Heritage House Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF921Mar 14, 2024

  Based on observation, staff interview and facility policy review the facility failed to ensure linen barrels did not block fire doors on one of two halls for one (1) of four (4) days of survey. This had the potential to affect 56 residents residing in the facility. Findings Include Record review of the facility policy titled, Safety and Security Plan with a revision date of 4/23 revealed #19 .Arrange equipment such as wheelchairs, tables, linen carts, etc., so as not to block aisles, exits, fire fighting equipment, alarm boxes, electric lighting, or power panels, etc .FIRE DOORS MUST BE KEPT CLEAR AT ALL TIMES . An observation on 03/11/24 at 6:45 PM, revealed the double fire doors leading to Hall 200 were open with two linen barrels propped against one of the doors. […]

• No harm, potential for more than minimal, isolatedF558Feb 26, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure Resident #5's right to reasonable accommodation of her physical limitations by not maintaining a call light within reach and not providing a call light she could independently activate to request assistance, for one (1) of nineteen (19) residents sampled. Findings include:A review of the facility's policy, Call Light/Bell revealed, Purpose.provide the resident a means of communication with staff members.Procedure 1. Ensure resident has call light in reach when in resident room.7. […]

• No harm, potential for more than minimal, isolatedF605Feb 26, 2026

  Based on interview, record review, and facility policy review, the facility failed to ensure a resident was evaluated for continued need of a PRN (as needed) psychotropic medication after fourteen (14) days for one (1) of five (5) residents reviewed for unnecessary medications, Resident #9. Findings include:A review of the facility's policy, Psychotropic Medications, with a latest review date of 02/25, revealed, . The facility will not use Psychotropic medications unless it is necessary to treat a specific condition as diagnosed and documented in the clinical record. PRN orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. […]

• No harm, potential for more than minimal, isolatedF641Feb 26, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was coded accurately to reflect a resident's tobacco use for one (1) of nineteen (19) residents whose MDS assessments were reviewed, Resident #46.Findings include:A review of the facility's policy, Resident Assessment, with a latest revision date of 09/19, revealed, An assessment will be completed on each resident utilizing the MDS (Minimum Data Set) . The Registered Nurse is responsible for verifying the completion of the assessment. The completed assessment guides the staff in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan. […]

• No harm, potential for more than minimal, isolatedF656Feb 26, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan intervention for one (1) of 19 sampled residents (Resident #5). Findings include:A review of the facility's policy, Care Plan Process (revised 12/2024) revealed, .Regulations require facilities to complete.a comprehensive, standardized assessment of each resident's functional capacity and needs.The results of the assessment.are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care.A record review of the Care Plan Detail for Resident #5 revealed a Focus of The resident is Moderate risk for falls. […]