Heritage Living Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 24, 2026

  Based on interviews and record review, the facility failed to protect the resident's(s') right to be free from neglect for one (Resident #1) of six residents reviewed for neglect. Specifically, the facility failed to ensure a cumulative effect of individual staff failures in the provision of care and services did not lead to an environment promoting neglect, when on 07/09/2026: - At or about 8:55 AM, CNA #1 performed a one-person pivot transfer of Resident #1 to the shower chair, in direct deviation from the resident's established care plan, which required two staff members and a mechanical lift for all transfers. Resident #1 reported to staff she heard a cracking sound and experienced pain in her leg. […]

• Actual harm, isolatedF689Jul 24, 2026

  Based on interviews, record review, and facility document review, the facility failed to ensure staff followed the Care Plan for one (Resident #1) of six residents reviewed. This failed practice led to an avoidable accident in which the resident obtained a fracture of the right distal femur. The findings include: Review of the Medical Diagnosis portion of the electronic health record revealed Resident #1 had diagnoses that included chronic obstructive pulmonary disease, kidney failure, type 2 diabetes, muscle wasting, and atrophy. Review of Resident #1s quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/16/26, revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF838Nov 26, 2025

  Based on interviews and facility document review, the facility failed to utilize the Facility Assessment to ensure the minimum weekend staffing needs were met a total of 8 out of 26 weekend days, for the residents during April, May, and June of 2025, based on the Facility Assessment staffing requirements. The findings include: Review of the Facility Assessment, last updated 10/31/2024, revealed an average daily census of 125-130 residents. The Facility Assessment, last updated 10/31/2024, revealed direct-care staffing needed to ensure residents' needs were met daily, were as follows: Total Number Needed Average or Range Licensed nurses providing direct care 8-11 Nurse aides 35-50 The Facility Assessment also revealed an Individual staff assignment for nurse staffing needs by shift, for… […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2024

  Based on observation, record review, and interview the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items to prevent the potential for cross contamination for the residents who received meals from 1 of 1 kitchen; Hot food items were not maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for the residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 127 residents who received meals from the Kitchen. The findings are: 1. On 06/02/24 at 10:30 AM, Dietary Aide (DA) #1 turned the sink on and washed her hands. She used her bare hands to turn off the faucet, contaminating her hands. […]

• No harm, potential for more than minimal, widespreadF812May 11, 2023

  Based on observation, record review, and interview, the facility failed to ensure that the foods stored in the freezer were covered and sealed to minimize the potential for food-borne illness for the residents who their received meals from 1 of 1 kitchen, dietary staff washed their hands between dirty and clean tasks, and before they handled clean equipment or food items to prevent potential for cross contamination. These failed practices had the potential to affect 127 residents who received meals from the kitchen (total census: 127), as documented on a list provided by Dietary Supervisor on 05/10/23 at 10:55 AM. The findings are: 1. On 05/08/23 between 11:30 AM and 12:54 PM, the following were observed in the kitchen: a. […]