The Heritage Rehabilitation and Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF604Nov 26, 2021

  Based on observation, record review, and interview conducted during the recertification survey, the facility failed to ensure each resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The facility failed to provide ongoing re-evaluation for the need of the restraint used and attempts to use the least restrictive alternative for the least amount of time. Specifically, residents were observed with restraints in place without 1) adequate assessment and re-evaluation, 2) physician's orders for the restraint, and 3) release from restraints at least every 2 hours per the physician's orders. […]

• No harm, potential for more than minimal, widespreadF812Nov 26, 2021

  Based on observation and staff interview conducted during the Recertification Survey and the Extended Survey, the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, (1). prepared, and frozen foods were not labeled, dated appropriately and (2). staff was observed not wearing beard guard appropriately in the kitchen. This was observed during the Kitchen facility task. The findings are: The facility policy and procedure titled Staff Hygiene and Ill Food Worker revised in 2021 documented that all staff will be in good health, will have clean personal habits and will use safe food handling practices. […]

• No harm, potential for more than minimal, widespreadF814Nov 26, 2021

  Based on the observation, interviews during the Recertification Survey and the Extended Survey, the facility did not dispose of garbage and refuse properly. Specifically, waste was not properly contained in closed dumpsters and the garbage dumpster area was not maintained to prevent potential feeding and harborage for pests. This was observed during the Kitchen facility task. The findings are: The facility's policy and procedure titled Waste Disposal revised in 2021 documented trash will be deposited into a sealed container outside the premises. On 11/19/21 at 11:44 AM, the garbage disposal area was observed. Five dumpsters were observed with attached lids and all lids were opened. On 11/22/21 at 9:59 AM, the garbage disposal area was observed. […]

• No harm, potential for more than minimal, patternF867Nov 26, 2021

  Based on observation, record review, and interview during the Recertification and Extended Survey from 11/16/2021 to 11/26/2021, the facility did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the QAA committee which is composed of the Administrator, Medical Director, Director of Nursing (DON) Et. Al. was aware of the identified concern of physical restraint/side rail use via Certification and Survey Provider Enhanced Reporting ([NAME]) and the plans of action implemented in June 2021 were shown to be ineffective resulting in both deficiency and immediate jeopardy during this recertification survey. The finding is. […]

• No harm, potential for more than minimal, patternF880Nov 26, 2021

  Based on observation, Interview, and record review conducted during the recertification survey, the facility did not ensure that infection control standards were maintained. Specifically, 1) a facility entertainer was observed without a face covering; and, 2) multiple staff were observed without the necessary Personal Protective Equipment (PPE) interacting with a Resident #123 on contact/droplet precautions (CDP). This was evident for 1 of 2 units and 1 of 4 residents reviewed for Transmission Based Precautions (TBP) in the infection control task. The findings are: The facility policy titled TBP dated 11/16 documented Staff must wear PPE when entering a resident's room on contact precautions and must wear a mask when closely interacting with residents on droplet precautions. […]