The Heritage Nursing and Rehabilitation Facility

In the surveyor’s words

From the most serious findings on record at The Heritage Nursing and Rehabilitation Facility, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550Oct 29, 2021

  Based on observation, interview, record review and review of facility policy, it was determined the facility failed to ensure residents were treated with dignity and respect for three (3) of twenty-seven sampled residents (Resident #10, #24 and #30). Observation on 10/26/2021 at 12:13 PM on the 200 hall revealed three (3) aides who were delivering resident lunch trays failed to knock on the resident's door before entering three (3) different resident rooms. The findings include: Review of the facility policy titled, Resident Rights undated, revealed employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to all residents of the facility. This included the right to privacy and confidentiality. […]

• No harm, potential for more than minimal, patternF812Oct 29, 2021

  Based on observation, interview, record and facility policy review, it was determined the facility failed to prepare, distribute and serve food in accordance with the professional standards for food service safety. Observation in the facility kitchen on 10/26/2021 at 10:40 AM revealed a cook with a full beard plating food for the residents' lunch. The cook's beard was not fully covered with a beard guard to prevent resident foods from potential contamination. In addition, the facility failed to maintain accurate and complete temperature logs for the steam table on three separate occasions, 10/03/2021 at 4:00 PM, 10/14/2021 at 4:00 PM and 10/20/2021 at 4:00 PM. […]

• No harm, potential for more than minimal, isolatedF657Apr 30, 2025

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to revise the care plan for one (Resident (R) 18) of 23 sampled residents. R18's comprehensive care plan called for the use of a call light as an approach to deal with care problems including falls and incontinence. Once R18 was no longer able to use a call light, the facility failed to revise the care plan to ensure the resident was able to summon help if needed. The findings include: Review of the facility's policy Care Plans-Comprehensive H5MAPL0110, revised 09/2022, revealed that assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. […]

• No harm, potential for more than minimal, isolatedF880Apr 30, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to take action to help prevent the development and transmission of communicable diseases and infections for one (Resident (R) 49) of three sampled residents reviewed during medication administration. Licensed Practical Nurse (LPN) 3) was observed to drop three of R49's medication tablets/capsules onto the top of the medication cart while pressing medications out of blister packets. LPN3, who was bare-handed, picked up each of the medications that were dropped onto the cart without wearing gloves, then placed the medications in a plastic cup with the rest of R49's medications, and administered the medications to the resident. […]

• No harm, potential for more than minimal, isolatedF656Oct 29, 2021

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure care plan interventions were implemented for one (1) of three twenty-seven (27) sampled residents ( Resident #5), related to positioning/orthotic devices for contractual management. The facility failed to apply a splint to Resident #5's right hand as indicated in the care plan. The findings include: Review of the facility policy titled Care Planning dated 08/01/2013, revealed the Care Planning/Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident. […]