Heritage Home

In the surveyor’s words

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

• Actual harm, isolatedF760Aug 19, 2025

  Based on staff interview, medical record review, incident report review, and facility investigation review, the facility failed to ensure resident's were free from significant medication errors for 1 of 7 sampled residents (#1) reviewed. This failure resulted in harm to resident #1 who was hospitalized following an insulin overdose. The findings were: 1. Review of the admission Minimum Data Set assessment dated [DATE] showed resident #1 had a brief interview for mental status score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which include heart failure, atrial fibrillation, renal insufficiency and diabetes mellitus. Further review showed the resident was insulin dependent for diabetes mellitus. The following concerns were identified: a. […]

• No harm, potential for more than minimal, widespreadF812Nov 18, 2021

  Based on observation, staff interview, and review of Food Code standards, the facility failed to ensure food equipment and surfaces were maintained in a sanitary condition in 2 of 3 meal service areas (TV room and sun room) and for 2 of 3 ice machines (kitchen and beauty shop). The census was 31. The findings were: 1. Observation on 11/15/21 at 4:04 PM showed the ice machine located in the kitchen was not clean. The interior white plastic piece that was located above the full ice bin was soiled with a black and pinkish build-up. 2. Observation on 11/17/21 at 11:49 AM showed the ice machine on the resident unit was located in the beauty shop. There was no separation between the area where hair was done and the area where the ice machine was located. […]

• No harm, potential for more than minimal, patternF880Jun 12, 2025

  Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure proper infection control practices for 1 of 2 sample residents (#10) with foley catheter placement and during 2 meal observations. The census was 35. The findings were: Regarding residents with foley catheters: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #10 had a brief interview for mental status score of 13 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included neurogenic bladder, diabetes mellitus, and dementia. […]

• No harm, potential for more than minimal, patternF656Feb 23, 2024

  Based on medical record review and resident and staff interview, the facility failed to develop a comprehensive care plan for 4 of 15 sample residents (#4, #9, #12, #20). The findings were: 1. Review of the 12/15/23 admission MDS assessment showed resident #4 received opioid medication and had indicators of pain on 3-4 days during the look-back period. Further review of the assessment showed pain triggered and review of the care area assessment (CAA) for pain showed the resident had a recent fracture, a weekly Butrans patch, oxycodone, and Tylenol was used to control pain. […]

• No harm, potential for more than minimal, patternF684Feb 23, 2024

  Based on medical record review, staff interview, and review of facility protocol, the facility failed to implement interventions to treat constipation for 3 of 3 sample residents (#4, #10, #20) reviewed for bowel management due to opioid medication use. The findings were: 1. Review of the 12/15/23 admission MDS assessment showed resident #4 had a femur fracture and received opioid medication. Review of current orders and the February 2024 MAR showed the resident was ordered the following opioid medications: Butrans patch weekly, 7.5 mcg/hour, on Friday; morphine concentrate 100 mg/5ml, 0.4 mL (8 mg), four times a day; and morphine concentrate 100 mg/5 mL, 0.4 ml (8 mg) every 8 hours PRN. The following concerns were identified: a. […]