4 Reports
Inspection Report — Aug 6, 2025
Routine CMS
Date: Aug 6, 2025
Visit Reason
Routine inspection of Heritage Health Care Center to assess compliance with regulatory standards including resident care, medication management, infection control, food safety, and facility sanitation.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, inadequate notification to the Ombudsman of resident discharges, insufficient assistance with activities of daily living, incomplete wound care documentation, improper medication reconciliation and storage, unsanitary food preparation and storage conditions, improper garbage disposal, and inadequate infection control related to nebulizer equipment.
Deficiencies (9)
F 0552: The facility failed to ensure informed consent for psychotropic medications including purpose, risks, and benefits for Resident 6.
F 0628: The facility failed to notify the Ombudsman of transfers or discharges for Residents 67 and 69, risking impaired resident rights.
F 0677: The facility failed to provide necessary bathing assistance to Resident 8, resulting in poor hygiene and quality of life risk.
F 0686: The facility failed to provide appropriate wound care and weekly assessments with measurements for Residents 58 and 2, risking delayed healing.
F 0755: The facility failed to adequately reconcile controlled substances on medication carts, risking medication misappropriation.
F 0761: The facility failed to ensure drugs and biologicals were properly labeled, stored, and secured, including undated insulin pens and unlocked medication carts.
F 0812: The facility failed to prepare and serve food under sanitary conditions, including soiled equipment, undated and spoiled food, and improper thawing practices.
F 0814: The facility failed to properly dispose of garbage and keep dumpster lids closed, risking insect and rodent attraction.
F 0880: The facility failed to implement infection control for nebulizer equipment, with undated and improperly stored devices for Residents 1, 3, and 18.
Report Facts
Sample size: 17
Medication carts: 3
Treatment carts: 2
Medication rooms: 2
Dumpster lids open: 3
Inspection Report — Dec 14, 2023
Routine CMS
Date: Dec 14, 2023
Visit Reason
Routine inspection of Heritage Health Care Center to assess compliance with healthcare regulations including resident care, safety, nutrition, infection control, and staffing.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity during catheter care, incomplete individualized care plans, inadequate pressure ulcer prevention and treatment, failure to follow fall prevention care plans, improper catheter tubing anchoring, delayed nutritional assessments, unsanitary food preparation conditions, inaccurate staffing data submission, and inadequate infection control in the beauty shop.
Deficiencies (12)
F 0550: The facility failed to show respect and dignity to Resident R14 by not closing window blinds and exposing the resident during catheter care.
F 0656: The facility failed to provide an individualized care plan for Resident R46 regarding facial shaving.
F 0657: The facility failed to review and revise care plans for Residents R8 and R4 to address decline in eating and antipsychotic medication use.
F 0677: The facility failed to provide bathing opportunities per Resident R21's preference, impacting wellbeing.
F 0677: The facility failed to provide appropriate ADL assistance for Resident R46 regarding facial shaving.
F 0686: The facility failed to assess and provide preventive pressure ulcer care for Resident R109, resulting in unstageable pressure injuries.
F 0689: The facility failed to ensure fall prevention interventions for Resident R8 by not providing nonskid socks/slippers when in bed.
F 0690: The facility failed to use a leg anchor for Resident R14's indwelling urinary catheter tubing to prevent injury.
F 0692: The facility failed to ensure timely nutritional assessments and interventions for Residents R107, R109, and R8 to maintain optimal nutrition and address weight loss.
F 0812: The facility failed to prepare and serve food under sanitary conditions and failed to use pasteurized eggs for soft-cooked eggs.
F 0851: The facility failed to electronically submit complete and accurate direct care staffing information to CMS, including agency and contract staff hours.
F 0880: The facility failed to follow appropriate catheter care guidelines for Resident R14 and failed to maintain sanitary conditions in the beauty shop to prevent infections.
Report Facts
Residents sampled: 17
Weight loss: 13.6
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided statements on catheter care expectations, care plan reviews, and infection control |
| Certified Nurse Aide NN | Certified Nurse Aide | Performed catheter care and stated catheter tubing was not anchored |
| Certified Nurse Aide OO | Certified Nurse Aide | Performed catheter care and stated catheter tubing was not anchored |
| Certified Medication Aide R | Certified Medication Aide | Stated all catheter tubing should be anchored |
| Licensed Nurse LN I | Licensed Nurse | Stated all catheter tubing should be anchored and noted resident unshaven |
| Licensed Nurse LN H | Licensed Nurse | Stated catheter tubing should be anchored and confirmed skin assessment issues |
| Dietary Staff BB | Dietary Staff | Provided statements on dietary assessments and kitchen sanitation |
| Dietary Staff CC | Dietary Staff | Noted use of unpasteurized eggs for soft-cooked eggs |
| Administrative Staff A | Administrative Staff | Confirmed staffing data inaccuracies and beauty shop sanitation issues |
| Certified Nurse Aide CNA M | Certified Nurse Aide | Observed resident without nonskid socks and provided statements on fall risk |
| Medical Consultant II | Medical Consultant | Provided expectations on nutritional and pressure ulcer care |
| Corporate Nurse Consultant HH | Corporate Nurse Consultant | Measured pressure ulcers and confirmed lack of admitting skin assessment |
Inspection Report — Dec 14, 2023
Complaint Investigation CMS
Date: Dec 14, 2023
Visit Reason
The inspection was conducted based on complaints regarding failure to provide appropriate assistance with personal hygiene and nutritional needs for residents.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to provide adequate personal hygiene assistance and nutritional care to specific residents. The complaints were substantiated with findings of minimal harm and few residents affected.
Findings
The facility failed to provide adequate bathing and shaving assistance to dependent residents and did not ensure timely nutritional assessments or interventions for residents with weight loss and post-operative needs. Several residents were found to have unmet personal hygiene and nutritional care requirements.
Deficiencies (2)
F 0677: The facility failed to provide frequent bathing opportunities per resident preference and appropriate assistance with personal hygiene for two dependent residents regarding facial shaving and bathing.
F 0692: The facility failed to ensure timely assessment and implementation of nutritional interventions by the Registered Dietician for residents with post-operative needs, weight loss, and other nutritional risks.
Report Facts
Residents sampled: 17
Residents reviewed for ADL: 4
Residents reviewed for nutrition: 7
Weight loss: 13.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA O | Certified Nurse Aide | Interviewed regarding resident bathing schedule and assistance. |
| CNA M | Certified Nurse Aide | Interviewed about resident providing own cares and bath aide assistance. |
| Administrative Nurse D | Administrative Nurse | Interviewed about bathing expectations and dietary assessments. |
| CNA OO | Certified Nurse Aide | Interviewed about resident cooperation and shaving status. |
| CMA R | Certified Medication Aide | Reported shaving practices on shower days. |
| LN I | Licensed Nurse | Noted resident was unshaven and did not refuse cares. |
| Dietary Staff BB | Dietary Staff | Interviewed about timing of nutritional assessments and diet orders. |
| Corporate Nurse Consultant HH | Corporate Nurse Consultant | Interviewed about expectations for dietary assessments. |
| Medical Staff KK | Medical Staff | Interviewed about nutritional services post surgery. |
| Administrative Staff A | Administrative Staff | Confirmed dietary assessment delays. |
| Administrative Staff E | Administrative Staff | Interviewed about resident's resistance to feeding assistance and weight loss. |
| Dietary Consultant GG | Dietary Consultant | Confirmed resident's weight loss and recommended fortified food. |
| Medical Consultant II | Medical Consultant | Aware of resident's weight loss and interventions. |
| Administrative Nurse F | Administrative Nurse | Added interventions to resident's care plan. |
Inspection Report — Mar 24, 2022
Routine CMS
Date: Mar 24, 2022
Visit Reason
Routine inspection of Heritage Health Care Center to assess compliance with regulatory requirements including resident care, medication management, food safety, and facility operations.
Findings
The facility had multiple deficiencies including failure to assess and document resident food and beverage preferences, failure to update care plans for bruising and hospice care, inadequate bathing for a resident, failure to implement pressure ulcer prevention measures, improper catheter care, failure to monitor medication lab tests, and unsanitary food storage and preparation practices.
Deficiencies (8)
F 0561: The facility failed to ensure encouragement for a resident to voice preferences for beverages and food, and did not complete a dietary assessment due to computer system issues.
F 0657: The facility failed to review and revise care plans for two residents, including lack of interventions to prevent further bruising and failure to implement hospice care instructions.
F 0677: The facility failed to provide adequate bathing opportunities to a resident, resulting in poor personal hygiene and greasy hair.
F 0684: The facility failed to develop interventions to prevent bruising for a resident with extensive bruising on the right hand.
F 0686: The facility failed to ensure a pressure reducing seat cushion was placed in the wheelchair for a resident with pressure ulcers to promote healing.
F 0690: The facility failed to properly anchor catheter tubing and prevent tubing from contacting the floor for two residents, risking urinary tract infections.
F 0760: The facility failed to obtain physician ordered PT/INR lab tests for two residents on anticoagulant therapy, risking adverse medication effects.
F 0812: The facility failed to maintain sanitary food preparation, storage, and serving practices, including undated and improperly stored food items, unclean kitchen equipment, and inadequate dishwasher sanitation.
Report Facts
Deficiencies cited: 8
Bruise size: 8
Bruise size: 6
INR lab result: 4
Dishwasher sanitation level: 100
Dishwasher sanitation minimum: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse I | Licensed Nurse | Noted failure to develop interventions for resident's bruising |
| Administrative Nurse D | Administrative Nurse | Confirmed failure to update care plans and obtain lab tests |
| Certified Nurse Aide NN | Certified Nurse Aide | Reported noticing resident's bruise and assisted resident |
| Dietary Staff BB | Dietary Staff | Reported lack of dietary assessment and food safety issues |
| Certified Nurse Aide M | Certified Nurse Aide | Observed catheter tubing dragging on floor |
| Certified Nurse Aide N | Certified Nurse Aide | Observed catheter tubing dragging on floor |
| Licensed Nurse H | Licensed Nurse | Discussed catheter care and lab test timing |
| Certified Nurse Aide Q | Certified Nurse Aide | Applied catheter tubing clip and discussed cleaning |
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