South Heritage Health & Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Sep 2, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for one resident (#1) out of seven sampled residents. Resident #1 sustained an unwitnessed fall on 08/21/25 and was not assessed after the fall. Resident #1 complained of hip pain on 08/23/25, an X-ray was obtained on 08/24/25 and Resident #1 was transferred to a higher level of care due to a right hip fracture on 08/24/25 and required surgical intervention.Findings included: An interview was conducted with Resident #2 on 09/02/2025 at 10:08a.m. Resident #2 was the roommate of Resident #1 and recalled the events of 08/21/2025 when Resident #1 had a fall. […]

• Actual harm, isolatedF600Apr 25, 2025

  Based on observations, record reviews, and interviews, the facility failed to protect the resident's right to be free from neglect by not ensuring one resident (#1) of three sampled residents, was provided transfer assistance in accordance with the resident's ability, care plan, facility policy, and/or the mechanical lifts manufacturer's recommendation, resulting in harm to Resident #1. Findings included: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF727Apr 25, 2025

  Based on record review and interviews, the facility did not ensure a Registered Nurse (RN) was providing services for eight consecutive hours a day, seven days a week, for the period of 4/6/25 to 4/12/25. Findings included: A review of the staff schedule dated 4/5/25 - 4/6/25 revealed the nursing staff on each shift (10:45 p.m. - 7:15 a.m., 6:45 a.m. - 3:15 p.m., and 2:45 p.m. - 11:15 p.m.) were all Licensed Practical Nurses (LPNs) and RN was indicated next to a staff name that was crossed out. On 4/24/25 at 3:34 p.m., an interview was conducted with the Director of Nursing (DON). She said the facility completed their staffing based on census to determine how many Certified Nursing Assistants (CNAs) and nurses they need per day. […]

• No harm, potential for more than minimal, widespreadF908Feb 13, 2025

  Based on observation staff interview and facility record review, the facility failed to ensure the kitchen dish washing machine was operating at optimum levels, to include excessive concentration with the chemical sanitizer delivery, in one of one facility kitchen, during one (2/11/25) of three days observed. Findings included: On 2/11/2025 at 9:08 a.m. the facility's kitchen was toured with the Dietary Manager, Staff A. Staff A, the only staff member in the kitchen demonstrated on how the dish washing machine is used. He revealed he had primed the machine for operation just minutes before. Staff A revealed the dish washing machine was a Low Temperature operation and indicated the wash temperature was to reach 120 degrees F. (Fahrenheit), and the final rinse was to reach 120 degrees F. […]

• No harm, potential for more than minimal, patternF759Oct 15, 2025

  Based on observations, record reviews, and interviews the facility failed to to ensure the medication error rate was less than 5.00%. Twenty-two medication administration opportunities were observed, and fifteen errors were identified for two residents (#3 and #2) of two residents observed. These errors constituted a 68.18% medication error rate. Failure to ensure the accurate administration of medications has the potential to greatly affect the effectiveness of the medication and jeopardize the health and safety of the resident. Findings included:1.On 10/15/25 at 10:06 a.m., an observation of medication administration with Staff A, Licensed Practical Nurse (LPN), was conducted with Resident #3. The resident's medication profile was colored red, showing medications were late. […]