Heritage Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to provide a discharge summary and supplemental oxygen at the time of discharge for 1 (Resident (R)137) of 4 sampled closed records reviewed.Findings include:Review of a facility policy titled Discharge Summary and Plan, revised on 10/2022, revealed, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. The policy specified, . 12. A copy of the following is provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary.Review of R137's admission Record revealed the facility admitted R137 on 11/07/2025. According to the admission Record, the resident had a medical history that included but was not limited to a diagnoses of respiratory failure. Per the admission Record, the resident discharged…

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, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for the use of enablers for 1 (Resident (R)76) of 24 sampled residents.Findings include:Review of a facility policy titled Care Planning, Comprehensive Person-Centered, revised on 03/2022, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified . 7. The comprehensive, person-entered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of a facility policy titled Enablers, revised on 05/05/2023, revealed Policy: 1. The nursing staff will use enablers whenever possible in lieu of restrains to assist the patient/resident to obtain, maintain and enhance the functional status, an improve his/her…

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, record review, and facility policy review, the facility failed to update the care plan to reflect the resident's use of fall matts for 1 (Resident (R)7) of 24 sampled residents.Findings include:Review of the facility policy titled Care Planning, Comprehensive Person-Centered, revised on 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy specified, . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.Review of R7's admission Record indicated the facility admitted R7 on 11/15/2024. According to the admission Record, the resident had a medical history that included, but was not limited to diagnoses of muscle weakness and unsteadiness on feet.Review of R7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2025, revealed R7 had a Brief Interview for Mental…

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, record review, and facility policy review, the facility failed to ensure weekly body audits (skin checks) were conducted and documented for 1 (Resident (R)137) of 3 sampled residents reviewed for pressure ulcers. Findings include:Review of the facility policy titled Pressure Injury/Wound/Skin Management, dated 08/2016, indicated, . 4. A Licensed Nurse performs a weekly body audit, wound measurements, and documents findings in the medical record.Review of R137's admission Record revealed the facility admitted R137 on 11/07/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnosis of unstageable pressure ulcer of sacral region. Per the admission Record, the resident discharged home with home health services on 11/27/2025.Review of R137's Baseline Care Plan Summary included a problem statement initiated on 11/07/2025, that indicated the resident had impaired skin on the sacrum. Interventions directed staff to perform weekly skin checks.Review of R137's admission Minimum Data Set (MDS) with 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.

Based on interview and record review, the facility failed to document the administration of a nutritional supplement ordered for 1 resident (Resident (R)137) of 24 sampled residents.Findings include:Review of R137's admission Record revealed the facility admitted R137 on 11/07/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnosis of severe protein-calorie malnutrition.Review of R137's admission Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2025, revealed R137 had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision or touching assistance with eating.Review of R137's Care Plan Report included a focus area initiated on 11/26/2025, that indicated the resident had a nutritional problem or potential for a nutritional problem.Review of R137's Order Summary Report revealed an order dated 11/21/2025 for a nutritional supplement with meals.Review of R137's Medication…

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, record review, and facility policy review, the facility failed to ensure a catheter drainage bag was not on the floor for 1 (Resident (R)4) of 3 sampled residents reviewed for urinary catheter.Findings include:Review of the facility policy titled Catheter Care, Urinary, revised 08/2022, revealed The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. The policy specified, . 2. Be sure the catheter tubing and drainage bag are kept off the floor.Review of R4's admission Record revealed the facility admitted R4 on 01/06/2026. According to the admission Record, the resident had a medical history that included but was not limited to diagnosis of retention of urine.Review of R4's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/2026, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for toileting and had 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 observations, facility policy, and interviews, the facility failed to remove expired medications and biologicals from 1 of 4 medication carts and from 1 of 1 medication storage rooms. Additionally, the facility failed to ensure the medication room was properly secure. Findings include: Review of the facility policy titled, Medication Storage in the Healthcare Centers with revised date 04/09/24 revealed, Policy Statement: .The medication supply is accessible only to licensed nursing personnel and pharmacy personnel .Procedure: 2. Only licensed nurses and the pharmacy personnel are allowed access to medications Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. Nurses are required to check all medications for deterioration and expiration before administration. Nurses are also required to inspect medication storage facilities, including medication carts, routinely .12. Outdated, contaminated, or deteriorated medications and those in containers that…

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 facility policy, record review, observation and interview, the facility failed to ensure ordered supplements were provided for 1 of 2 residents, (R)50 reviewed for nutritional supplements. Findings include: Record review of the facility policy dated 07/03/2019 titled, Telephone/Verbal Orders From Physician revealed under the policy, Llicensed staff may obtain orders from their extenders via verbal order or telephone orders. The nursing staff may repeat the order back to the physician or extender for verification if necessary. The physician signs the order on his/her next visit. Record review of R50's medical record revealed she was admitted to the facility on [DATE] with diagnosis that include but are not limited to anemia, hyperlipidemia, cerebral infarction, anxiety, gastroesophogeal reflux and osteoporosis. Record review of R50's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 13, indicating she is cognitively intact. Record review…

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 review of the facility policy, record review, observation, and interview, the facility failed to ensure hand hygeine was followed for 1 of 4 residents, (R)58, reviewed for pressure ulcers. Findings include: Review of the facility policy, date unspecified, titled, Wound Care/Dressing Change Procedure states under the policy, Clean the wound according to the order. Remove gloves and place in the trash. Hand hygeine. Put on clean gloves. Apply clean dressing as ordered. Remove gloves and place in the trash can. Make resident comfortable. Hand hygiene. Record review revealed R58 was admitted on [DATE] with diagnoses that included but not limited to dementia, depression, Alzheimers' Disease, dysphagia, and hypertension. Review of R58's treatment orders revealed a treatment order dated 09/03/24 to cleanse sacral wound with normal saline, apply medihoney and calcium alginate to wound bed, and cover with a dry dressing until healed. Apply house barrier cream and antifungal powder to skin surrounding wound to…

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 review of the facility policy, record review, interviews, and observation, the facility failed to ensure Resident (R)60, 1 of 1 reviewed with food allergies, did not receive food items to which s/he was allergic. Findings include: Review of the facility's undated policy and procedure titled, ALLERGIES states: Policy- To avoid administration of medications and foods that cause residents to experience adverse reactions. The facility admitted R60 with diagnoses including but not limited to type 2 diabetes, anemia, osteoarthritis, and hyperlipidemia. Review of the Minimum Data Set with an Assessment Reference Date (ARD) of 11/28/22 revealed R60 has a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating he is cognitively intact. Record review on 01/05/23 at approximately 09:05 AM revealed a dietary order dated 11/22/22 stating CCHO REGULAR CONSISTENCY DIET *NO FISH, NO PORK, NO SEAFOOD, AND NO IODINE CONTAINING COMPOUNDS*. Record review on 01/05/23 revealed a progress note dated 01/04/23 at 02:22 PM stating Resident ate a piece of shrimp gumbo during…

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.