Heritage Gardens Rehabilitation and Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 8, 2025

  Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #2) reviewed for abuse.The facility failed to ensure Resident #2 was free from abuse when Resident #1 punched him on 06/21/25, causing Resident #2 to have a laceration to his top lip.This failure could place residents at risk for severe and long-lasting impact for physical, psychological and emotional wellbeing. Findings included: Record review of Resident #2's MDS Assessment, dated 05/26/25, reflected the Resident#2 was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted [DATE]. He had no BIMS score recorded. His MDS indicated he had no behaviors. […]

• No harm, potential for more than minimal, widespreadF812Oct 5, 2023

  Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 10/03/23 at 9:34 AM revealed: - 3 tomatoes withered and 1 tomato with white spots - 2 heads of cabbage with black spots. Observation of the facility's freezer storage on 10/03/23 at 9:37 AM revealed: -1 box of country fried beef steak open and exposed to air - 1 bag of chicken undated; and -1 bag of fries undated. […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure meats, when thawing, were done so in a safe manner, at refrigeration temperatures and were not replaced in the freezer after thawing. 2. The facility failed to discard items stored in the refrigerator or freezer that were not properly sealed/secured, damaged, or past the 'best use by', consume by or expiration dates. 3. […]

• No harm, potential for more than minimal, patternF689Apr 14, 2026

  Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 3 of 4 hallways (200 Hall, 300 Hall, and 400 Hall) reviewed for accidents and hazards.The facility failed to ensure 3 of 3 mechanical lifts on 3 Halls (200 Hall, 300 Hall and 400 Hall) were locked and secured when not in use.This failure could place residents, at risk of falls and/or injuriesFindings include:Observation of the 200 Hall on 04/14/26 at 1:13 PM revealed 1 unlocked and unsecured mechanical lift parked on the 200 Hall parked in between room [ROOM NUMBER] and room [ROOM NUMBER].Observation of the 400 Hall on 04/14/26 at 1:27 PM revealed 1 unlocked and unsecured mechanical lift parked on the 400 Hall parked outside of… […]

• No harm, potential for more than minimal, patternF726Mar 13, 2025

  Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 Nurse Aides (NA A and NA B) of four nurse aides reviewed for proficiency of nurse aides. The facility failed to ensure NA A and NA B were CNAs after four months of being hired 06/03/24. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being. Findings include: 1. Record review of NA A's employee record revealed she was hired 06/03/24 as a Nurse Aide trainee. […]