The Heritage Rehabilitation and Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews conducted during the Recertification Survey from 05/12/2025 to 05/15/2025, the facility did not ensure that the baseline care plan was completed within 48 hours of a resident's admission. This was evident for 1 (Resident #327) of 1 resident reviewed for Communication out of 20 sampled residents. Specifically, the baseline care plan for Resident #327 was not completed until 04/29/2025 which was four days after admission. The findings are: The facility policy titled Baseline Care Plan last reviewed March 2024 stated the Baseline Care Plan must be developed within 48 hours of a resident's admission. Resident #327 was admitted to the facility on [DATE] with diagnoses that included Encounter for removal of internal fixation device, and Multiple myeloma. The admission Minimum Data Set, dated [DATE] documented Resident #327 was cognitively intact, and both Resident #327 and their representative participated in the assessment. The Baseline Care Plan and Summary Report - IDT…

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 staff interviews conducted during the Recertification survey from 05/12/2025 to 05/15/2025, the facility did not ensure that based on the comprehensive assessment of a resident, and consistent with the resident's needs and choices, communication including language was provided. This was evident for 1 (Resident #327) of 1 resident reviewed for Communication out of 20 sampled residents. Specifically, Resident #327 whose primary language is Cantonese was not provided with interpretation services during the admission nutrition assessment. The findings are: The facility policy titled Communication reviewed on 05/15/2024 stated the telephonic interpreter and interpreters via language bank will be utilized. The policy also documented the facility will ensure that adequate communication is maintained, and resident's needs are met. The facility policy titled Language Bank reviewed on 1/2/2024 stated a language bank is set up to support clear communication channels for those who do not speak…

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 observations, interviews, and record review conducted during the Recertification Survey from 08/10/2023 to 08/17/2023, the facility did not ensure that menus were followed. This was evident for 1 (Resident #9) of 3 residents reviewed for food out of 20 total sampled residents. Specifically, Resident # 9 did not receive items listed on their tray ticket during mealtimes. The findings are: The facility policy titled Serving Food dated February 2023 documented resident preferences at mealtime are important to the satisfaction of the dining experience and the staff will call for alternative trays upon resident request. Food preferences will be indicated on tray cards meal. Resident #9 had diagnoses of Alzheimer's disease and anemia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #9 was moderately cognitively impaired and required set up and supervision with eating. On 08/10/2023 at 11:07 AM, Resident #9 was interviewed and stated they need soft food and stated that they don't get soft food…

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, record review, and interview during the Recertification and Extended Survey from 11/16/2021 to 11/26/2021, the facility did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the QAA committee which is composed of the Administrator, Medical Director, Director of Nursing (DON) Et. Al. was aware of the identified concern of physical restraint/side rail use via Certification and Survey Provider Enhanced Reporting (Casper) and the plans of action implemented in June 2021 were shown to be ineffective resulting in both deficiency and immediate jeopardy during this recertification survey. The finding is. The facility policy and procedure titled Quality Assessment and Assurance with effective date 11/16 documented Heritage Center will operate a Quality Assessment and Assurance Committee to identify quality issues and develop and implement appropriate plans of action to correct identified quality deficiencies within Heritage Center through an…

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 observation, Interview, and record review conducted during the recertification survey, the facility did not ensure that infection control standards were maintained. Specifically, 1) a facility entertainer was observed without a face covering; and, 2) multiple staff were observed without the necessary Personal Protective Equipment (PPE) interacting with a Resident #123 on contact/droplet precautions (CDP). This was evident for 1 of 2 units and 1 of 4 residents reviewed for Transmission Based Precautions (TBP) in the infection control task. The findings are: The facility policy titled TBP dated 11/16 documented Staff must wear PPE when entering a resident's room on contact precautions and must wear a mask when closely interacting with residents on droplet precautions. 1) On 11/17/21 at 02:39 PM, the facility entertainer (ETR) was observed entering the 1st floor hallway from the stairwell door. ETR was holding a minstrel, had a full beard, and had no face covering. ETR turned and walked towards the…

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 observations, interviews, and record review during the Recertification Survey, the facility did not ensure that a safe, functional, sanitary, and comfortable environment for residents was provided. Specifically, a patio exit door, situated in the 1st floor resident dining room was not secured with a properly functioning alarm or door hardware to secure and prevent residents from exiting unattended. The findings are: An undated facility policy titled Outdoors/Patio documented outdoor time will be announced on the loudspeaker and residents will be transported to and from their unit. Resident #28 was admitted to the facility with diagnoses that included Major Depressive Disorder and Acute ischemic heart disease. The Minimum Data Set (MDS) documented that resident was cognitively intact and required limited assistance of one-person for walking in the corridor and locomotion on unit. On 11/17/21 at 02:16 PM, Resident #28 was observed opening the patio door located on the 1st floor dining room, and going out onto the patio, unattended. After several minutes, Resident #28 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure a resident's right to a dignified existence were respected. Specifically, a photograph and identifying information of Resident #48 were posted in a public area visible to other residents, staff, and visitors. This was evident for 1 of 1 residents reviewed in the area of Dignity. The findings are: Facility policy titled Patient Dignity and Rights dated 1/1/21 documented a resident's dignity will be maintained by keeping resident information confidential. Resident #48 was moderately cognitively impaired and diagnosed with Alzheimer's disease. The Minimum Data Set, dated [DATE] documented Resident #48 had a behavior of wandering 1-3 days in the 7 days prior to the assessment. The behavior had worsened since the last assessment but did not put the resident at risk of getting to a dangerous area. From 11/17/21 at 02:31 PM through 11/26/21 at 03:13 PM, a 8 1/2 X 11 sheet of paper containing 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview during the recertification survey completed [DATE], the facility did not ensure a resident's wishes for Advance Directives were ordered and correctly identified. Specifically, the facility did not ensure that Resident #220 Physician's orders for Advance Directives, were updated and consistent with the resident's MOLST (Medical Orders for Life Sustaining Treatment). This was evident for 1 of residents reviewed for Advance Directives (Resident #220). The findings are: The undated facility's policy titled Advanced Directives documented that the social work department advises the Registered Nurse (RN) Coordinator on duty when a Do not resuscitate (DNR) consent has been signed. The social work department also writes a note in the Medical Doctor's (MD) book for a DNR to be written. The Physicians will write the DNR order in the medical record and include a justification for the order in their progress notes. Resident #220 was admitted with diagnoses that include…

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 observation and interviews conducted during the recertification survey, the facility did not ensure that a safe, clean, comfortable, and homelike environment was provided to residents. Specifically, 2 resident rooms were observed with dirty and sticky floors not swept, torn wallpaper and paper blind, and stained toilet door for multiple observations over several days. This was evident for 1 of 2 resident units observed for Environmental Observations (Floors 1). The findings are: The facility's untitled policy, with heading 'Objectives of Department', documented that to provide a clean, safe orderly and comfortable and attractive environment both interiorly and exteriorly, following factors in housekeeping standards listed below. The Policy also documented that the facility provides the housekeeping and maintenance personnel services necessary to maintain sanitary and comfortable environment and provide sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the…

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 observations, interviews and record review conducted during the recertification survey, the facility did not ensure that all alleged violations of of abuse and neglect, including injuries of unknown source were thoroughly investigated. Specifically, the facility did not initiate an investigation after a resident was found with a large ecchymosis, with swelling, warm to touch over her left upper arm and elbow. This was evident for 1 of 1 resident reviewed for Abuse (Resident #11). The findings are: The facility's policy titled 'Prohibition of Resident Abuse, Neglect and Misappropriation of Property' documented that residents have the right to be free from verbal, sexual, physical, mental, involuntary seclusion and misappropriation of property and neglect. The policy also documented that the facility shall provide investigations and maintain records of alleged violations involving abuse, mistreatment or neglect and shall include in the investigative report the corrective action taken if the alleged…

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 interviews conducted during the Recertification and Extended Survey, the facility did not ensure, to the extent practicable, that residents were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 2 of 2 residents reviewed for Participation in Care Planningout of a sample of 44 residents. (Resident #69 and #38) The findings are: The facility policy and procedure titled Comprehensive Care Plans dated 11/16 documented that the comprehensive care plan would be prepared by the interdisciplinary team (IDT) and the resident and resident's representative to the extent practicable. An untitled document dated 10/1/2010 documented under section Notification of Interdisciplinary Care Plan Meeting for Residents and Family Members a). Residents and their family…

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 observations, interview, and record review conducted during the recertification survey, the facility did not ensure appropriate equipment to maintain or improve mobility. Specifically, Resident #16 was at risk for contracture and was observed on multiple occasions without the Physician ordered (MDO) handroll in place. This was evident for 1 of 2 residents reviewed for Position/Mobility. The findings are: The facility policy titled Splinting dated 1/1/21 documented static splints are used to prevent contracture and a wearing schedule would be discussed with the caregiver. Resident #16 was severely cognitively impaired and diagnosed with Alzheimer's dementia and left hand contracture. On 11/17/21 at 02:19 PM, Resident #16 was observed sitting in a gerichair with left hand contracted into a closed fist. Resident #16 was able to move the left pointer and thumb fingers and was unable to move the left middle, ring, and pinky finger. A handroll was on the overbed table in front of Resident #16 gerichair. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review conducted during the Recertification and Extended Survey from 11/16/2021 to 11/26/2021, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. Specifically, there was no documented evidence of an assessment and review of physical restraint use for 2 residents with seat belts and four (4) side rails. This was evident for 2 of 4 residents reviewed for physical restraint out of a sample of 44 residents. (Resident # 13 & # 2). The findings are: The policy and procedure titled Physician's Responsibilities with effective date 5/15 documented a physician who will examine, diagnose, treat and evaluate care and services on a periodic basis attends each resident and The physician evaluates the resident at least once every 28 days utilizing monthly history and physical. 1.Resident # 13 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease,…

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.