Heritage Plaza Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF607Sep 4, 2024

  Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 14 residents (Resident #1) reviewed for abuse and neglect in that: The facility failed to suspend an alleged perpetrator immediately following CNA A roughly handling Resident #1 during ADL care. The facility allowed CNA A to work 7 more shifts before suspension while investigation the abuse allegations, and the facility failed to report the abuse within 24 hours to the state agency. The ADON and CNA B failed to report the abuse to the abuse coordinator immediately. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/09/2024 and ended on 04/17/2024. […]

• Immediate jeopardy, isolatedF684May 2, 2022

  Based on interview and record review the facility failed to provide care in accordance with resident's comprehensive assessment and failed to ensure resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 11 residents reviewed for quality of care. (Resident #1) The facility did not monitor the condition of Resident #1's right foot when a CNA reported the resident's foot looked discolored. Resident #1 developed gangrene (the death of body tissue due to a lack of blood flow or a serious bacterial infection) in three of his right toes. […]

• Actual harm, isolatedF692Sep 10, 2025

  Based on interview and record review the facility failed to ensure a therapeutic diet was offered when there were nutritional problems and the therapeutic diet was recommended for 1 of 2 residents reviewed for nutrition.The facility failed to put interventions in place when Resident # 1 had poor intake related to swallowing food, inability to consume meals as result of physical decline. Resident #1 had a wound and did not receive a dietician consult as needed. Resident #1 did not have updated care plan interventions related to her change in condition . […]

• Actual harm, isolatedF689Sep 4, 2024

  Based on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 2 of 8 residents reviewed for accidents. (Resident #3 and Resident #5) 1.The facility failed to ensure CNA D performed safe repositioning with two staff members during incontinent care for Resident #3 on 3/26/24, which resulted in Resident #3 falling off the bed and required stitches to the inside of her lip. 2. […]

• Actual harm, isolatedF770Oct 21, 2021

  Based on interview and record review the facility failed to promptly notify the physician of abnormal laboratory results for 2 of 2 residents receiving [MEDICATION(S)] and reviewed for laboratory services. (Residents #20 and #47) The facility did not notify the physician of Resident #47's high [MEDICATION(S)] level on 09/16/2021. The facility continued to administer [MEDICATION(S)] to Resident #47 until 10/08/2021 when the Resident's [MEDICATION(S)] level was at a critical high level (a laboratory result that is life threatening unless some action is taken in a very short time). The resident was sent to the hospital on 10/11/2021 and was admitted for [MEDICATION(S)] Toxicity (high levels of [MEDICATION(S)] that has become harmful). […]