Heritage Nursing and Rehabilitation Community

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Apr 23, 2021

  Based on observation, interview, and record review, the facility failed to follow CDC guidance and/or appropriate infection control practices resulting in an immediate jeopardy on 4/20/21 when 1)All kitchen staff failed to follow current CDC COVID 19 guidelines, when on 4/20/21 all kitchen staff were observed not wearing masks. All facility staff received infection control re-education on 4/21/21. On 4/22/21 all kitchen staff were observed not wearing masks and a kitchen staff worker (cook) tested positive for COVID 19. The cook reported having cold like symptoms i.e. runny nose, could not taste food, and did not report those symptoms to management nor document those symptoms on sign in screen sheets. […]

• Actual harm, patternF880Nov 16, 2021

  This citation pertains to intake M 1878 and M 3755 Based on observation, interview, and record review, the facility failed to implement best infection control practices in the facility for 4 residents (Resident #12, Resident #14, Resident #17 and Resident #19), 2 treatment carts, and the environment, resulting compromised wound care, maggots in a wound, wound cultures not addressed by a physician, opened wound dressings and supplies stored in soiled and unsanitary treatment carts, dirty commodes shared between residents and then stored in the soiled utility, dirty ceiling fans, and dirty bedside tables and resident rooms. Findings include: Resident #12 (R12) Review of a Face Sheet revealed R12 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Apr 23, 2021

  Based on observation, interview and record review, the facility failed to assess, follow orders, maintain infection control, and prevent pressure ulcers for 2 (Resident #6 and Resident #16), resulting in pressure ulcers. Findings include: Resident #6 Review of a Face Sheet revealed Resident #6 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) indicating he is cognitively intact and required extensive assistance of 2 for transfers and had limited range in motion on one side for the upper and lower extremity. The resident was at risk for a pressure ulcer but did not have one. […]

• Actual harm, isolatedF697Apr 23, 2021

  Based on observation, interview and record review, the faciltiy failed to assess, control and implement measures for pain for 1 (Resident #6) with comorbities that have painful tendencies resulting in unresolved pain that can affect care and quality of life. Findings include: Resident #6 Review of a Face Sheet revealed Resident #6 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) indicating he is cognitively intact and required extensive assistance of 2 for transfers and had limited range in motion on one side for the upper and lower extremity. […]

• No harm, potential for more than minimal, widespreadF812Mar 17, 2026

  Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 03/15/2026 at 8:55AM, observed in the residents' refrigerator, an open container of [NAME] Thickened Water (no flavor), without an open date, or a facility provided use by date. When asked who is responsible for dating the foods in the residents' refrigerator, Dietary [NAME] (DC) N said the [NAME] thickened water should have had a date on it, and that nursing staff is responsible for dating product used for med-pass, and resident's food. The container was discarded by DC N. […]