Heritage Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents, (Resident 139) who was admitted with intact skin integrity (undamaged skin) did not develop a blood blister (fluid-filled pocket that forms when small blood vessels break under the skin, usually caused by pinching, crushing, or rubbing) on the left calf that deteriorated to a deep tissue injury ([DTI] (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) and later progressed to a Stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon [a tough cord of fibrous tissue that connects a muscle to a bone], ligament, cartilage, or bone) pressure injury (localized damage to the skin… […]

• Actual harm, isolatedF684Jun 13, 2025

  Based on interview and record review, the facility failed to provide the necessary care and treatment for four of six sampled residents (Resident 19, 14. 61 and 39). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 8, LVN 9 and Registered Nurse (RNS) 4 assessed and monitored Resident 19 when the resident had a change in condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, and understand] behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by shivering and shaking on 6/8/2025 at 11:10 p.m., and every two hours thereafter. 2. Ensure LVN 8 informed LVN 9 of Resident 19's shivering and shaking on 6/8/2025 at 11:10 p.m. […]

• Actual harm, isolatedF689Jun 13, 2025

  Based on observation, interview and record review, the facility failed to ensure residents, who were identified at risk for falls, did not fall and sustain injury for two of three sampled residents (Resident 50 and Resident 89). The facility failed to: 1. Ensure Resident 50's talking device (recordable voice alarm with a personalized message that plays when an alarm is triggered) was turned on as one of the interventions of fall risk prevention program for Resident 50. 2. Ensure the licensed nurses evaluated the effectiveness of interventions of Resident 50's care plan titled, At risk for falls, difficulty maintaining sitting/standing balance, history of falls/multiple falls initiated on 12/25/2024, after the resident's fall on 4/19/2025, to develop new interventions to prevent the… […]

• Actual harm, isolatedF692Jun 13, 2024

  Based on interview, and record review, the facility failed to prevent the resident's unplanned severe weight loss (a weight loss greater than 5 % in one month, greater that 7.5% in three months and greater than 10 % in 6 months) of nine (9) pounds ([lbs.] 9.57 percent [%] in one month for one of two sampled residents (Resident 129). The facility failed to: 1. Ensure the Registered Dietician's ([RD] a health professional who has a special training in diet and nutrition) recommendation to increase Resident 129's enteral (form of nutrition that is delivered into the digestive system as liquid) feeding from 250 milliliter ([ml] unit of measurement) four times per day to 250 ml five times per day totaling 1500 calories ([kCal] energy people get from the food and drink they consume, and the… […]

• Actual harm, isolatedF697Jun 13, 2024

  Based on observation, interview and record review, the facility failed to ensure the resident, who had a Stage 4 pressure ulcer (wound that penetrate all layers of skin exposing muscles, tendons [tissue that unites a muscle with a bone] cartilage {tissue that lines a joints}, and bones caused by prolonged pressure on the skin) to sacrum (tailbone area), did not experience unnecessary pain and suffering during pressure ulcer treatment and repositioning for one of five sampled residents (Resident 73). The facility failed to: 1. Ensure the Registered Nurse (RN 6) provided Resident 73 with effective pain relieve when Resident 73 loudly screamed and moaned during the sacral pressure ulcer treatment. 2. […]