Inspection Reports for
Heritage Gardens Health and Rehabilitation Center LLC

The plan outlines corrective actions, system changes, and monitoring strategies for multiple deficiencies affecting current residents, including transfer/discharge notices, activity scheduling, weight monitoring, wound prevention, call light accessibility, respiratory care, dementia care, dietary preparation, and immunization offers.

The facility was found deficient in multiple areas including discharge process documentation, activity programming on weekends, quality of care related to daily weights, pressure ulcer prevention, fall prevention interventions, respiratory care sanitation, dementia care services, nutritional preparation of pureed diets, infection prevention practices, and immunization documentation.

The facility was found deficient in multiple areas including failure to provide required transfer/discharge notices, inconsistent weekend activities, failure to follow physician orders for daily weights, inadequate pressure ulcer prevention, insufficient fall prevention measures, improper respiratory equipment storage, inconsistent dementia care, improper preparation of pureed diets, infection control lapses, and failure to obtain pneumococcal vaccination consents.

The findings represent the results of complaint investigations #KS00183801, KS00183765, and KS00183769. The facility failed to adequately supervise Resident 1 and implement interventions to prevent elopement despite documented exit seeking behaviors and attempts to leave the facility.

The facility failed to provide adequate supervision and failed to identify and implement interventions to address elopement risk and attempts for Resident 1, who exhibited exit seeking behavior and actual attempts to elope from the facility, placing the resident at risk for elopement and other preventable accident hazards.

The complaint investigation found that Resident 1 had multiple documented behaviors of exit seeking and attempts to elope, but the care plan lacked appropriate risk identification and interventions. Staff interviews revealed inconsistent awareness of the resident's elopement risk status.

The facility failed to identify and implement interventions to address elopement risk and attempts for Resident 1, who exhibited wandering and exit seeking behaviors, placing the resident at risk for elopement and other preventable accident hazards.

The facility identified 12 residents at risk for wandering or elopement who were care planned accordingly. The facility updated the elopement book and implemented staff education and ongoing audits to ensure compliance with wandering/elopement risk policies.

The facility failed to maintain a safe, clean, and homelike environment, including issues with odors, missing tiles, and noisy call light systems. Additionally, the facility failed to secure rooms containing hazardous materials, placing cognitively impaired residents at risk for preventable injuries.

The facility identified multiple deficiencies related to resident care, rights, environment, and staff training. Corrective actions, system changes, and monitoring plans were implemented to achieve substantial compliance by October 27, 2023.

The facility was found deficient in multiple areas including failure to ensure dignified care environment, inadequate posting of state agency information, failure to issue required Medicare notices timely, unsafe and unclean environment, incomplete care plans, inconsistent bathing and toileting assistance, inadequate pressure ulcer prevention, failure to maintain range of motion devices, unsecured hazardous materials, incomplete staff training and evaluations, incomplete nurse staffing postings, inadequate dementia care, and lapses in infection control practices.

The inspection included a complaint investigation related to resident rights and dignity, infection control, and care planning.

The facility was found deficient in multiple areas including resident rights and dignity, required postings, Medicaid/Medicare notices, safe and homelike environment, comprehensive care planning, ADL care, pressure ulcer prevention and treatment, range of motion maintenance, accident hazards, bowel/bladder incontinence management, nurse aide training, nurse staffing postings, dementia care, and infection prevention and control.

The complaint investigations #KS00178670 and KS00178243 involved allegations of abuse and neglect concerning Resident 3. The facility failed to prevent neglect during transfers and failed to timely report abuse allegations to the State Agency.

The facility failed to prevent neglect when staff did not use the care planned transfer method for R3, resulting in bruising. Additionally, the facility failed to report allegations of abuse made by R3 to the State Agency within the mandated timeframe.

The complaint investigation involved allegations of abuse and neglect of Resident 3. The abuse, neglect, and exploitation were ruled out after investigation, but the facility failed to report the allegations to the State Agency within the required two-hour timeframe, placing R3 at risk for unresolved and ongoing abuse.

The facility failed to prevent neglect when staff did not use the care planned transfer method for R3, resulting in bruising. Additionally, the facility failed to report allegations of abuse made by R3 to the State Agency within the mandated timeframe.

The facility identified issues related to resident transfers and injury assessments, including the need for staff re-education on transfer procedures and abuse prevention. Corrective actions include assessments, training, and ongoing monitoring to ensure compliance and resident safety.

The complaint investigations #KS00175735 and KS00175738 involved allegations of abuse and neglect related to bruises of unknown origin on Resident 1. The facility failed to report and investigate these bruises properly, placing the resident at risk.

The facility failed to ensure R1 received necessary protective oversight to prevent potential abuse or neglect when staff did not report or investigate bruises of unknown origin as potential abuse or neglect. This failure placed the resident at risk for unresolved abuse, decreased psychosocial well-being, and further injuries.

The facility failed to properly investigate bruising injuries to resident R1 and did not follow required processes to prevent potential abuse, exploitation, or mistreatment. Staff education and ongoing monitoring plans were implemented to address these issues.

The facility developed and implemented a home-wide system to assure correction and continued compliance with regulations, specifically addressing residents' rights to use a telephone without staff interference and ensuring privacy during telephone communications.

The complaint investigations #KS00174013 and KS00173960 were substantiated as the facility failed to protect Resident 1's right to telephone use without staff interference.

The facility failed to ensure Resident 1 was able to use a telephone without interference from staff, as staff took the phone from him during a call. This practice placed the resident at risk for isolation and impaired dignity and well-being.

The facility addressed multiple deficiencies related to resident dignity during meals, notification of roommate changes, surety bond for resident funds, privacy for phone calls, termination notice of skilled services, safe and homelike environment, accurate MDS coding, comprehensive care plans, medication administration, infection control, and COVID screening. The facility implemented education, audits, and monitoring plans to ensure compliance and prevent recurrence.

The inspection included complaint investigations #168245 and #168437.

The facility was found deficient in multiple areas including resident dignity during meals, notification of roommate changes, security of personal funds, privacy during phone calls, safe and homelike environment, accuracy of assessments, comprehensive care planning, medication administration errors, medication storage, infection prevention and control, and behavioral health services.

The facility had multiple deficiencies including failure to treat residents with dignity during meals, failure to notify a resident of a new roommate, inadequate surety bond coverage for resident funds, lack of privacy for phone calls, failure to provide a safe and homelike environment, inaccurate resident assessments, incomplete care plans, failure to provide range of motion exercises, unsafe environment hazards, medication administration errors, improper medication storage, incomplete COVID screening, and infection control breaches.

The complaint investigation #KS00167695 and KS00164636 involved allegations of staff to resident abuse. The allegation was initially reported on 08/07/21. The facility was unable to locate the completed investigation paperwork but acknowledged the investigation was conducted. The facility failed to submit the investigation results to the state agency within the required timeline.

The facility failed to submit a completed investigation of a staff to resident abuse allegation to the state survey agency within five working days as required by federal regulations. The investigation paperwork could not be found despite the facility's knowledge that the incident was investigated.

The facility reported results of completed investigations to the state agency within the required timeline. The Administrator was counseled regarding timely reporting and will monitor incident reviews to ensure compliance.

The complaint investigation #KS00165996 involved allegations that Licensed Nurse G forcefully escorted an agitated and confused resident to her room, causing a red mark on the resident's neck. Staff witnesses delayed reporting the incident to administration by two days due to fear of retaliation and being busy. The facility suspended the nurse pending investigation.

The facility failed to prevent an incident of staff-to-resident abuse when a licensed nurse forcefully escorted an agitated resident to her room, placing the resident and others at risk. Additionally, the facility failed to ensure staff immediately reported the incident to the administrator, delaying the report by two days.

The facility addressed deficiencies related to prevention of staff-to-resident abuse and ensuring staff immediately report incidents of abuse to the facility administrator. The plan includes staff training, education for agency staff, posting reminders, quizzes, and ongoing monitoring to ensure compliance.

The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The visit was triggered by complaint investigation #149905. The facility was found noncompliant in multiple areas including environmental safety, accident prevention, medication management, and food safety.

The facility failed to provide a safe, clean, and comfortable environment in multiple hallways, failed to prevent accidents for two residents, failed to properly review and act on drug regimens including inappropriate psychotropic medication use, and failed to maintain sanitary food preparation and kitchen environment.

The facility addressed multiple deficiencies including environmental maintenance, fall assessment and prevention, medication management, psychotropic medication documentation, food service sanitation, and kitchen environment safety. Corrective actions and staff reeducation plans were implemented with ongoing audits and quality assurance reporting.

The plan addresses multiple deficiencies including resident rights to refuse treatment, grievance procedures, discharge notices, assessment accuracy, care planning, respiratory care, nurse staffing postings, and medication regimen reviews. The facility describes reeducation efforts and monitoring plans to ensure compliance.

The inspection was triggered by complaints identified as #KS00138623, KS00137956, KS00134836.

The facility was found deficient in multiple areas including failure to clearly identify residents' resuscitation choices, failure to maintain a grievance log and ensure anonymous grievance filing, failure to notify the state Long-Term Care Ombudsman of resident transfers, failure to complete timely Care Area Assessments, failure to develop comprehensive care plans, failure to provide necessary respiratory care, failure to post nurse staffing information, and failure to ensure proper drug regimen review and monitoring.

The survey found a pattern of deficiencies at an 'E' level severity, indicating no actual harm but potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 06/20/2018.

The plan addresses multiple deficiencies related to G-Tube care, medication administration, infection control, medication labeling, and monitoring of medication effectiveness. The facility describes training, in-service education, and monitoring systems to ensure compliance and prevent recurrence of cited issues.

The inspection was triggered by complaints leading to a Health Resurvey and Complaint Investigation with multiple citations issued.

The facility was found deficient in multiple areas including tube feeding management, nursing staff competency, drug regimen review, medication error rate, medication labeling and storage, infection prevention and control practices.

All deficiencies cited in the prior inspection were corrected as of 04/06/18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The facility was found deficient for failing to prevent abuse from one resident to others on the secured unit. The facility responded by moving the alleged abusive resident off the secured unit and initiating staff in-servicing on abuse prevention and resident safety.

The complaint investigation #KS00128245 found that resident #2 repeatedly abused residents #3 and #4 in a secured unit. The facility failed to protect nine residents in the secured unit from abuse by resident #2, who had Huntington's Chorea and psychosis. The abuse incidents occurred multiple times between January and April 2018. The facility abated immediate jeopardy by moving resident #2 to a non-secured area and initiating staff training.

The facility failed to protect residents in a secured unit from repeated abuse by one resident with Huntington's Chorea, placing multiple residents in immediate jeopardy. The facility implemented corrective actions including moving the abusive resident to a non-secured area and staff in-service training.

All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2018-03-05, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This revisit was based on deficiencies found during a complaint survey conducted on November 17, 2017. The deficiencies constituted a level of actual harm or above.

The revisit found the most serious deficiencies to be F223 and F225 at 'D' level severity. Due to these deficiencies, a denial of payment for new Medicare and Medicaid admissions was imposed effective December 7, 2017.

The facility failed to provide an environment free from physical abuse when resident #4 punched resident #5 on 2017-11-20. The facility also failed to report this incident of physical abuse to the State Agency as required.

The facility implemented staff in-service training on abuse, neglect, and reporting policies, updated care plans to address resident behaviors, and established monitoring and reporting procedures to ensure resident safety and compliance. Licensed nurse staff involved in violations were suspended or terminated and reported to the State Board of Nursing.

The facility was found not in substantial compliance and conditions constituted immediate jeopardy to resident health or safety. Deficiencies cited included F223, F309, and F225, resulting in enforcement remedies including denial of payment for new admissions.

The investigation was triggered by complaint KS00122760 concerning abuse and neglect. The complaint was substantiated with findings of resident-to-resident abuse, failure to report and investigate abuse, inadequate nursing assessments, and insufficient staffing.

The facility failed to provide an environment free from verbal and physical abuse by resident #2 towards residents #3, #4, and #5, failed to timely report and investigate abuse allegations, and failed to provide timely assessments and emergency response for resident #1 who experienced a hypoxic episode. Staffing was inadequate to meet residents' needs.

This Plan of Correction is related to a complaint investigation at Hickory Pointe dated 09/22/2017.

The facility submitted corrective actions addressing grievance policy documentation, staff registry verification and background checks, skin assessment and wound prevention, physician order compliance, and nursing staff posting requirements. The facility aims to achieve substantial compliance by 09/26/2017.

The inspection was triggered by multiple complaint investigations identified by numbers #KS00120243, #KS00120095, #KS00119972, #KS00119928, #KS00117845, #KS00117924, #KS00110083, #KS00105406, and #KS00101572.

The facility failed to make grievance filing information available to residents, did not provide timely license verification and criminal background checks for staff, failed to prevent and treat pressure ulcers for one resident, did not administer prescribed topical medication for another resident, and failed to retain and post nurse staffing information as required.

The survey found the most serious deficiency to be an 'F' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective September 26, 2017.

This Plan of Correction is related to a complaint investigation identified as Hickory Pointe complaint 08252017.

The facility prepared a Plan of Correction addressing deficiencies related to resident physician documentation and involuntary discharge notices. The facility asserts that the alleged deficiencies do not jeopardize resident health or safety and outlines corrective actions to ensure compliance.

The survey found a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective August 29, 2017.

The complaint investigation KS00119775 focused on the involuntary discharge of resident #1. The facility did not have physician documentation supporting the discharge and failed to include the discharge location in the notice.

The facility failed to ensure the resident's physician documented the reason for involuntary discharge in the medical record and failed to include the location of transfer or discharge in the 30-day notice to the resident.

All deficiencies previously reported on the CMS-2567 were corrected by the dates indicated, with corrective actions completed mostly by 04/01/2016 and one by 04/14/2016.

The report confirms that the deficiency identified under regulation 28-39-149(d) was corrected as of 04/01/2016. No other deficiencies or uncorrected issues are noted.

The report confirms that the previously identified deficiency under regulation 483.25(h) was corrected by 04/14/2016. No uncorrected deficiencies were noted at the time of this revisit.

The facility maintains that the alleged deficiencies do not jeopardize resident health or safety and outlines corrective actions including staff in-service training on elopement risk policies and monitoring of care plans for residents at risk of elopement.

The survey found the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from March 23, 2016 through April 11, 2016 related to F323, CFR 483.25(h). Enforcement remedies including denial of payment for new admissions were imposed.

The survey was triggered by complaints regarding inadequate supervision and safety of residents at risk for elopement. The complaint investigations found the resident eloped on 3/23/16 and was missing for over 6 hours before being found by law enforcement.

The facility failed to provide adequate supervision to a cognitively impaired, independently mobile resident at high risk for elopement, resulting in the resident leaving the facility unnoticed for over 6 hours and suffering hypothermia requiring hospital intensive care. The facility lacked clear policies and procedures for assessing and managing elopement risk.

The facility submitted a Plan of Correction addressing multiple deficiencies related to resident care, notification of changes, financial accounting of deceased residents' funds, investigation of alleged mistreatment and abuse, dignity and respect in care, housekeeping and maintenance, individualized care plans, medication management, infection control, and pharmaceutical services. The facility aims to achieve substantial compliance by April 1, 2016.

The visit included a complaint investigation with multiple complaint numbers cited. The findings were substantiated as the facility failed to maintain required personal possession inventories.

The facility failed to maintain written inventories of residents' personal possessions for 2 of 3 residents sampled, including missing documentation of items sent with residents to the hospital and missing inventory sheets at admission.

The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The report confirms that deficiencies previously cited under regulations 483.10(b)(11), 483.13(b), and 483.13(c)(1)(i)-(iii), (c)(2)-(4) were corrected by 05/06/2015.

The facility was found not in substantial compliance and conditions constituted immediate jeopardy to resident health or safety from March 20, 2015 through April 25, 2015. Enforcement remedies including denial of payment for new admissions and possible termination of provider agreement were recommended.

The facility failed to obtain physician orders for admission to the special care unit and lacked admission criteria identifying diagnosis, behavior, or clinical needs. Additionally, the special care unit lacked specialized activities and appropriate comprehensive assessments and care plans for residents.

The facility addressed deficiencies related to resident safety, abuse prevention, notification procedures, and admission criteria for the special care unit. Staff were in-serviced on relevant policies and procedures, and ongoing monitoring and reporting to the Quality Assurance committee were planned.

The facility addressed multiple deficiencies including provision of clean linens, comprehensive resident assessments, resident participation in care planning, maintenance of urinary function, and hot water temperature regulation. Corrective actions and monitoring plans were outlined to ensure substantial compliance by January 14, 2015.

The survey found the most serious deficiencies to be an "E" level deficiency pattern, indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.

The inspection included complaint investigations 75375 and 75376 as stated in the initial comments.

The facility failed to consistently provide clean linens in resident rooms, did not comprehensively assess residents' functional capacity after significant changes, failed to revise care plans appropriately, did not provide adequate treatment to maintain urinary function for a cognitively impaired resident, and allowed water temperatures above 120 degrees in resident rooms posing accident hazards.

The survey found the most serious deficiencies to be widespread 'F' level deficiencies with no harm but potential for more than minimal harm, not constituting immediate jeopardy. A plan of correction was required to address these deficiencies.

The facility addressed multiple deficiencies including timely notification of Medicare non-coverage, resident fund account statements, cleaning and maintenance, individualized care plans, assistive device assessments, dietary and medication administration protocols, and staffing adjustments. All corrective actions include staff re-training and ongoing audits to ensure compliance.

All previously reported deficiencies identified by regulation numbers were corrected by the revisit date of 09/26/2013. The facility submitted a summary of uncorrected deficiencies from the prior survey dated 8/27/2013.

The inspection was triggered by complaints regarding multiple areas of noncompliance including resident rights, personal funds management, environment, care planning, nutrition, staffing, sanitation, and medication administration.

The facility was found deficient in multiple areas including failure to provide required notices to residents, inadequate management of personal funds, unsanitary and unsafe environment, insufficient nursing staff, failure to provide therapeutic diets and restorative therapy, and improper medication administration.

The report confirms that the previously identified deficiency under regulation 28-39-158(a) was corrected as of 07/16/2012. No other deficiencies or issues are noted.

The report confirms that the deficiencies previously cited under regulations 483.10(b)(11), 483.25(h), and 483.75(o)(1) were corrected as of the revisit date.

The facility addresses deficiencies related to notification of significant changes to residents, maintaining a safe environment free of accident hazards, and ensuring proper oversight by the quality assessment and assurance committee. The facility outlines corrective actions including staff in-service training, monitoring of residents, and ongoing quality assurance reviews.

The facility failed to provide a certified dietary manager for 2 of 2 days on resurvey. Dietary staff observed were not certified, and administrative staff acknowledged the lack of certification since the prior survey.

All previously cited deficiencies were corrected as of the revisit dates listed, with corrections completed between 06/12/2012 and 06/14/2012.

The facility identified multiple deficiencies related to resident care, abuse reporting, housekeeping, maintenance, care planning, infection control, medication monitoring, and environmental safety. The Plan of Correction details specific actions, staff in-service training, monitoring, and timelines to resolve these issues by June 1, 2012.

The facility failed to provide a certified dietary manager for 4 of 4 days during the survey. Observations and staff interviews confirmed noncompliance with certification requirements.

The facility addressed issues related to providing an environment free from abuse, neglect, exploitation, and misappropriation of resident property. The plan includes re-education of staff, resident room reassignment to reduce interaction, close monitoring of residents, and ongoing review of incidents to ensure safety and compliance.