Heritage Specialty Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 16, 2023

  Based on clinical record review, staff interviews, family interviews, resident interviews, policy review, and observations the facility failed to provide adequate supervision for 2 of 5 residents reviewed for adequate supervision (Resident #21 and #26). The facility failed to ensure the resident's safety by allowing Resident #21 to leave the facility with a male friend without the consent and knowledge of the resident's Guardian and failed to ensure a resident's safety by failing to complete a thorough search of the premises after a Wander guard alert system sounded. These failures resulted in possible endangerment for both residents, therefore causing an Immediate Jeopardy (IJ) to the health, safety and security of two residents. […]

• Immediate jeopardy, isolatedF689Nov 1, 2022

  Based on observations, clinical record review, staff and resident interviews, the facility failed to supervise two residents adequately to prevent elopements from the facility for two of seven residents reviewed with elopement/wandering risks (Residents #1 and #3) and also failed to take immediate and appropriate action on 9/26/2022 to a hazard in the environment when a staff member pulled a gun out of her purse, waived it in the air and stated she would take matters into her own hands if the facility did not take care of it. This failure resulted in an Immediate Jeopardy (IJ) to the health, safety, and security of the residents. The facility reported a census of 151 residents. Findings Include: 1. […]

• Actual harm, isolatedF689Nov 6, 2025

  Based on clinical record review, observations, staff and resident interview and facility policy review the facility failed to provide safe transfers for 3 of 4 residents reviewed (Residents #1, #6, #7). The facility reported a census of 115 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident#1 dated 8/1/25, listed diagnoses of stroke, high blood pressure (HTN), heart failure, non-Alzheimer's Dementia, Bipolar disorder, seizure disorder. The MDS reflected the Brief Interview for Mental Status (BIMS) score of 15 out of 15 intact cognition. The MDS identified Resident #1 dependent on staff for transfers, dressing, toileting, and hygiene. […]

• Actual harm, isolatedF658Jun 12, 2025

  Based on observation, record review, resident, family and staff interview, the facility failed to administer medications as ordered for two of three residents reviewed (Residents #2 and #3). The facility reported a census of 118 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #2 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 and had the following diagnoses: Heart Failure, Coronary Artery Disease, Wound Infection, and Diabetes Mellitus. […]

• Actual harm, isolatedF684Jun 12, 2025

  Based on record review, family and staff interview, and facility policy review, the facility failed to properly assess and intervene after administration of a rapid acting insulin (without consuming the meal) to 1 of 3 residents reviewed with orders for insulin (Resident #1). This resulted in the resident becoming unresponsive with a blood glucose of 25 and being sent to the hospital. The facility reported a census of 118 residents. Findings include: The Minimum Data Set, dated [DATE] identified Resident #1 as severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 0 and had the following diagnoses: Heart Failure, Urinary Tract Infection, and Diabetes Mellitus. […]