shoulder. In addition, the facility was aware of and failed to acknowledge an allegation of abuse voiced by Resident #55. This was true for two (2) of three (3) residents reviewed for the care area of abuse and neglect. Resident identifiers: #72 and #55. […]

• Actual harm, isolatedF689Apr 21, 2021

  Based on observation, medical record review and staff interview, the facility failed to ensure residents receive adequate supervision and assistive devices to prevent accidents. Facility staff failed to follow orders to ensure a safe transfer for Resident #72. As a result, Resident #72 sustained a fractured shoulder. In addition, Resident #48 did not have interventions in place to address falls. This was true for two (2) of six (6) residents reviewed for the care area of accidents and falls. Resident identifiers: #72 and #48. Facility census: 141. Findings included: a) Resident #72 On 04/19/21 at 11:45 AM, Resident #72 was noted to be lying in her bed. […]