Inspection Reports for
Heritage Center
1201 W Buena Vista Rd, Evansville, IN 47710, United States, IN, 47710
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
75% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Life Safety
Census: 129
Capacity: 172
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Heritage Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for Medicare and Medicaid participating providers. The facility is fully sprinklered except for two detached wood sheds and one garage used for storage.
Report Facts
Certified beds: 172
Census: 129
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 25, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on April 25, 2025.
Findings
Heritage Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Routine
Deficiencies: 15
Date: Apr 25, 2025
Visit Reason
Routine inspection of Heritage Center nursing home to assess compliance with regulatory requirements including resident care, medication management, infection control, and care planning.
Findings
The facility had multiple deficiencies including failure to respect resident dignity, incomplete and untimely Minimum Data Set (MDS) assessments, inadequate care planning and care plan conferences, incomplete neurological assessments after falls, inadequate personal hygiene care, failure to monitor weight and nutrition properly, improper use and documentation of psychotropic medications, unsafe medication storage and handling, poor infection control practices, and incomplete antibiotic stewardship.
Deficiencies (15)
F 0550: The facility failed to ensure a resident's dignity was respected when a resident was told to urinate in her brief instead of being assisted to the toilet for staff convenience.
F 0636: The facility failed to complete the admission Minimum Data Set (MDS) Assessment within 14 days of admission for 1 of 1 residents reviewed.
F 0638: The facility failed to ensure quarterly MDS assessments were completed timely for 1 of 13 residents reviewed.
F 0641: The facility failed to ensure a resident's MDS assessment was completed accurately regarding medication use for 1 of 5 residents reviewed.
F 0656: The facility failed to develop comprehensive care plans for 1 of 2 residents reviewed for Hospice and 1 of 1 residents reviewed for urinary tract infection (UTI).
F 0657: The facility failed to hold quarterly care plan conferences for 13 of 25 residents reviewed for care plans.
F 0658: The facility failed to complete neurological assessments following unwitnessed falls for 2 of 2 residents reviewed.
F 0677: The facility failed to provide necessary grooming and personal hygiene care for 1 of 4 residents reviewed, resulting in long, untrimmed toenails.
F 0684: The facility failed to ensure daily weights and thorough assessments for edema were completed for 1 of 1 residents reviewed for edema.
F 0690: The facility failed to ensure treatment and services were provided to prevent urinary tract infections for 1 of 5 residents reviewed, including failure to notify physician, lack of urine testing, and double dosing of antibiotics.
F 0692: The facility failed to implement dietitian recommendations to prevent unnecessary weight loss for 1 of 3 residents reviewed for nutrition.
F 0758: The facility failed to ensure residents were free from unnecessary psychotropic medications for 3 of 4 residents reviewed for PRN antianxiety medications.
F 0761: The facility failed to ensure safe and secure storage of medications, including unlocked medication carts, loose pills in carts, and incomplete temperature logs for medication refrigerators.
F 0880: The facility failed to ensure a safe, sanitary, and comfortable environment to prevent infections, including inadequate hand hygiene, improper handling of clean linen, and unwashed activity items.
F 0881: The facility failed to establish a complete antibiotic stewardship program to ensure antibiotics were given as ordered and appropriate antibiotics were selected based on culture results for 3 of 4 residents reviewed for UTIs.
Report Facts
Deficiencies cited: 14
Resident weight loss percentage: 21.44
Medication doses: 4
Medication doses: 2
Medication doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 11 | Certified Nurse Aide | Named in dignity violation finding for Resident 14 |
| LPN 7 | Licensed Practical Nurse | Named in dignity violation finding for Resident 14 |
| RN 9 | Registered Nurse | Named in medication administration and infection control findings |
| DON | Director of Nursing | Named in multiple findings including medication errors, infection control, and care planning |
| ADON | Assistant Director of Nursing | Named in infection control and medication review findings |
| UM 15 | Unit Manager | Named in podiatry and medication storage findings |
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441448.
Complaint Details
Complaint IN00441448 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00441448 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 121
Census Bed Type - SNF/NF: 114
Census Bed Type - SNF: 7
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 89
Census Payor Type - Other: 21
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 3, 2024
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 23, 2024.
Findings
Heritage Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the PSR to the Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 120
Capacity: 172
Deficiencies: 0
Date: May 9, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 04/03/24.
Findings
At this PSR, Heritage Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including fire safety and sprinkler systems, with no deficiencies noted.
Report Facts
Certified beds: 172
Census: 120
Inspection Report
Re-Inspection
Census: 128
Capacity: 128
Deficiencies: 3
Date: Apr 23, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on March 19, 2024.
Findings
The facility was found deficient in several areas including prevention and treatment of pressure ulcers, fall prevention interventions, and care of enteral feeding tubes. The facility failed to ensure accurate documentation and timely interventions for pressure ulcers and falls, and proper care and labeling of feeding tube extension tubing.
Deficiencies (3)
Failed to ensure preventative measures and accurate assessments to prevent pressure ulcers for 1 of 3 residents reviewed.
Failed to prevent falls for 1 of 3 residents reviewed; new interventions were not implemented and included in the care plan following a fall.
Failed to ensure appropriate care of MIK-KEY G-tube feeding tubing; tubing lacked date and initials when changed and facility policy did not address extension tubing use.
Report Facts
Census: 128
Total Capacity: 128
Medicare Census: 15
Medicaid Census: 91
Other Payor Census: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Strickland | Administrator | Signed the report |
| Director of Nursing | Interviewed regarding pressure ulcer and fall findings; no full name provided | |
| RN 2 | Interviewed regarding feeding tube care; no full name provided |
Inspection Report
Annual Inspection
Census: 126
Capacity: 172
Deficiencies: 3
Date: Apr 3, 2024
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including failure to provide complete documentation for emergency power system testing, failure to ensure cooktop stove/ovens were shut off when not in use, and failure to replace a sprinkler head partially covered with corrosion.
Deficiencies (3)
Failed to provide complete documentation for the testing of 3 of 3 Emergency Power Standby Systems as required by NFPA 110.
Failed to ensure the cook top for 3 of 3 stove/ovens were shut off at the switch when not in use.
Sprinkler head in 1 of 12 smoke compartments partially covered with corrosion was not replaced.
Report Facts
Certified beds: 172
Census: 126
Emergency Power System Generators: 3
Load test duration: 4
Inspection date: Apr 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Strickland | Administrator | Named in relation to findings and exit conference |
Inspection Report
Annual Inspection
Census: 128
Capacity: 128
Deficiencies: 6
Date: Mar 19, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 11 to March 19, 2024.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, pressure ulcer prevention and treatment, fall prevention and supervision, tube feeding management, respiratory care, and nurse staffing information posting. Several residents had inaccurate MDS assessments, inconsistent fall interventions, improperly managed oxygen equipment, and unlabeled feeding tubes. Staffing sheets lacked actual shift times worked.
Deficiencies (6)
Failed to ensure the MDS Assessment was completed accurately for residents reviewed for elopement and falls.
Failed to ensure preventative measures were in place or orders followed to prevent pressure ulcers for 1 of 2 residents.
Failed to ensure residents received consistent implementation of interventions to prevent falls for 2 of 5 residents.
Failed to ensure appropriate care of PEG/G-tube feeding tubing; tubing lacked date, label, and initials.
Failed to ensure oxygen equipment was properly labeled and oxygen properly administered for 3 of 6 residents at risk for respiratory complications.
Failed to post actual shift times worked of licensed and unlicensed nursing staff per shift daily for 9 of 9 days reviewed.
Report Facts
Census: 128
Total Capacity: 128
Falls: 24
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Strickland | HFA | Facility representative signing the report |
| MDS Coordinator 7 | Indicated chair alarm coding error on 2/22/24 Quarterly MDS Assessment | |
| MDS Coordinator 9 | Indicated wander/elopement alarm should be marked on 12/29/23 MDS Assessment | |
| DON | Director of Nursing | Provided treatment administration records and interview regarding wound care and falls |
| CNA 4 | Certified Nurse Aide | Indicated chair alarm cords were loose and requested replacements |
| CNA 6 | Certified Nurse Aide | Observed removing and reattaching Resident 11's nasal cannula to portable oxygen tank without turning it on |
| RN 5 | Registered Nurse | Observed Resident 86's bed not in lowest position and adjusted it |
| RN 8 | Registered Nurse | Checked Resident 11's oxygen saturation after portable oxygen tank was turned on |
| QMA 12 | Qualified Medication Aide | Indicated tubing change policy and oxygen concentrator maintenance schedule |
| CNA 11 | Certified Nurse Aide | Indicated Resident 11's portable oxygen tank was not turned on |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 19, 2024
Visit Reason
Routine inspection of Heritage Center nursing home to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility had multiple deficiencies including inaccurate MDS assessments, inadequate pressure ulcer care, inconsistent fall prevention interventions, improper feeding tube care, and unsafe respiratory care practices. Additionally, the facility failed to post accurate nurse staffing shift times as required.
Deficiencies (6)
F0641: The facility failed to ensure the MDS Assessment was completed accurately for residents with elopement and falls, including coding errors on alarms used.
F0686: The facility failed to ensure preventative measures were followed to prevent pressure ulcers, including missed daily skin checks and lack of wound assessment.
F0689: The facility failed to ensure adequate supervision and consistent implementation of fall prevention interventions for residents with multiple falls.
F0693: The facility failed to ensure appropriate care of feeding tube tubing, lacking date, label, and staff initials on feeding bags and tubing.
F0695: The facility failed to ensure oxygen equipment was properly labeled and oxygen was properly administered, including unlabeled supplies and portable oxygen tanks not turned on.
F0732: The facility failed to post actual shift times worked by nursing staff daily as required by policy.
Report Facts
Falls sustained: 24
Residents affected: 1
Residents affected: 2
Residents affected: 3
Days reviewed: 9
Inspection Report
Complaint Investigation
Census: 129
Capacity: 129
Deficiencies: 0
Date: Jan 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00421730.
Complaint Details
Investigation of Complaint IN00421730; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 129
Total Capacity: 129
Medicare Census: 14
Medicaid Census: 93
Other Payor Census: 22
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00419698 completed on November 1, 2023.
Complaint Details
Investigation of Complaint IN00419698; paper compliance review completed with findings of compliance.
Findings
Heritage Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the Investigation of Control IN00419698 Survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging staff to resident abuse at the facility.
Complaint Details
This citation relates to complaint IN00419698.
Findings
The facility failed to report an allegation of physical and verbal abuse to the facility administrator within the required time frame. The administrator was not made aware of the abuse allegation until 20 days after the incident occurred.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse to the administrator as required. An allegation of abuse was reported 20 days late, violating facility policy.
Inspection Report
Complaint Investigation
Census: 129
Capacity: 129
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419698 and IN00420497. Complaint IN00419698 resulted in federal/state deficiencies cited at F 609, while complaint IN00420497 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00419698 was substantiated with deficiencies cited at F 609 related to failure to timely report alleged abuse. Complaint IN00420497 had no deficiencies related to the allegations.
Findings
The facility failed to ensure an allegation of staff to resident abuse was reported to the facility administrator within the required timeframe for 1 of 2 allegations reviewed. The administrator was not made aware of the abuse allegation until 20 days after the incident. The facility took corrective actions including termination of the alleged employee and staff re-education on immediate reporting of abuse allegations.
Deficiencies (1)
Failure to report an allegation of abuse to the facility administrator within the required timeframe.
Report Facts
Census SNF/NF beds: 129
Census total residents: 129
Medicare residents: 14
Medicaid residents: 94
Other payor residents: 21
Days late reporting abuse: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Strickland | Administrator | Facility administrator who was not notified timely of abuse allegation |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 125
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407918 at The Heritage Center.
Complaint Details
Complaint IN00407918 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 19
Medicaid residents: 85
Other payor residents: 21
Inspection Report
Complaint Investigation
Census: 121
Capacity: 121
Deficiencies: 0
Date: Apr 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00406681 and IN00406760.
Complaint Details
Investigation of Complaints IN00406681 and IN00406760 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaints IN00406681 and IN00406760 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Medicare census: 13
Medicaid census: 84
Other payor census: 24
Inspection Report
Complaint Investigation
Census: 122
Capacity: 122
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
This visit was conducted for the investigation of two complaints, IN00396186 and IN00385545.
Complaint Details
Complaint IN00396186 - Substantiated with no deficiencies cited. Complaint IN00385545 - Substantiated with no deficiencies cited.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census SNF/NF: 122
Census Medicare: 19
Census Medicaid: 81
Census Other: 22
Inspection Report
Re-Inspection
Census: 124
Capacity: 124
Deficiencies: 0
Date: Aug 16, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on July 5, 2022, including a PSR to the Investigation of Complaint IN00382901 completed on July 5, 2022.
Complaint Details
Complaint IN00382901 was investigated and found to be corrected.
Findings
Heritage Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification, State Licensure Survey and the PSR to the Investigation of Complaint IN00382901.
Report Facts
Census SNF/NF: 124
Census Payor Type Medicare: 14
Census Payor Type Medicaid: 86
Census Payor Type Other: 24
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jul 5, 2022
Visit Reason
Complaint investigation related to multiple care deficiencies including failure to follow physician orders, pressure ulcer care, restorative nursing services, fall prevention, catheter care, and food safety.
Complaint Details
Complaint IN00382901 related to pressure ulcer care was substantiated. Other complaints involved falls, restorative care, catheter care, and food safety.
Findings
The facility failed to follow physician orders for resident care, provide adequate pressure ulcer prevention and care, ensure restorative nursing services were delivered, prevent falls and related injuries, maintain proper catheter care to prevent infections, and uphold food safety and sanitation standards in the kitchen.
Deficiencies (7)
F 0656: The facility failed to ensure physician orders were followed for 1 resident; daily weights were not taken and Tubi-grips for edema were not applied as ordered.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 1 resident who developed an unstageable pressure ulcer on the spine.
F 0688: The facility failed to provide restorative nursing services to maintain or improve range of motion for 7 residents with limited mobility.
F 0689: The facility failed to ensure adequate supervision and assistance to prevent falls for 2 residents, resulting in multiple falls and fractures.
F 0690: The facility failed to provide appropriate catheter care and prevent urinary tract infections for 2 residents; catheter bags were hung on trashcans with bags resting on the floor.
F 0732: The facility failed to post completed nurse staffing sheets daily for 6 of 6 days on 3 units; sheets lacked specific staff numbers and exact hours worked.
F 0812: The facility failed to ensure food was served in a sanitary manner; staff did not perform adequate hand hygiene, hairnets were improperly worn, ceiling paint was peeling, and expired food items were stored.
Report Facts
Falls: 15
Skin tear size: 0.5
Pressure ulcer size: 15.5
Restorative nursing missed days: 20
Restorative nursing missed days: 18
Restorative nursing missed days: 20
Restorative nursing missed days: 20
Restorative nursing missed days: 16
UTI documented: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 5 | Registered Nurse | Indicated Resident B acquired an unstageable pressure ulcer and should have daily skin assessments. |
| LPN 3 | Licensed Practical Nurse | Indicated Resident 16 and Resident 72 care details including restorative services and catheter care risks. |
| CNA 15 | Certified Nurse Aide | Observed providing care to Resident 75 and commented on restorative nursing duties. |
| MDS Coordinator | Restorative Program Leader | Indicated restorative nursing team staffing issues and delegation of ROM exercises. |
| QMA 7 | Qualified Medication Aide | Reported Resident 41 required close supervision to prevent falls. |
| Kitchen Manager | Acknowledged food safety violations including peeling paint and inadequate hand washing. |
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