Heritage Wellness & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF610Feb 19, 2025

  Based on interview and record review, the facility failed to follow the facility policy and procedure and investigate an injury of unknown origin of a fractured (broken) arm for one sampled resident (Resident #35); and failed to investigate the cause of skin tears and bruises for one sampled resident (Resident #30) out of 14 sampled residents. The facility census was 55 residents. The Administrator was notified on 2/14/25 at 9:00 P.M. of the Immediate Jeopardy (IJ) which began on 1/3/25. […]

• No harm, potential for more than minimal, widespreadF727Feb 19, 2025

  Based on interview and record review, the facility failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week. This had the potential to affect all residents of the facility. The facility census was 55 residents. Review of the facility's Staffing, Sufficient and Competent Nursing policy, dated as revised August 2022, showed: -Licensed nurses and Certified Nursing Assistants (CNA) were available 24 hours a day, seven days a week to provide competent resident care services. -A RN provides services at least eight consecutive hours every 24 hours, seven days a week. -RNs may be scheduled more than eight hours depending on the acuity needs of the resident. 1. […]

• No harm, potential for more than minimal, widespreadF865Feb 19, 2025

  Based on interview and record review, the facility failed to address areas of needed improvement by not developing and implementing Performance Improvement Plans (PIP - a process designed to help facilities address and fix deficiencies) which could affect all facility areas including residents quality of life. The facility census was 55 residents. Review of the facility's Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) Program - Governance and Leadership Policy, dated March 2020, showed: -The QAPI program was overseen and implemented by the QAPI committee and reported findings, actions and results to the administrator and governing body. […]

• No harm, potential for more than minimal, widespreadF867Feb 19, 2025

  Based on interview and record review, the facility failed to develop and implement written procedures for its Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) Program which led to the inability to gather feedback for quality improvement. This practice had the ability to affect all residents. The facility census was 55 residents. Review of the facility's QAPI Program - Governance and Leadership policy, dated March 2020, showed: -The Administrator was ultimately responsible for the QAPI program. -The QAPI program was based on data, resident and staff input, and other information that measured performance. […]

• No harm, potential for more than minimal, widespreadF880Feb 19, 2025

  Based on observation, interview, and record review, the facility failed to ensure five sampled residents (Resident #3, #9, #30, #39, and #37) who should have been on Enhanced Barrier Precautions (EBP), a set of infection control measures that used personal protective equipment (PPE- specialized clothing or gear worn to protect the wearer from injury, infection, or illness) to reduce the spread of multidrug-resistant organism (MDRO - bacteria or microorganisms that have become resistant to multiple antibiotics) for residents who had wounds or indwelling medical devices. […]