Heritage Health Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF757Feb 27, 2026

  Based on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure one of five sampled residents (Resident #36), was not administered pain medications outside provider-ordered parameters. This deficient practice places residents at risk for adverse drug reactions. The sample size was 5. The universe was 68. -Regarding Resident # 36 Resident # 36 was admitted to the facility on [DATE] with conditions that included Type 2 Diabetes Mellitus without complications, pressure ulcer of the right heel, and acute osteomyelitis of the right ankle and foot. Review of the quarterly Minimum Data Set, dated [DATE], revealed the resident had a Brief Interview Mental Status score of 15 indicating he was cognitively intact. […]

• No harm, potential for more than minimal, patternF812Apr 22, 2021

  Based on observations, staff interviews, and review of facility policies, the facility failed to ensure food in unit nourishment refrigerators was stored in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses. Findings include: Regarding the East unit An observation of the East unit nourishment area was conducted on April 21, 2021 at 2:14 p.m. with the Kitchen manager (staff #37). The following were observed: -Refrigerator #1 was observed to have a temperature within the correct range and contained ham and cheese sandwiches, fruit (cut fruit and grapes), jello, pudding, and pitchers of juice. […]

• No harm, potential for more than minimal, isolatedF578Feb 27, 2026

  Based on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure that a valid advance directive and an updated medical directive were completed and readily accessible for two residents (Residents #5, #22). The deficient practice could result in residents receiving services that are not in accordance with their wishes, and they may be unaware of services that may or may not have been provided to the resident. The sample was 4. […]

• No harm, potential for more than minimal, isolatedF580Feb 27, 2026

  Based on review of clinical records, staff interviews, facility documentation, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) guidance, and facility policy, the facility failed to ensure that physician insulin administration orders for notification of abnormal blood glucose results were followed for two of sampled residents (#4 and #36). This deficient practice placed residents at risk for delayed treatment or inadequate management of blood glucose levels. […]

• No harm, potential for more than minimal, isolatedF609Feb 27, 2026

  Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to implement their policy regarding reporting allegations of abuse and neglect and to ensure that allegations of neglect were reported within a timely manner to the state agency for one of one sampled resident (Resident #32). The deficient practice could result in further instances of allegations of neglect not being reported and investigated promptly, and in accordance with professional standards. […]