Heritage Hall King George

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 26, 2026

  Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide a safe transfer with a mechanical lift for one (1) resident (Resident #13) in a survey sample of forty-three (43) residents, which resulted in the resident falling from the mechanical lift sustaining a laceration to right posterior scalp requiring four (4) staples. This constituted the identification of immediate jeopardy (IJ) at Level Four, Isolated scope and severity and substandard quality of care. Upon verification of the removal of the IJ, the scope and severity was lowered to Level Three, Isolated. […]

• Immediate jeopardy, isolatedF689May 23, 2024

  Based on interview clinical record review and facility documentation the facility staff failed to ensure that Residents receive adequate supervision and assistance to prevent accidents for 1 Resident (#1) in a survey sample of 5 Residents. Immediate Jeopardy (IJ) was identified on 5/22/24 at 12:55 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the implementation of the facility's immediacy removal plan, it was determined the IJ was removed on 5/23/24 at 11:15 AM. The scope and severity were lowered to level 3, isolated. The findings included: For Resident #1, the facility staff failed to ensure the Resident was always supervised in the whirlpool tub. […]

• Actual harm, isolatedF658Oct 31, 2023

  Based on staff interview, facility documentation review and clinical record review, the facility staff failed to meet professional standards of quality for one Resident (Resident #2) which resulted in harm for one Resident (Resident #1) in a survey sample of three Residents. Findings included: For Resident #2, on 11/18/22, the facility staff failed to follow professional standards regarding medication administration. Facility staff, Registered Nurse-B (RN-B) left a cup of medications containing 5 pills (including psychiatric drugs) at the bedside unattended. […]

• Actual harm, isolatedF760Oct 31, 2023

  Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure one resident (Resident # 1) of 3 residents in the survey sample was free of significant medication errors. For Resident #1, the facility staff failed to ensure the roommate's medications including psychiatric medications were not left unattended and available for incidental consumption by Resident # 1, resulting in hospitalization for 4 days. This constitutes harm. […]

• No harm, potential for more than minimal, widespreadF732Sep 1, 2022

  Based on observation, staff interview, and facility documentation review, the facility staff failed to post daily staffing information for Residents, staff, and visitors to see, which has the potential to affect all Residents. The findings included: On 9/1/22 at approximately 11:00 AM, a faciltiy tour was conducted to look for daily staffing posted. Surveyor E was unable to locate it. On 9/1/22 at approximately 12:40 PM, the Director of Nursing (DON) was asked where the daily staffing is posted. The DON and Surveyor E went to the B unit and found the Daily Unit Assignment sheet posted in the hallway. This posting listed the date, staff's first names and their assigned shift. No census data or hours worked was noted. The DON and Surveyor E then went to the A unit. […]