Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heather Hill Healthcare Center during CMS and state inspections, most recent first.
A resident with stroke, severe vascular dementia, vision loss, weakness, gait impairment, and a history of falls was not adequately supervised, and multiple unwitnessed falls were documented without corresponding nursing notes. The resident was later outside with another resident in a wheelchair, tripped and fell onto the other resident, and sustained a major left shoulder fracture requiring hospital transfer. Interviews with the DON, NHA, and LPN confirmed the resident’s declining cognition, prior falls, and that the incident occurred on a weekend when no supervisory staff were at the front desk.
Residents in the facility received burnt grilled cheese sandwiches, which were inedible and unappealing. Despite complaints from residents and their families, the issue persisted, particularly during evening meals. The facility's management was unaware of the problem until the survey, and the kitchen staff had not effectively addressed the issue, lacking documentation of corrective training for the cook responsible.
The facility failed to complete PASRR Level II evaluations for several residents with qualifying mental health diagnoses, such as Major Depressive Disorder and Dementia. The PASRR Level I assessments did not reflect these diagnoses, and necessary Level II evaluations were not conducted. Staff interviews revealed awareness of the issue, but there was a lack of follow-up and communication to ensure updates were made.
The facility failed to ensure proper hospice care coordination for two residents and did not manage a resident's behavior effectively. A resident on hospice care lacked a specific care plan and documented collaboration with the hospice provider. Another resident with a history of mental health issues was observed with self-inflicted injuries due to skin picking, but staff failed to document or address the behavior. Additionally, a resident receiving palliative care had no hospice progress notes or plan of care in their records, indicating a lack of care coordination.
The facility failed to provide sufficient staffing in the 400-unit, resulting in residents being left without interaction or assistance during meals and activities. Observations showed residents sitting idle or playing with food without staff intervention. Interviews with staff and family members confirmed the lack of adequate care, with staff overwhelmed and family members stepping in to assist. The DON acknowledged the need for more attention and assistance for residents.
The facility did not ensure that residents and their representatives understood arbitration agreements they signed. A resident with intact cognition signed without understanding the waiver of rights, while another with severe impairment had paperwork signed by a next of kin who was not a healthcare surrogate or POA. A third resident's responsible party did not recall signing anything related to dispute resolution. Staff acknowledged the overwhelming nature of the paperwork and the lack of a specific policy on arbitration agreements.
The facility failed to maintain proper infection control practices during medication administration and dining. An LPN and an RN were observed not performing hand hygiene during medication pass, and a CNA did not sanitize hands between delivering dinner trays. Additionally, a CPR backboard and tray tables with uncleanable surfaces posed infection risks. The DON acknowledged these issues, and facility policies emphasized the need for proper hand hygiene.
The facility failed to maintain resident dignity during meal times, with instances of residents being left without meals, staff standing while assisting with eating, and residents being referred to by demeaning labels. Residents were also observed eating in hallways without activities, contrary to care plans and facility policies.
A resident's responsible party reported frequent issues with saturated incontinent products, which were not promptly addressed or documented by the facility staff. Despite multiple complaints to an LPN, the grievance was not logged until later, contrary to the facility's grievance policy.
The facility did not update the PASRR Level 1 Screens for three residents when new diagnoses were added. One resident had dementia, anxiety disorder, and mood disorders added, another had seizure disorder, depression, and OCD, and a third had non-Alzheimer's dementia and schizophrenia. The interim social worker acknowledged the issue, and the facility's policy requires such updates, but they were not completed.
A facility failed to develop comprehensive care plans for two residents, one requiring pain management for a broken leg and fibromyalgia, and another needing diabetes management with insulin use. Despite having pain and diabetes management regimens, the care plans lacked specific goals and interventions. The MDS Coordinator and DON acknowledged the absence of these care plans, which did not align with the facility's policies on comprehensive, person-centered care planning.
Failure to Supervise a High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision for a resident with significant cognitive impairment, a history of falls, gait abnormalities, weakness, sudden vision loss, and a prior stroke. The resident’s record showed a physician-signed incapacity form, a DPOA for medical and financial decisions, and a care plan that identified impaired cognition, limited mobility, high fall risk, and actual falls. The care plan included interventions such as cueing, reorientation, supervision as needed, assistance with transfers, and maintaining a safe environment, but the record did not show identification, evaluation, or analysis related to the resident’s falls. The resident had multiple unwitnessed falls documented in the facility’s incident report list, including falls on 1/11/2026, 2/10/2026, 3/9/2026, and 4/12/2026. Nursing notes did not document the reported falls on 1/11/2026, 2/10/2026, and 3/9/2026. One progress note documented that after the 2/10/2026 fall, the resident had been pushing another resident in a wheelchair, tripped, and fell on the wheelchair with no injuries noted. The quarterly MDS showed a BIMS score of 7, indicating significant cognitive deficits, and noted that the resident used a wheelchair for mobility and had experienced two or more falls since admission. On 4/12/2026, the resident was outside with another resident when the resident pushed the other resident in a wheelchair, tripped, and fell onto the other resident. A witness reported seeing the resident fall in the grassy area and went inside to get help. Staff later found the resident on the ground complaining of pain, with the other resident still in the wheelchair. The resident returned from the hospital with a comminuted left humeral head fracture with surgical neck involvement and displacement of the greater tuberosity. Interviews with the LPN, DON, and NHA confirmed the resident’s prior falls, declining cognition, and that the event occurred outside on the weekend when there was no supervisory staff or reception staff manning the front desk. The NHA and DON also confirmed the resident was at risk for falls and fall injuries due to the prior falls.
Burnt Grilled Cheese Sandwiches Served to Residents
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that six residents received grilled cheese sandwiches that were consistently burnt and charred, making them inedible. Photographic evidence provided by a family member of one resident showed the sandwiches were completely blackened. Despite complaints from residents and their families, the issue persisted, particularly during evening meals. Interviews with residents indicated that the problem was widespread, with several residents reporting that they had to send back the burnt sandwiches or stopped ordering them altogether. Some residents mentioned that replacements were also burnt or took a long time to arrive. The residents expressed a desire to eat grilled cheese sandwiches if they were prepared correctly. Despite these complaints, the facility's management, including the Nursing Home Administrator and Director of Nursing, were unaware of the issue until it was brought to their attention during the survey. The kitchen staff, including the Certified Dietary Manager and Assistant Kitchen Manager, acknowledged the problem but had not effectively addressed it. They admitted to receiving some complaints but did not have documentation of any corrective training or in-service provided to the cook responsible for the burnt sandwiches. The facility's policies on food safety and resident rights were not adhered to, as the burnt food was not caught by supervisory staff or tray line staff before being served to residents.
Failure to Complete PASRR Level II for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II for residents with qualifying mental health diagnoses. This deficiency was identified for seven residents who had diagnoses such as Major Depressive Disorder, Dementia, Schizoaffective Disorder, Anxiety, and other mental health conditions. The PASRR Level I assessments for these residents did not reflect their qualifying mental health diagnoses, and as a result, the necessary Level II evaluations were not conducted. Interviews and record reviews revealed that the facility's social services department was aware of the issues with the PASRRs. The interim social worker acknowledged the deficiencies and indicated that the new social service staff member would assist in addressing the PASRR issues. However, there was a lack of follow-up and communication between the medical records department and social services to ensure that new diagnoses were updated in the PASRR assessments. The Director of Nursing (DON) and other staff members confirmed that the previous social worker had not completed the necessary documentation for Level II PASRRs. The DON stated that the expectation was for the Social Services Director to verify the accuracy of PASRRs and update them as needed. Despite these expectations, the PASRRs remained incomplete, with missing diagnoses and unsubmitted referrals to the state agency for review.
Deficiencies in Hospice Care Coordination and Behavior Management
Penalty
Summary
The facility failed to ensure proper hospice care coordination for two residents with a hospice diagnosis. Resident #12, who was on hospice care for hypertensive heart and chronic kidney disease, did not have a specific hospice care plan or documented collaboration between the facility and the hospice provider. Despite having a care plan that included working with the hospice team, there were no care notes in the electronic record to show coordination of care. Resident #5, who had a history of Alzheimer's Disease, dementia, schizophrenia, and anxiety disorder, was observed with a bloody forehead and chest due to skin picking behavior. The facility's records did not document any behaviors or changes in condition related to skin picking, despite the resident's care plan addressing these behaviors. The Director of Nursing noted that a recent gradual dose reduction of Geodon might have contributed to the resurgence of the behavior, but staff failed to identify and document this change. Resident #52, who was receiving palliative care, also lacked documentation of hospice care coordination. The facility's electronic medical records did not contain hospice progress notes or a plan of care, and staff interviews revealed a lack of understanding about the need for such documentation. The facility's policy required coordinated care plans to include the hospice plan of care, but this was not implemented, leading to a deficiency in care coordination.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents in the 400-unit, particularly during mealtime and activities. Observations revealed that residents were left without interaction or engagement, with some residents sitting idle for extended periods. For instance, Resident #17 was observed sitting in the dining room without any staff interaction or activities throughout the day. Similarly, Resident #64 was seen playing with her food without receiving any assistance or redirection from staff, highlighting the lack of adequate supervision and care. During meal services, the staffing was insufficient to provide necessary assistance to residents. On one occasion, only two staff members were present to assist 23 residents in the dining area, leading to situations where residents were not properly assisted with their meals. Resident #10, for example, was observed with her food untouched for an extended period without any staff offering assistance or cueing. Additionally, Resident #17's meal was left to become cold before a staff member could assist her, indicating a delay in care due to inadequate staffing. Interviews with staff and family members further corroborated the observations of insufficient staffing. Staff members expressed being overwhelmed and unable to provide adequate care, while family members reported having to assist with basic care needs due to the lack of staff. The Director of Nursing acknowledged the need for more attention and assistance for residents in the 400-unit, emphasizing that the current staffing levels were inadequate to meet the residents' needs. Despite having an activities program in place, the lack of staff engagement resulted in residents being left without meaningful activities or interaction throughout the day.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents and their representatives understood the contents of arbitration agreements they signed. Three residents were involved in this deficiency. Resident #342, who had intact cognition, signed the arbitration agreement during orientation but later stated she did not understand the document and was not aware of waiving her rights. Her family member, who was present during the signing, confirmed that the explanation was over the resident's head, although he understood it. Resident #22, with severe cognitive impairment, had her admission paperwork signed by a next of kin who was not her healthcare surrogate or POA. The next of kin was unaware of signing an arbitration agreement and expressed confusion about the paperwork. Resident #87, also with intact cognition, had a responsible party who did not recall signing anything related to dispute resolution and expressed a lack of understanding of the legal implications. Interviews with staff revealed that the admissions process involved presenting the arbitration agreement along with other paperwork, but there was no specific policy on arbitration agreements. Staff members acknowledged that the language in the agreements could be legal and overwhelming, and they attempted to involve family members in the process. However, the facility did not ensure that residents or their representatives fully comprehended the arbitration agreements, leading to the deficiency. The Nursing Home Administrator and Director of Nursing recognized the overwhelming nature of the admission paperwork but stated that the expectation was to ensure residents and representatives understood that signing the arbitration agreement was not a condition for admission.
Infection Control Deficiencies During Medication Pass and Dining
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, as observed in multiple instances. A Licensed Practical Nurse (LPN) was seen preparing and administering medication without performing hand hygiene before and after the process. The LPN handled body cleanser bottles from a resident and documented on the computer without sanitizing her hands. Similarly, a Registered Nurse (RN) with artificial nails was observed using her fingernail to pull a pill from a bottle and breaking a pill with her bare hands without performing hand hygiene. The RN also failed to clean a blood pressure cuff before placing it back on the medication cart. During a tour, a piece of wood with unfinished edges was found on top of the code cart, identified as a CPR backboard, which was not properly sanitized. The Director of Nursing (DON) acknowledged the porous nature of the board and its potential infection risk. Additionally, bedside tray tables with exposed particle board were observed, creating uncleanable surfaces. The DON confirmed these should have been reported for maintenance and replacement. In another instance, a Certified Nursing Assistant (CNA) was observed not sanitizing hands between delivering dinner trays. The CNA picked up a cup from the floor, used a bathroom, and cleaned a spill without performing hand hygiene before continuing tray delivery. When questioned, the CNA responded aggressively and did not acknowledge the need for hand hygiene between rooms. The facility's policies on hand hygiene and infection control were reviewed, highlighting the need for proper handwashing and sanitization practices.
Dignity and Meal Assistance Deficiencies
Penalty
Summary
The facility failed to maintain the dignity of residents in the dining areas and hallways, as observed during multiple instances. In one dining room, a resident with moderately impaired cognition was left without a meal while others at the table were served, leading her to retrieve her own tray. Staff were observed standing while assisting residents with eating, which was against the facility's policy of sitting to promote dignity. Additionally, residents were served meals at different times, causing some to eat before others at the same table. In another instance, residents were observed sitting in the hallway with bedside tables in front of them, waiting for meals without any activities present. The facility's Director of Nursing acknowledged that this practice was not encouraged and should be documented in the care plan, especially for residents with severe cognitive impairments. The residents were placed in the hallway for supervision due to fall risks, but this was not reflected in their care plans. Furthermore, staff were overheard referring to residents needing assistance with feeding as "a feed," which was not in line with the facility's dignity policy. The Director of Nursing stated that residents should be referred to as "residents who need assistance," and not by demeaning labels. The facility's policies emphasized treating residents with dignity and respect, prohibiting practices that compromise these values.
Failure to Address Grievance Regarding Resident Care
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance for a resident in the memory care unit. The resident's responsible party (RP) reported that the resident was often found with a saturated incontinent product upon their arrival, approximately four days a week. The RP had communicated these concerns to the nursing staff, specifically to a Licensed Practical Nurse (LPN), on multiple occasions. Despite these complaints, the issue persisted, and the grievance was not documented in the facility's grievance logs until a later date. The facility's grievance policy requires that any staff member receiving a complaint should document it for tracking and resolution. However, the LPN admitted to not formally documenting the RP's complaints, believing that having the Certified Nursing Assistant (CNA) change the resident immediately was sufficient. The facility's social services staff explained the grievance process, which includes logging grievances, addressing them within five days, and following up with the complainant. The Nursing Home Administrator confirmed that the expectation is for all staff to document grievances, but this procedure was not followed in this case.
Failure to Update PASRR Level 1 Screens for Residents
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) Level 1 Screen was updated when new diagnoses were added for three residents. Resident #17 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, and later had dementia, anxiety disorder, and persistent mood disorders added to her diagnoses. However, her PASRR Level 1 Screen was not updated to reflect these changes. Similarly, Resident #9's PASRR Level 1 Screen, which initially indicated a diagnosis of bipolar disorder, was not updated to include new diagnoses such as seizure disorder, depression, and obsessive-compulsive disorder. Resident #11 also had multiple diagnoses, including vascular dementia and bipolar disorder, but her PASRR Level 1 Screen was not updated with new diagnoses like non-Alzheimer's dementia and schizophrenia. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders through the PASRR process. Despite this policy, the facility did not update the PASRR Level 1 Screens for the residents in question when new diagnoses were added. During an interview, the interim social worker acknowledged the issues with the PASRRs and mentioned that the new social service staff member would assist in addressing the problem. The facility's failure to update the PASRR Level 1 Screens as required by their policy led to the deficiency identified in the report.
Deficiencies in Pain and Diabetes Management Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for pain management for a resident who had a history of a broken leg that was improperly set and required rebreaking and resetting. Despite being in pain, the resident reported that the pain medication provided was ineffective, and she declined morphine as it was too strong. The facility's records showed that the resident was on a pain regimen that included Percocet and Pregabalin, but there was no care plan developed for managing her non-acute pain or fibromyalgia. The MDS Coordinator acknowledged that the resident was assessed for pain and received medications, but the pain management was not included in the care plan. Another deficiency was identified in the care planning for a resident with diabetes who was on insulin therapy. The resident's records indicated active physician orders for diabetes management, including insulin and monitoring for hypoglycemia and hyperglycemia. However, the care plan did not reflect these orders or include specific goals and interventions related to insulin use. The MDS Coordinator confirmed the absence of a diabetes care plan related to insulin use, despite the resident having a care plan for other diabetes-related concerns. The facility's policies on pain assessment and management, as well as comprehensive person-centered care plans, emphasize the importance of developing care plans that include measurable objectives and timetables to meet residents' needs. The Director of Nursing stated that care plans should follow physician orders and be updated as residents' conditions change. However, the deficiencies in care planning for pain management and diabetes management indicate a failure to adhere to these policies, resulting in incomplete care plans for the affected residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Port Richey
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southern Pines Nursing Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Nursing & Rehabilitation Center Of New Port Richey | 0.6 mi | ★★★★★ | 3 | 0 |
| Madison Pointe Care Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Aspire At Ridge Haven | 1.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of New Port Richey | 2.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.