Heritage Pointe Of Warren

Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies to prevent contamination of a urinary catheter for 1 of 2 residents reviewed for indwelling catheters. (Resident 70)Findings include:During an observation, on 4/7/26 at 9:53 a.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.On 4/8/26 at 10:58 a.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.On 4/8/26 at 11:18 a.m., Resident 70 was laying on her back in her bed. Her indwelling catheter drainage bag hung on the top of the bed's footboard. The indwelling catheter tubing protruded from under the blanket at the foot of the mattress, ascended upwards, curved over the top of the footboard, and descended to insertion site on drainage bag. The tubing and bag were located above the level of Resident 70's bladder.On 4/8/26 at 2:28 p.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to securely store medications during a random observation of 1 of 6 medication carts (2B New End Medication Cart).Finding includes:During a random observation on the 2B hallway, on 4/9/26 beginning at 8:11 a.m., a medication cup with various pills was observed sitting on top of an unlocked medication cart left unattended in the hallway. No nursing staff members were in visual range of the cart. Activity Assistant 11 walked down the hall and stood by the medication cart, indicating she needed to speak with the nurse. At 8:13 a.m., RN 12 opened a resident's door across the hall and approached the medication cart. During an interview, at the time of the observation, she indicated the medication cart should not have been left unlocked, nor with medications sitting on top. The medications belonged to Resident 92 and were intended for his morning medication pass. RN 12 left the cart unlocked with the medications on top when the resident across the hall began yelling for help and was found to have urinated throughout…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

A. Based on observation, record review, and interview, the facility failed to ensure food was served and handled under safe and sanitary conditions for 2 of 19 residents observed during meal service. (Residents 3 and 57)B. Based on observation and interview, the facility failed to ensure universal precautions and hand hygiene were implemented during the administration of nasal spray for 1 of 4 residents observed during medication administration. (Resident 19) Findings include:A. During a lunch observation, on 4/6/26 at 12:10 p.m., the following was observed: CNA 4 pulled out a piece of bread with her bare hands from the plastic container. The bread was placed on Resident 3's tray. CNA 4 opened another plastic bag containing bread, removed that piece of bread with her bare hands. CNA 4 placed the second piece of bread on top of the first piece on Resident 3's tray. CNA 4 washed her hands with soap and water before walking over to Resident 57. She opened a plastic bag containing a piece of bread. CNA 4 removed the bread with her bare hands and placed it on Resident 57's tray. CNA 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide or offer eligible residents and/or the residents' representatives the current pneumococcal immunization according to the Centers for Disease Control and Prevention (CDC) guidelines for 2 of 5 residents reviewed for immunizations. (Resident 57 and Resident 73). Findings include: 1. Resident 73's clinical record was reviewed on 4/8/26 at 3:37 p.m. Diagnoses included type 2 diabetes mellitus, chronic kidney disease, stage 3 a, and heart failure.Resident 73 received the pneumococcal conjugate vaccine (PCV) 13 on 7/14/17 and the pneumococcal polysaccharide vaccine (PPSV) 23 on 11/28/18.An immunization consent, signed on 9/25/25, indicated the resident's representative wanted the resident to receive the most current pneumonia vaccine if eligible and indicated by the physician and have it administered by the facility, specifically the pneumococcal conjugate 20 (PCV 20).The clinical record lacked indication the resident was given the most current pneumonia vaccine, specifically the PCV 20 or the pneumococcal conjugate 21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to administer a COVID-19 vaccination per the Center for Disease and Control (CDC) guidance and per resident request for 1 of 5 residents reviewed for vaccinations. (Resident 70)Finding includes:Resident 70's clinical record was reviewed on 4/9/26 at 10:50 a.m. Diagnoses included pulmonary embolism without acute cor pulmonal (a blood clot in the lung artery that has not caused heart failure or strain), cerebral infarct (stroke), and hypertension (high blood pressure).A quarterly Minimum Data Set (MDS) assessment, dated 2/17/26, indicated her COVID-19 vaccination was not up to date.A review of the resident's vaccination history indicated the following:A vaccination consent form, dated 8/19/24, indicated the resident representative was provided education and consented to the administration of the most current COVID-19 vaccination.The clinical record lacked documentation of the administration of the appropriate COVID-19 vaccination. The clinical record lacked an updated or yearly COVID-19 vaccination consent or declination.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure baseline tuberculin skin testing employed the two-step method within the required time frames for 2 of 3 residents reviewed for tuberculin testing. (Resident D and E) Findings include: 1. Resident E's clinical record was reviewed on 6/12/25 at 12:28 p.m. The first-step tuberculin skin test (TST) was given and read at the hospital prior to admission to the facility. The resident record lacked administration and reading of a second-step tuberculin skin test. 2. Resident D's clinical record was reviewed on 6/12/25 at 1:59 p.m. The first step TST was given on 5/26/25 at 8:46 p.m. and read on 5/28/25 at 3:58 p.m. During an interview, on 6/13/25 at 9:04 p.m., LPN 4 indicated residents were given a TST on admission which was read 48 to 72 hours later. A second step TST was given one to three weeks later and also read 48 to 72 hours after given. During an interview, on 6/13/25 at 11:39 a.m., LPN 3 tuberculosis testing was initiated immediately upon admission. The TST was read 48 to 72 hours after given. During an interview,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to complete post-dialysis assessments on 1 of 1 resident reviewed for dialysis. (Resident 48) Findings include: Resident 48's clinical record was reviewed on 2/21/25 at 9:42 a.m. Diagnosis included end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus, essential hypertension, hypothyroidism, and muscle weakness. Current physician orders included complete dialysis assessment under the assessment tab one time a day every Monday, Wednesday, and Friday. [NAME] dialysis communication binder with current vitals were to accompany resident to every dialysis appointment. Bed bath only due to dialysis port. Review of the clinical record indicated no dialysis assessment was completed on January 8, January 17, February 12, and February 14, 2025. Resident 45's dialysis binder indicated dialysis had been completed on these dates. During an interview, on 2/25/25 at 10:28 a.m., LPN 6 indicated once the resident returns from dialysis, the nurse would complete the post-dialysis assessment. That assessment was located…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure shift to shift narcotic count and reconciliation was completed for 2 of 3 medication carts reviewed for medication reconciliation. (100 Hall) Findings include: 1. During a medication storage observation of the 100A new medication cart, on 2/21/25 at 10:49 a.m., accompanied by RN 4, the Narcotic Sheet Log/ Tracking Form was reviewed and the following dates lacked shift to shift count and reconciliation signatures of controlled medications: January 2025- lacked a narcotic card, liquid, and/or bottle count: 1/12 on evening shift 1/13 on day shift and evening shift 1/17 on evening shift and night shift 1/18 on night shift 1/19 on day shift 1/20 on day shift, evening shift and night shift 1/21 on day shift and night shift 1/22 on day shift and night shift 1/23 on day shift 1/25 on day shift 1/27 on evening shift 1/31 on evening and night shift February 2025- lacked a narcotic card, liquid, and/or bottle count: 2/1 on day shift and evening shift 2/3 on day shift and night shift 2/5 on night shift 2/6 on day shift, evening…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

A. Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies during wound care for 1 of 1 residents reviewed for pressure ulcers (Resident 76). B. Based on observation, interview, and record review, the facility failed to ensure transmission-based precautions were followed for 2 of 12 residents placed on transmission-based precautions (Resident 44 and Resident 45). Findings include: A. Resident 76's clinical record was reviewed on 2/24/25 at 10:05 a.m. Diagnoses included need for assistance with personal care, gastrostomy status, and encounter for surgical aftercare following surgery on the digestive system. Current physician's orders included the following: apply hydrocolloid (for wound healing) dressing to right and left buttock every day shift every Wednesday for protection related to wound and apply after shower (2/19/2025), Monitor hydrocolloid dressing to bilateral buttocks and replace if dressing is soiled or no longer intact every shift (2/12/25), and enhanced barrier precautions - wear gown/gloves to enter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer for a dependent resident for 1 of 3 residents reviewed for pressure ulcers. (Resident 28) Finding includes: Resident 28's clinical record review was completed on 3/6/24 at 3:03 p.m. Diagnoses included unspecified dementia, intervertebral disc degeneration of the lumbar region, type 2 diabetes mellitus, generalized muscle weakness, unsteadiness on feet, other reduced mobility, and need for assistance with personal care. Current physician orders, dated 1/26/24, included the following: float heels while in bed every night shift for offloading, apply skin preparation (skin protectant) to bilateral heels every shift for protection, and apply pressure relief boot to right foot at all times except during transfers. A current physician order, dated 2/1/24, included a weekly foot inspection on evening shift. A Braden Scale (for predicting pressure sore risk), dated 12/11/23, indicated the following: the ability to respond meaningfully to pressure-related discomfort was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure gastrostomy tube placement was confirmed prior to medication administration according to facility policy for 1 of 1 resident reviewed for tube feedings. (Resident 1) Findings include: Resident 1's clinical record was reviewed on 3/6/24 at 10:32 a.m. Diagnoses on the resident's profile included, but were not limited to, post-immunization acute disseminated encephalitis (swelling in the brain and spinal cord that causes damage to the sheath covering the nerve fibers), and dysphagia (difficulty swallowing), A physician's order, dated 5/13/2019, indicated check G-tube placement prior to bolus and medication administration and to maintain NPO (nothing by mouth), no exceptions. A physician's order, dated 7/11/21, indicated administer medications via g-tube, medications may be mixed together and mixed with 30 mL sterile water. Flush with 30 mL before and after medication administration, every shift. An annual MDS assessment, dated 2/7/24, indicated the resident had paraplegia (paralysis affecting the legs), a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.