Heritage Inn Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Heritage Inn Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689May 20, 2021

  Based on observation, record review, facility staff and Hospice staff interviews, the facility failed to provide adequate supervision when serving hot broth to one resident (R) (R#1) of six sampled residents. This failure resulted in actual harm for R#1 who sustained [CONDITION(S)] on her body. Findings include: Review of the [NAME] Health Care website (standfordhealthcare.org) Burn Stages revealed that First degree [CONDITION(S)] were superficial and affected only the epidermis, or outer layer of skin. The burn site was red, painful, dry and had no blisters. A mild sunburn was an example. Second-degree [CONDITION(S)] involved the epidermis and part of the dermis layer of skin. […]

• No harm, potential for more than minimal, widespreadF812Jun 19, 2025

  Based on observation, staff interviews, and facility policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner, failed to ensure food items were dated, and failed to discard food items on or before their expiration or discard dates. These failures had the potential to create an environment for food-borne illnesses, which could affect 52 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled Cleaning and Sanitizing, dated 12/27/2024, indicated, It is the intent of this center to clean and sanitize utensils, dishware, pots and pans, workspace, and equipment to minimize the risk of food-borne illnesses . […]

• No harm, potential for more than minimal, isolatedF600Jul 23, 2026

  Based on interviews, record reviews, and review of the facility's policy titled Abuse Prohibition, the facility failed to ensure one out of six sampled residents (R) (R66) was free from abuse. Specifically, R66 was hit by another resident (R11), resulting in the facility's failure to protect R66 from resident to resident physical abuse.Findings include:Review of the facility's policy titled, Abuse Prohibition dated December 27, 2025 documented under Intent revealed, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. […]

• No harm, potential for more than minimal, isolatedF609Jul 23, 2026

  Based on interviews, record reviews, and review of the facility's policy titled Abuse Prohibition - Reporting and Investigating, the facility failed to report abuse in a timely manner after a resident to resident altercation for one of six sampled residents (R11). This deficient practice resulted in a delay in notifying the State Survey Agency, which placed residents at risk for unrecognized abuse, delayed protective interventions, and inadequate oversight of resident safety.Findings include:Review of the facility's policy titled Abuse Prohibition - Reporting and Investigating, dated December 27, 2025, documented under INTENT It is the intent of this center to establish standards of practice for investigation and reporting of abuse, neglect, mistreatment, exploitation, and misappropriation… […]

• No harm, potential for more than minimal, isolatedF689Jun 19, 2025

  Based on observation, record review, and staff interviews, the facility failed to ensure safe resident transfers by using two staff to assist with a transfer by a mechanical lift for one of one resident (R) (R4) reviewed for transfers out of 20 sampled residents. This had the potential to place the resident at risk for injury. Findings include: 1. Review of R4's Face Sheet, located in the admission Record tab of the electronic medical record (EMR), revealed R4 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia and osteoarthritis. […]