Heritage Gardens Health and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF575Sep 20, 2023

  The facility identified a census of 52 residents. Based on observation, record review, and interviews, the facility failed to post the pertinent state agencies and advocacy groups in a manner that was accessible and clearly visible to residents and/or their representatives. This placed the residents at risk for impaired access to resident advocacy groups and agencies. Findings included: - On 09/18/23 at 11:54 AM the facility had the state agencies and advocacy group contact information posted in the main dining room but not at wheelchair height. The height of the posting was aproximately five feet. The posting text was too small to discern the contact information, right to file a complaint with the state agency and the relevant phone numbers in order to do that. […]

• No harm, potential for more than minimal, widespreadF730Sep 20, 2023

  The facility had a census of 52 residents. The sample included 15 residents and five Certified Nurse Aide's (CNA) were reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure three of the five CNA staff reviewed had received yearly performance evaluations and had the required 12 hours of in-service education per year. This placed the residents at risk for inadequate care. Findings included: - Review of the facility's in-service records revealed CNA M, CNA O, and CNA P lacked the required 12 hours of yearly in-service education. […]

• No harm, potential for more than minimal, widespreadF880Sep 20, 2023

  The facility identified a census of 52 residents. Based on observation, record review, and interviews, the facility to ensure staff practiced standard infection control practices regarding appropriate hand hygiene during wound care. The facility also failed to ensure staff disinfected resident's items after dirty items were placed on bedside table where the resident ate her meals. The facility failed to ensure the Infection Preventionist tracked and trended infections within the facility. This had the potential to increase the residents' risk for transmission of infectious disease. Findings included: - On 09/20/23 at 07:32 AM Licensed Nurse (LN) H entered Resident (R) 34's room to obtain a blood glucose level. […]

• No harm, potential for more than minimal, widespreadF880Jan 27, 2022

  The facility had a census of 44 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility staff failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to conduct a complete COVID (acute respiratory infection) screening process for visitors and staff prior to entering the facility. The facility failed to utilize aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) technique when providing tracheotomy ([CONDITION(S)]-opening though the neck into the trachea through which an indwelling tube may be inserted) care failed to ensure staff performed appropriate hand hygiene when provided care to R13, R16 and R27. […]

• No harm, potential for more than minimal, patternF679May 22, 2025

  The facility identified a census of 54 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to consistently provide activities on the weekends, the facility identified 28 residents with moderately impaired or severely impaired cognition. This deficient practice had the risk of a decline in physical, mental, and psychosocial well-being and independence for these residents. Findings included: - A review of the facility's Activity Calendars for April and May 2025 that revealed no scheduled activities were listed for the weekends. On 05/21/25 at 09:42 AM, during the Resident council meeting the residents stated there was no consistent if any weekend activities provided by the staff. […]