Heritage Skilled Nursing and Therapy

In the surveyor’s words

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

• Actual harm, isolatedF600Nov 22, 2021

  Based on interview and record review, the facility failed to ensure residents were free from mental abuse for one (#1) of three sampled residents reviewed for abuse and neglect. The facility failed to prevent a staff member from photographing a resident after an incontinent episode and posting the photograph on social media. The deficient practice was determined to be past-noncompliance since the facility identified the situation and implemented interventions to prevent the recurrence of the situation. […]

• No harm, potential for more than minimal, patternF656Mar 27, 2025

  Based on record review and interview, the facility failed to develop comprehensive care plans for 2 (#24 and #38 ) of 19 resident care plans reviewed. The administrator identified 65 residents resided in the facility. Findings: 1. Resident #24 was admitted to the facility on [DATE] with diagnosis of displaced fracture of upper end of left humerus. The admission (comprehensive) assessment was completed on 02/28/25. Care areas that were triggered (potential areas of concern) during the comprehensive assessment included: cognitive loss/dementia, ADL function, urinary incontinence, and psychoactive drug use. The care plan did not include cognitive loss, ADL function, urinary incontinence, or psychoactive drug use when reviewed on 03/25/25. […]

• No harm, potential for more than minimal, patternF693Mar 27, 2025

  Based on observation, record review, and interview, the facility failed to ensure bottles containing tube feeding were labeled and dated for 2 (#30 and #215 ) of 2 sampled residents observed for tube feeding. The administrator identified three residents required tube feedings. 1. On 03/26/25 at 7:48 a.m., the tube feeding for Resident #30 was observed running at 60 ml/hr. The bottle was not labeled with the date or time opened, or who hung the bottle. A Tube Feeding policy, dated 06/24/10, read in part, Change and label (name of resident, date, and time) feeding set (tubing and appropriate syringe) every 24 hours. Resident #30 admitted to the facility with diagnoses which included dysphagia, diabetes mellitus, major depressive disorder, chronic pain, and cerebral infarction. […]

• No harm, potential for more than minimal, patternF812Nov 16, 2023

  Based on observation and interview, the facility failed to ensure the kitchen and dining area were kept clean and maintained in good repair. The DM identified 67 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: On 11/13/23 at 7:33 a.m., a tour of the kitchen was conducted. The following observations were made: a. there was a hole in the wall around the piping below the dish machine, b. ceiling lights were burned out and/or not working. End caps were missing on the light shields, c. there was an accumulation of black residue on the floor and the walls below and behind the dish machine and cook area, and d. […]

• No harm, potential for more than minimal, patternF883Nov 16, 2023

  Based on record review and interview, the facility failed to ensure the resident or their legal representative received education regarding the benefits and potential side effects of the influenza immunization and obtain consents before administering the immunization for three (#46, 49, and #55) of five sampled residents reviewed for immunizations. The DON identified 69 residents resided in the facility. Findings: The facility's Influenza Vaccination Program policy, revised on 10/11/05, read in parts, .It is the policy of this facility to provide all residents .who do not have allergy to the vaccine, the influenza vaccination yearly .obtain consent forms .Provide education to residents or resident representative on the benefits and potential side effects of the influenza vaccine .before… […]