Heritage Hills Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Heritage Hills Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 18, 2025

  Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident received adequate supervision for 1 of 1 resident reviewed who was able to successfully elope from the facility, Resident ID #15.Findings are as follows:Record review of a facility policy titled, Wandering and Elopements states in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the residents' safety.If an employee observes a resident leaving the premises, he/she should.attempt to… […]

• Immediate jeopardy, isolatedF805Sep 18, 2025

  Based on surveyor observation, record review, and resident and staff interview, it has been determined that the facility failed to provide and prepare food in a form designed to meet individual needs for 2 of 4 residents reviewed with a physician's order for moderately thickened (honey) consistency fluids, Resident ID #s 49 and 19. Findings are as follows:Record review of the facility's diet manual states in part, .Thickened Liquids.Honey-like: Sticks to sides of a cup like honey. Pours very slowly, such as honey and cream soup.1. […]

• Immediate jeopardy, isolatedF689May 9, 2024

  Based on record review and resident and staff interview, it has been determined that the facility failed to ensure that residents receive adequate supervision to prevent an elopement for 1 of 1 resident reviewed who successfully eloped from the facility, Resident ID #2. Findings are as follows: Review of a facility policy titled, Wandering and Elopement dated March 2019, states in part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety . […]

• Actual harm, isolatedF686Jun 16, 2026

  Based on clinical record review and staff interview, the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 3 residents reviewed for pressure ulcers (an injury to the skin and underlying tissue caused by prolonged pressure on the skin over a bony prominence), Resident ID #2. Specifically, the resident was admitted to the facility without any skin impairments and while at the facility s/he developed a stage III pressure ulcer (an ulcer that has completely broken through the top 2 layers of skin and into the fat layer below) and an unstageable pressure ulcer (an ulcer that occurs when the wound bed is completely covered by dead tissue, slough, or eschar,… […]

• Actual harm, isolatedF760Jun 28, 2023

  Based on record review and staff and resident interview it has been determined that the facility failed to ensure that the residents are free from significant medication errors for 1 of 4 residents reviewed, Resident ID #6. Findings are as follows: Review of a community reported complaint sent to the Rhode Island Department of Health on 6/28/2023 alleges that Resident ID #6 had not been receiving his/her medication as ordered. Review of the packaging insert for Keppra, last revised in January 2023, states in part, Medication Guide .Do not stop KEPPRA without first talking to a healthcare provider. Stopping KEPPRA suddenly can cause serious problems. Stopping a seizure medicine suddenly can cause seizures . 1A. […]