Heritage Grove Estates

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 29, 2025

  The facility identified a census of 64 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision for cognately impaired Resident (R)1, a resident with a risk for elopement and falls, to prevent an elopement. On 01/26/25, R1 self-propelled in his wheelchair down a hallway to a locked door with a keypad. The door was not latched and R1 left the unit and proceeded out a set of double doors that exited the building. When R1 opened the double doors, an alarm sounded at the nurse ' s station, but the staff turned the alarm off without checking the door. Per interview and investigation, R1 exited the facility building at 05:58 AM and entered the Assisted Living (AL) building at 07:02 AM. […]

• Actual harm, isolatedF686Feb 2, 2023

  The facility identified a census of 56 residents. The sample included 14 residents with two residents reviewed for pressure injuries. Based on observation, record review, and interview, the facility failed to ensure preventive measures were in place for Resident (R)40 who developed a facility acquired pressure injury to his coccyx (small triangular bone at the base of the spine) area and further failed to implement treatment orders, and routinely monitor the wound. R40's pressure injury evolved into a stage three (full thickness, extending into tissue beneath the skin) pressure ulcer. The facility further failed to ensure preventive measures were in place for R32 who developed a pressure injury to her left heel and further failed to monitor the wound routinely. […]

• Actual harm, isolatedF689Feb 2, 2023

  The facility reported a census of 56 residents. The sample included 14 residents with seven residents reviewed for accidents/hazards. Based on observation, record review, and interview, the facility to ensure Resident (R)41 remained free from avoidable accidents when staff left R41, who required one-to-one assistance, alone in the bathroom to perform hygiene tasks, which resulted in a fall for R41. As a result, R41 sustained a cut to the back of her head which required emergent treatment and surgical staples to close the wound. The facility further failed to identify and implement appropriate interventions, investigate for causal factors, and follow residents' plan of care to prevent avoidable accidents and falls. […]

• No harm, potential for more than minimal, widespreadF730Jul 22, 2026

  Based on record reviews and interviews, the facility failed to provide regular in-service education based on the outcome of performance reviews. This placed the residents at risk of impaired care. Findings included:- The facility's employment records documented nine nurse aides were employed at the facility for at least one year. The facility's in-service records documented that 2 of those nurses' aides reviewed had not completed in service education on the outcome of performance reviews for competencies. […]

• No harm, potential for more than minimal, widespreadF880Jul 22, 2026

  Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to sanitize multi-resident use equipment between resident use. Staff also failed to utilize adequate infection control measures when providing urinary catheter care for Resident (R) 15. The facility also failed to establish a water management program to prevent the growth of Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) and other water-borne pathogens. Findings included:- 1. On 07/20/2026 at 02:00 PM, observation revealed R15 sat in a wheelchair in the family area by the nurses' station. […]