Heritage Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF692Mar 2, 2022

  Based on record review and interview, the facility failed to timely identify a significant weight loss and implement interventions for 1 of 1 resident reviewed for weight loss (Resident D). Resident D had a significant weight loss of 20.4 pounds and 14.6 % weight loss in 13 days. Finding includes: The record for Resident D was reviewed on 2/28/22 at 4:03 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 2/28/22, indicated the resident had a tube feeding and oral diet to meet her nutritional and/or hydration needs to support her overall metabolic demands. She had malabsorption and ulceration of the gastrointestinal tract and was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 2/28/22, indicated the resident had [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF812Aug 5, 2025

  Based on observation, interview and record review, the facility failed to ensure food items were labeled with the date received, the reach-in refrigerator was maintained at a safe temperature, and temperature logs were up to date. This deficient practice had the potential to affect 68 of 69 residents who received food from the kitchen.Findings include:1. During the initial kitchen tour with [NAME] 2, on 7/30/25 at 10:21 a.m., the following pre-packaged food items were found to be not labeled with the date received:a. six (6) packages of gravy mixb. three (3) containers of cream of wheatc. eight (8) bags of brown sugard. four (4) packages of brownie mixe. one can of sauerkrautf. one can of peasg. one can of marinara sauceh. […]

• No harm, potential for more than minimal, patternF804Aug 5, 2025

  Based on observation, interview and record review, the facility failed to ensure pureed foods were prepared according to the recipe to ensure the nutritive value, flavor, and appearance were conserved for 5 of 5 residents reviewed for a pureed diet.Findings include:During an observation, on 7/30/25 at 10:48 a.m., [NAME] 2 was observed to add 5 cooked and seasoned hamburger patties to a food processor. He added an unmeasured amount of water, turned on the processor, and mixed until a pudding consistency was obtained. He did not refer to a recipe during the observation.During an interview, on 7/30/25 at 10:48 a.m., [NAME] 2 indicated he was unsure if there was a recipe for purees. He did not know where it was and thought it may have been in with the regular recipes. […]

• No harm, potential for more than minimal, patternF921Aug 5, 2025

  Based on observation, interview and record review, the facility failed to ensure the facility and resident rooms were maintained for 8 of 33 rooms reviewed for environment. (room [ROOM NUMBER], 16, 23, 18, 21, 32, 36, 103).Findings include: During an observation, on 7/30/25 beginning at 12:21 p.m., the following were observed.1. In room [ROOM NUMBER], the wall under the window had a large area with no paint. 2. In room [ROOM NUMBER], the wall had paint peeled off under the window and on the right side by the bathroom door.3. In room [ROOM NUMBER], the wall had black scuff marks and missing paint on the lower portion of the wall.4. In room [ROOM NUMBER], the bottom of the door had black scuff marks.5. […]

• No harm, potential for more than minimal, patternF761Jul 12, 2024

  Based on observation, interview and record review, the facility failed to ensure medications administered orally were separated from topical medications and eye drops, to store cleaning supplies separately from medications, correctly label OTC (over the counter) medications, date opened medications, and routinely dispose of medications after the date of expiration for 4 of 4 medication carts reviewed. (medication cart 1, medication cart 2, medication cart 3, and medication cart 4) Findings include: During a medication cart observation with Qualified Medical Assistant (QMA) 6, on [DATE] at 11:06 a.m., medication cart 1 was observed to have the following: a. […]