Heritage Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF695May 13, 2026

  Based on record review, observation, and interview the facility failed to ensure respiratory care was provided with professional standards of practice by not following the facility's policy regarding oxygen administration for 1(#25) of 2 (#7 and #25) reviewed for respiratory care. Findings:PolicyReview of the facility's Oxygen Administration Policy dated 01/15/2026 revealed: All safety precautions and care of equipment shall be performed according to recommended State and Federal guidelines and facility procedures. Prefilled humidifier bottles and nasal cannulas/masks will be changed every week and PRN (as needed). All tubing and bottles are to be labeled each week when changed. When the tubing is not being used, it should be stored properly in a zip lock bag. […]

• No harm, potential for more than minimal, patternF609Mar 26, 2025

  40015 Based on record review and interviews, the facility failed to ensure an alleged injury of unknown origin was reported to the State Survey Agency for 1 (#37) out of 4 (#7, #26, #32, #37) sampled residents investigated for accidents. Findings: Review of the facility's SIMS (Statewide Incident Management System) Investigation and Reporting Policy Statement policy with the latest revision date of 01/15/2025 revealed, in part: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source, falls with fractures related to unknown origin, and elopement shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. […]

• No harm, potential for more than minimal, patternF656Mar 26, 2025

  Based on record review and interviews the facility failed to implement a comprehensive person-centered care plan for 1 (#26) of 4 (#1, #12, #26, #87) residents reviewed for nutrition. The facility failed to ensure Resident #26 was weighed weekly as per the physician order and in accordance with Resident #26's plan of care. Findings: Review of Resident #26's medical record revealed and admitted [DATE] with diagnoses including, in part, type 2 diabetes mellitus with diabetic neuropathy unspecified, dysphagia oropharyngeal phase, unspecified protein-calorie malnutrition, depression, and essential (primary) hypertension. […]

• No harm, potential for more than minimal, patternF684Mar 26, 2025

  37867 Based on record reviews, observations, and interviews, the facility failed to ensure 2 (#4, #12) of 20 sampled residents (#2, #37, #32, #34, #87, #6, #10, #27, #1, #19, #8, #20, #26, #4, #7, #36, #33, #25, #35, #12) received treatment and care in accordance with professional standards of practice by failing to ensure: 1. Resident #4 was administered Lasix (a diuretic medication) as ordered by the physician 2. Resident #12 was care planned for diabetes and had not been evaluated by a registered dietician. Findings: Resident #4 Review of Resident #4's record revealed an admitted [DATE] and diagnoses including end stage heart failure. Review of Resident #4's current Physician orders revealed orders included: -an order dated 02/12/2025-Monitor for Edema every shift. Chart Severity. […]

• No harm, potential for more than minimal, patternF686Mar 26, 2025

  37867 40015 Based on record review and interviews, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the development of new pressure ulcers for 3 (#4, #8, and #19) of 3 (#4, #8, and #19) residents investigated for pressure ulcers by failing to: 1. perform weekly wound assessments for pressure ulcers for Resident # 4, #8, and #19 and; 2. conduct weekly skin assessments for Resident # 8 3. develop a care plan for pressure ulcers for Resident #4, #19 Findings: Review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol (undated) revealed in part: The nurse shall describe and document/report the following: a. […]