Heritage Square Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 8, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to monitor and supervise severely cognitively impaired residents and ensure exit door codes were secured to prevent elopement for one (Resident 46) of three residents reviewed for wandering/elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• No harm, potential for more than minimal, widespreadF755Jan 28, 2022

  Based on observation, record review and interview, the facility failed to ensure physician-ordered medication was acquired and available for administration and medications were administered only to residents for whom they were prescribed to prevent potential complications for 1 (Resident #7) of 2 (Residents #6 and #7) sampled residents who had an order for [MEDICATION(S)]. The findings are: 1. Resident #7 was admitted with a diagnosis of Chronic Pain Syndrome and Gastro-[CONDITION(S)] Reflux Disease without Esophagitis. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] documented the resident scored 15 (,d+[DATE] indicates cognitively intact) on a Brief Interview for Mental Status. a. […]

• No harm, potential for more than minimal, patternF584Mar 14, 2024

  Based on observation and interview, the facility failed to ensure the walls were free of scrapes, blotchy and/or missing paint, and that the floors were clean and free of dead insects (roaches). The findings are: 1. On 03/11/2024 at 11:00 AM, during initial rounds and on 03/13/2024 at 9:10 AM, Rooms 13, 15, 26, 27, 29, 36, and 38's walls were bare of pictures and/or decor. 2. On 03/11/2024 at 11:20 AM, the following observations were made: a. In room [ROOM NUMBER] there were scratches beside the bed with paint and plaster missing and sheetrock exposed. b. In room [ROOM NUMBER], one and a half feet off the floor, the paint was scraped off the wall. c. In room [ROOM NUMBER], as you enter the room, scrapes were all the way down the left side of the room with paint missing. d. […]

• No harm, potential for more than minimal, patternF677Mar 14, 2024

  Based on observation, interview, and record review, the facility failed to ensure facial hair was removed from 1 (Resident #1) of 7 sampled residents who were dependent on staff for shaving; failed to provide nail care for 2 (Residents #39 and #61) of 28 sampled residents who were dependent on staff for nail care. The findings are: 1. Resident #1 had a diagnosis of Other recurrent depressive disorders. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/2024 documented Resident #1 scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). A Care Plan initiated 01/10/2023 documented, .The resident is totally dependent on staff for personal hygiene . […]

• No harm, potential for more than minimal, patternF695Mar 14, 2024

  Based on observation, interview, and record review, the facility failed to follow physician orders and maintain oxygen concentrations in accordance with physician orders for one (Resident #21) of 8 sampled residents. The findings are: Resident #21 had diagnoses of Chronic obstructive pulmonary disease, Shortness of breath, and Acute and chronic respiratory failure. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/04/2024 documented a Brief Interview for Mental Status (BIMS] of 15 (13-15 indicates cognitively intact) received continuous oxygen therapy. On 03/11/2024 at 11:30 AM, Resident #21 was lying in bed with oxygen on per oxygen concentrator via nasal canula, at 3.5 liters per minute. […]