Heritage Estates

Licensure Reference Number 175 NAC 12-006.1(A)(i)Based on observation, record review, and interview the facility failed to ensure that residents were served the approved menu serving sizes. This affected 11 observed residents served food from the facility kitchen (Residents 77, 73, 19, 7, 65, 41, 92, 10, 60, 79, and 85). The facility census was 99.Findings are: A. Record review of the facility Resident Policies dated 12/2020 revealed that the facility will provide the resident with a diet that their physician has ordered. The menu selections are served to meet their orders and have been approved by a qualified dietitian. Record review of the undated Questions & Answers from the undated facility admission packet revealed that the facility serves three meals a day. A dietician oversees dietary needs. Record review of the recipe for Pureed Beef Soft Tacos (pureed is a cooked food item that has been ground with a blender into a smooth pudding-like consistency for residents with difficulty chewing or swallowing) dated 2026 revealed that the portion (serving size) was two #6 scoops (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.

License Reference Number 175 NAC 12-006.18(B)(D)Based on record review and interview, the facility failed to ensure that infection control measures for hand hygiene were followed while assisting residents with eating meals and when donning (putting on) and doffing (taking off) gloves. This affected 8 residents of 8 sampled (Residents 57, 99, 16, 47, 36, 2, 22, and 55.); and the facility failed to ensure that those who had indwelling catheters had catheter bags kept off the floor. This had the potential to affect all residents in the 500 hall (Residents 22, 93, 99, 15, 24, 28, 69, 46, 90, 78, 16, 76, 82, 58, 57, and 5). The facility census was 99. Findings were: Record Review of the Hand Hygiene Competency dated 12/2019 revealed when one is to wash their hands with working within the facility. Hands were to be washed:Before eating or drinkingBefore each resident contactAfter touching a resident or handling their belongingsAfter contact with any body fluidsAfter handling contaminated itemsBefore and after glovingWhenever indicatedHand Hygiene using hand sanitizer was to be completed:…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview the facility failed to obtain complete consents for psychoactive medications for 2 of 5 residents (Residents 28 and 46), and failed to ensure that the resident power of attorney (POA; a legal document that allows a person to designate someone else to make decisions or act on their behalf regarding financial, legal, or medical matters) provided informed consent for use of psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) as required for 1 of 5 residents reviewed (Resident 51). The facility census was 99. Findings are:Record review of a facility document titled, Psychoactive medication and medication regimen review standard, dated 6/2026, revealed a policy for managing residents' medication regimens, as well as guidelines for psychoactive medications. The policy also revealed a consent for the use of psychoactive medications must be completed prior to initiating any psychoactive…

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.

Licensure Reference Number 175 NAC 12-006.05(E)(F)Based on record review and interview, the facility failed to ensure that Resident Rights, which are presented to the residents and resident representatives at the time of admission, are honored and followed as written. This affected one resident of one sampled, Resident 22. The facility census was 99. Record review of the Resident Rights (federally protected rights that ensure a safe, dignified, and respectful life which guarantee freedom from abuse, the ability to make personal choices, and the right to proper medical care. Facilities must fully inform residents of these rights upon admission.) received from the Facility Administrator (FA) had a copyright date of 2017 and revealed the document is to inform you of your rights as a resident of this facility. Federal law requires that we provide these rights in writing, in a language and format you understand, upon admission and throughout your stay. Carefully review these rights by yourself and / or with your responsible party. During your stay, if any of these change, you will be…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to submit accurate Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities) for the medication regimen for 1 (Resident 5) of 5 sampled residents. The facility identified a census of 99 residents. Findings are:Record review of a facility document titled, admission record, revealed Resident 5 was admitted on [DATE] with diagnoses of Type 2 diabetes mellitus (a chronic disease in which the body does not use insulin effectively, leading to irregular blood sugar levels and medical complications), acute respiratory failure, lymphedema (tissue swelling caused by extra fluid that is usually drained by the body's lymphatic system), and chronic lymphocytic leukemia (CLL, a type of cancer that affects the blood and bone marrow).Record review of Resident 5's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities)…

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.

Licensure Reference Number 175 NAC 12-006.05 (E)Licensure Reference Number 175 NAC 12-006.09 (E)(i)Licensure Reference Number 175 NAC 12-006.09 (F)(ii) Based on record review and interview the facility failed to ensure that residents , as well as their resident representatives, were invited to the care plan meetings on a quarterly basis for 1 of 4 residents reviewed (Resident 22); and failed to revise the care plan to meet the needs of the resident when an antipsychotic was initiated for 1 resident (Resident 51) of 5 residents sampled. The facility census was 99. Findings are:Record review of the policy Comprehensive Care Plans dated 11/28/2026 revealed that the facility will develop and implement a comprehensive care plan (a detailed, step-by-step guide used in long-term care (LTC). It lists a resident's exact medical, physical, and emotional needs. The goal is to help the resident stay as healthy and happy as possible) for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and…

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 review of the 2022 Food Code, the facility failed to ensure: 1) there was a trash can near the handwashing sink; 2) pots and pans were stored inverted; 3) expired food items were discarded; and 4) staff washed their hands when they entered the kitchen before they began to prepare food. These deficient practices affected all residents who received food from the kitchen. Findings included: 1. Section 4-903 Storing of the 2022 Food Code published by the United States Food and Drug Administration, indicated (B) Clean equipment and utensils shall be stored as specified under [symbol] (A) of this section and shell be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted. Section 6-301.20 Disposable Towels, Waste Receptables. A handwashing sink or group of adjacent handwashing sinks that is provided with disposable towels shall be provided with a waste receptable as specified under [symbol] 5-501.16(C). During a concurrent observation and interview on 04/14/2025 at 9:00 AM, the surveyor noted there was not a trash…

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 implement care plan interventions to prevent the development of pressure ulcers for 1 (Resident #10) of 2 sampled residents reviewed for pressure ulcer/injury. Findings included: An admission Record revealed the facility admitted Resident #10 on 09/22/2023. According to the admission Record, the resident had a medical history that included a diagnosis of pressure-induced deep tissue damage of the sacral region. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with lower body dressing and was dependent on staff for putting on/taking off footwear. According to the MDS, the resident was at risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. Resident #10's Care Plan Report included a focus area initiated…

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 pressure ulcer treatment interventions were implemented in an effort to prevent new or worsening pressure ulcers for 1 (Resident #10) of 2 sampled residents reviewed for pressure ulcer/injury. Findings included: An admission Record revealed the facility admitted Resident #10 on 09/22/2023. According to the admission Record, the resident had a medical history that included a diagnosis of pressure-induced deep tissue damage of the sacral region. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required substantial/maximal assistance with lower body dressing and was dependent on staff for putting on/taking off footwear. According to the MDS, the resident was at risk for developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. Resident #10's Care Plan Report…

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 store respiratory equipment when not in use to prevent contamination for 1 (Resident #9) of 3 sampled residents reviewed for respiratory care. Findings included: An admission Record revealed the facility admitted Resident #9 on 11/13/2018. According to the admission Record, the resident had a medical history to include a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/19/2025, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident was severe cognitive impairment. The MDS indicated that the resident required oxygen therapy. Resident #9's Care Plan Report included a focus area initiated 06/26/2024, that indicated the resident was at risk for altered respiratory function related to oxygen therapy. Interventions directed staff to check oxygen saturation as required and monitor for shortness of breath as needed. Resident #9's physician's order dated 11/15/2024, indicated oxygen at 2 liters per…

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.

Licensure Reference 175 NAC 12-06.09(J)(i)(1) Based on record reviews and interviews, the facility staff failed to implement interventions to manage weight loss for 2 (Resident 1 and 2) of 3 sampled residents. The facility staff identified a census of 97. Findings are: A record review of an undated facility policy Significant Weight Loss indicated the following: - Significant weight loss in 1 week is 1-2%; more than 1-2% is considered severe weight loss. - Significant weight loss over 1 month is 5%; more than 5% is considered severe weight loss. - Significant weight loss over 3 months is 7.5%; more than 7.5% is considered severe weight loss. - Significant weight loss over 6 months is 10%; more than 10% is considered severe weight loss - The policy defined avoidable weight loss as an individual that did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following: evaluate the individual's clinical condition, define and implement interventions, monitor and evaluate the impact of the interventions, and revise the interventions…

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.

Licensure Reference Number 172 NAC 12-006.05(21) Based on observations, interviews, record reviews, and facility policy review, the facility failed to maintain the dignity of 3 (Residents #43, #87, and #60) of 3 residents who were observed during dining. The facility failed to serve all residents who were sitting at the same table their meal at the same time before proceeding to the next table, leaving the residents to watch their tablemate's eat. The facility census was 99. Findings are: An undated excerpt from the employee handbook titled [Name of facility ownership] Values revealed, We will create a living environment that radiates love, peace, spiritual contentment, dignity and safety, while encouraging personal independence. A. A review of an admission Record revealed the facility admitted Resident #43 on 04/02/2017. According to the admission Record, the resident had a medical history that included diagnoses of hypertension and dementia. A review of Resident #43's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/10/2024 revealed Resident #43 had 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.

Licensure Reference Number 175 NAC 12-006.14 Based on observation, interviews, record review, and facility policy review, the facility failed to provide routine dental services for 1 (Resident #71) of 1 sampled resident reviewed for dental services. The facility census was 99. Findings are: A review of the facility policy titled Dental Policy dated August 2017, revealed the Facility must arrange for transportation to and from the dental services locations; and must assist residents who are eligible to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan such as Medicaid. A review of an admission Record indicated the facility admitted Resident #71 on 04/13/2021 with diagnoses of unspecified dementia and convulsions. The admission Record identified Dental Provider D as Resident #71 dental provider and indicated the resident was a Medicaid recipient. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2024, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 3, which…

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.