Heritage Square

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Sep 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure kitchen staff wore hair restraints and failed to ensure the freezer was in working order. This applies to all 24 residents residing in the facility. The findings include: The facility's Long-Term Facility Application for Medicare and Medicaid (CMS 671), dated 9/22/25, shows the facility census is 24. On 09/22/2025 at 9:30 AM, V3, Food Service Director, opened the freezer door. The ceiling contained ice drops. There were multiple boxes and containers of food items covered with ice and frost on the top shelves of the freezer. The freezer fan was running and making a very loud clanking noise. There was a food cart with loaves of bread and trays of foiled covered dishes, dated 8/16/25. […]

• No harm, potential for more than minimal, widespreadF812Dec 29, 2021

  Based on observation, interview, and record review, the facility failed to ensure refrigerated foods were labeled with an opened date, and failed to ensure resident food was free from contamination for all residents residing in the facility. The findings include: The facility's Resident Census and Conditions Form (CMS 672), dated 12/28/21, shows 19 residents reside in the facility. On 12/27/21 at 9:38 AM, in the chest freezer in the kitchen, there was a cardboard box containing stuffed shells in a plastic bag. The bag was open to air, and was not labeled with a date. On 12/27/21 at 9:40 AM, the cooler in the kitchen had an unlabeled bottle of lemon and prune juice, and a half used container of salad dressing. All three items were partially used, without an opened date. […]

• No harm, potential for more than minimal, widespreadF755Mar 23, 2021

  Based on observation, interview, and record review, the facility failed to implement it's policy for the reconciliation of the resident's controlled substances. This failure has the potential to affect all residents in the facility. The findings include: The resident census and conditions of residents report, dated 3/23/21, showed 22 residents residing in the facility. On 3/23/21 at 2:00 PM, V8, Registered Nurse, unlocked a cupboard in a utility room on the second floor. In this cupboard was a black, steel lock box, which V8 stated was the resident's emergency supply of controlled substances. V8 obtained a key for the emergency supply controlled substance lockbox, which was in the medication room across the hallway. […]

• No harm, potential for more than minimal, patternF812Jul 10, 2024

  Based on observation, interview, and record review, the facility failed to handle mechanically altered food in a manner to prevent cross-contamination. This applies to 2 of 2 residents (R4 and R12) reviewed for dietary services in the sample of 11 and 4 residents (R7, R9, R11, and R16) outside the sample. The findings include: The plating of the 7/9/24 lunch service was observed from its initiation through its completion (11:17 AM until 11:30 AM) On 7/9/24 at 11:17 AM, V7 (Cook) was plating all meals including mechanical soft diets. During the plating, V7 touched numerous surfaces including oven handles, door handles, and the handle for the tray cart. V7 did not change her gloves when going from these high touch surfaces and then back to serving lunch. […]

• No harm, potential for more than minimal, isolatedF686Jul 10, 2024

  Based on interview and record review, the facility failed to obtain orders and implement treatments for wounds to a residents feet upon admission to the facility for 1 of 1 residents (R13) reviewed for pressure ulcers in the sample of 11. The findings include: R13's Nurse's Notes, dated 6/17/24, showed, (R13) was admitted to the facility on [DATE]. A skin assessment was done and charted. Will continue to monitor. R13's Admit Shower Sheet, dated 6/17/24, showed the left foot had a 1 cm (centimeter) open area to the inner foot; a 1 cm area to the right inner foot that did not say it was open; and a 2 cm x 1 cm area to the right heel. The shower sheet was signed by the nurse. […]