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.

• Actual harm, isolatedF686Jul 14, 2026

  Based on medical record review, observation, staff interview, review of hospital records, review of the National Pressure Injury Advisory Panel (NPIAP) guidelines and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure necessary and effective interventions were in place to prevent the development and/or worsening of pressure ulcers for Resident #5 and to ensure wound treatments were completed as ordered for Resident #3. This affected two residents (#3 and #5) of three residents reviewed for pressure ulcers. The facility census was 30. […]

• Actual harm, isolatedF600Jan 26, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, facility self-reported incident (SRI) and investigation review, staff interview, facility policy and procedure review, and review of facility corrective action, the facility failed to prevent resident to resident abuse and failed to ensure Resident #20 was free from visitor-to-resident physical abuse. Actual harm occurred on 01/03/24 when during a resident-to resident-altercation involving Resident #20 and Resident #39 in Resident #39's room, a visitor in Resident #39's room, began swinging a dust mop in an attempt to get Resident #20 away from Resident #39 and struck Resident #20 on the head. […]

• No harm, potential for more than minimal, widespreadF727Jul 14, 2026

  Based on review of the Facility Assessment, review of the Payroll Based Journal (PBJ), policy review, and interview, the facility failed to ensure Registered Nurse (RN) staffing coverage of at least eight consecutive hours per day, and the facility had a one-star rating on the PBJ for the second quarter of 2026. This finding had the potential to affect all 30 residents residing in the facility. Findings include:Review of the Facility assessment dated [DATE] revealed nursing services included RNs of approximately 12 hours per day; RNs with Administrative Duties approximately two hours per day Monday through Friday; Licensed Practical Nurses (LPNs) approximately six hours per day; LPNs with administrative duties one Monday through Friday; Certified Nursing Assistants (CNAs) at approximately… […]

• No harm, potential for more than minimal, widespreadF880Jul 14, 2026

  Based on observation, interview, record review and policy review the facility failed to ensure proper infection control procedures were implemented related to glucometer use, respiratory equipment storage and sanitation of the laundry room. This affected Resident #4 and #8 and had the potential to affect all 30 residents in the facility. Findings include:1. Review of the medical record for Resident #8 revealed an admission date 03/18/25 with diagnoses including vascular dementia, type II diabetes, hypertension, alcohol abuse, gout, chronic kidney disease stage three. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # had impaired cognition and received insulin injections. […]

• No harm, potential for more than minimal, widespreadF921Apr 9, 2024

  Based on observation and interview, the facility failed to ensure a sanitary environment for residents. This affected Residents #15 and #38 and had the potential to affect all 41 residents residing in the facility. Findings include: Observation on 04/08/24 at 7:43 A.M. revealed the entire length of the floors on the two main hallways had scattered dried brown and orange colored liquid staining and dirt and other various debris. In addition there was a strong smell of urine in the hallways. Interview immediately after the observation with Licensed Practical Nurse (LPN) #100 verified the dried liquid, dirt an various other debris on the floor and strong smell of urine. Interview on 04/08/24 at 8:15 A.M. with Housekeeper #103 revealed she cleaned resident rooms and communal areas daily. […]