The Harrison at Heritage

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656May 31, 2024

  Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of eleven residents reviewed for care plans. The facility failed to ensure Resident #1 was attended and supervised while left in 96-degree heat for approximately 2 hours resulting in unresponsiveness, second degree skin burns, hospitalization , and heat stroke. […]

• Immediate jeopardy, isolatedF689May 31, 2024

  Based on observation, interview, and record review, the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) eleven residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was attended and supervised while left in 96-degree heat for approximately 2 hours resulting in unresponsiveness, second degree skin burns, hospitalization , and heat stroke. The facility failed to ensure Resident #1 was safe from hazards when he sat on the facility's patio in 96-degree heat for at approximately 2 hours resulting in unresponsiveness, second degree skin burns, hospitalization , and heat stroke. An Immediate Jeopardy (IJ) was identified on 05/30/2024. […]

• Immediate jeopardy, isolatedF760Apr 23, 2022

  Based on interviews and record reviews the facility failed to ensure residents were free from significant medication errors for 2 of 3 residents (Resident #1 and Resident #2) reviewed for administration of medications. LVN B failed to ensure she administered medications to the correct resident. LVN B administered Resident #2's medications ([MEDICATION(S)] 25mg, [MEDICATION(S)] 600mg, [MEDICATION(S)] 2mg, Tylenol-[MEDICATION(S)] #3 300 mg-30 mg, Omeprazole 20 mg, [MEDICATION(S)] 5mg, acetaminophen 325mg) to Resident #1 on 04/15/22 in addition to the resident receiving her own medications that same morning. […]

• Actual harm, isolatedF689Apr 16, 2024

  Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. The faciltiy failed to provide Resident #1, who had cognitive impairment and unsteady gait with a history of attempting to get up from her wheelchair unassisted, adequate supervision to prevent her falling. The resident was left alone in her room, and she fell sustaining lacerations to multiple sites on her scalp and neck and an injury to her wrist, which required the resident to be sent to the hospital where she received six staples to the back of her scalp, two staples on the left side of her scalp, and a brace to her wrist for a contusion. […]

• No harm, potential for more than minimal, patternF914Dec 4, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure each bed had ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 2 of 21 residents (Resident #16 and #82) reviewed for privacy curtains. The facility failed to ensure Residents #16 and #82 were ensured full visual privacy by not having ceiling suspended curtains that extend around the bed. These failures could place residents at risk of lowered self-esteem. Findings included:1. […]