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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Center during CMS and state inspections, most recent first.
A resident with an indwelling catheter had a Foley placed with the wrong balloon size because the ordered catheter was not available, and CT results later showed the balloon was improperly inflated. In separate findings, an LPN gave a resident Breyna inhaler without offering mouth rinsing as ordered, and hydralazine administration for another resident was documented without required BP readings or clear reasons for doses given or held. The DON stated she was unaware of the catheter issue and could not find documentation supporting the hydralazine administration decisions.
Infection control practices were not followed for a resident with a Foley catheter and a resident receiving wound care. A resident’s catheter tubing was observed dragging on and touching the floor while the resident was in a wheelchair and moving inside the facility. During wound treatment for another resident with quadriplegia, trach, and wounds, an RN used the same gloves between soiled wound care and clean tasks, including touching an iPad and cell phone without changing gloves.
The facility failed to ensure accurate MDS Assessments for two residents. One resident with dementia had a Secure Care bracelet for elopement prevention, which was not documented in the MDS Assessment. Another resident with a history of falls was documented as using a bed alarm but not a chair alarm, despite physician orders and observations confirming the use of both alarms. These discrepancies were acknowledged as coding errors by the MDS Coordinators.
A resident with multiple health conditions developed an unstageable pressure ulcer due to the facility's failure to consistently perform daily skin checks and follow wound care orders. The wound became infected, requiring antibiotic treatment, and the DON could not explain how the wound occurred.
The facility failed to ensure consistent implementation of fall prevention measures for two residents, resulting in multiple falls and inadequate supervision. Observations revealed non-functioning alarms and unupdated care plans, despite policies requiring regular assessments and revisions.
The facility failed to ensure proper care of a resident's PEG/G-tube feeding tubing, as observations revealed the feeding container lacked necessary labels and documentation. The resident's care plan and physician orders required specific documentation and timely changes of feeding supplies, which were not followed.
The facility failed to ensure proper labeling and administration of oxygen equipment for three residents, leading to potential respiratory complications. Observations revealed undated storage bags and unchanged tubing for two residents, while another resident experienced multiple instances of low oxygen saturation without proper notification to the physician. Staff also failed to turn on a portable oxygen tank during a transfer, temporarily dropping the resident's oxygen saturation.
The facility failed to post the actual shift times worked by licensed and unlicensed nursing staff directly responsible for resident care for nine consecutive days. The staff posting sheets included the date, census, and total hours each discipline was in the building but did not specify the actual shifts worked, contrary to the facility's Posted Nurse Staffing policy.
Failure to Follow Physician Orders for Catheter Placement and Medication Administration
Penalty
Summary
The facility failed to ensure services met professional standards of quality when a urinary catheter was not placed as ordered for Resident M. Resident M had diagnoses including obstructive and reflux uropathy and hydronephrosis, and the quarterly MDS indicated the resident was cognitively intact and had an indwelling catheter. Physician orders required a 16 fr Foley catheter with a 10 cc balloon and catheter changes every 21 days and as needed for occlusion. The record showed that on 6/3/26, Resident M was sent to the hospital for altered mental status, and a nursing progress note documented that a 16 fr 30 cc balloon Foley catheter was placed because a 16 fr 10 cc balloon catheter was not available. Hospital CT results from the same day indicated the Foley catheter balloon was insufficiently inflated within either the prostatic or distal membranous urethra and should be removed or repositioned. During interview, the DON stated she was not aware of the CT results showing the catheter balloon was improperly inflated and said she had not been notified that staff used a different sized catheter balloon. The DON stated physician orders should always be followed and she should have been notified if there was a problem. The facility’s Foley Catheter Orders policy stated orders must include the size of the Foley, amount of fluid to inflate, and diagnosis, and the Charting and Documentation policy required care-specific details and notification of family, physician, or other staff if indicated. The facility also failed to administer medications as ordered for Resident F and Resident L. Resident F was observed receiving two puffs of Breyna inhaler, but the LPN did not offer the resident the opportunity to rinse her mouth afterward, despite the physician order to rinse mouth after use. Resident L had an order for hydralazine 25 mg three times daily for hypertension, held if systolic blood pressure was below 110, but the MAR showed administrations and omissions without corresponding blood pressure documentation for several entries, including one dose given when the blood pressure was marked N/A and other entries where the blood pressure was blank or marked X. The DON stated she could not find a reason for the administration or lack of administration in the record, and the QMA stated that when a medication was not given, the reason code would be entered into the MAR.
Infection Control Practices Not Followed for Foley Catheter and Wound Care
Penalty
Summary
Infection prevention and control practices were not followed for a resident with an indwelling Foley catheter. Resident N, who had diagnoses including postpolio syndrome, benign prostatic hyperplasia, and paraplegia, was observed sitting in a wheelchair outside in the courtyard with the Foley catheter bag and tubing hanging under the wheelchair. The tubing was seen touching the ground, and later dragged the ground into the building and continued to touch the floor once inside the facility. The resident’s record showed he was cognitively intact, dependent on staff for transfers, had an indwelling catheter, and did not have a UTI. The Infection Preventionist stated the catheter tubing should not rest on or drag the floor and should be elevated off the floor or other surfaces. Infection control practices were also not followed during wound care for Resident R, who had diagnoses including quadriplegia and tracheostomy and had wounds, a tracheostomy, and gastrostomy tubes documented on the MDS. During treatment of the resident’s left and right foot/heel wounds, the Wound Nurse used gloves while touching soiled wound areas and then touched the iPad and cell phone without changing gloves. The nurse also used the iPad to take wound pictures and later previewed pictures on the iPad without cleaning it. The Infection Prevention Nurse stated staff should not use the same gloves to touch a wound or wound dressing and then touch a phone, tablet, or computer, and that gloves should be changed between soiled and clean tasks.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the MDS (Minimum Data Set) Assessment was completed accurately for two residents. Resident 117, who had a diagnosis of dementia, was noted to have a Secure Care bracelet for elopement prevention. However, the Quarterly MDS Assessment dated 12/29/23 did not indicate the use of a wander/elopement alarm, despite physician orders and treatment records confirming its use. This discrepancy was acknowledged by the MDS Coordinator as a coding error. Resident 117 was observed with the Secure Care bracelet in place, further confirming the inaccuracy in the MDS Assessment. Similarly, Resident 115, who had a history of falls and severe cognitive impairment, was documented in the Quarterly MDS Assessment dated 2/22/24 as using a bed alarm but not a chair alarm. However, physician orders and the February 2024 MAR indicated the use of both bed and chair alarms, and the resident was observed with a chair alarm in place. The MDS Coordinator confirmed that the chair alarm was incorrectly coded in the MDS Assessment. These inaccuracies in the MDS Assessments highlight the facility's failure to ensure accurate resident assessments, as required by the RAI User Manual.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to ensure preventative measures were in place or orders were followed to prevent an ulcer from forming and progressing for a resident with type 2 diabetes mellitus, Alzheimer's disease, and restless leg syndrome. The resident required extensive assistance for mobility, transfers, and toileting, and had orders for daily skin checks and specific wound care. However, documentation showed that daily skin checks were not consistently completed on several dates in February and March. Additionally, there was a lack of follow-up or assessment of the resident's reported pain in the left leg and ankle, which later developed into an unstageable pressure ulcer with significant slough, eschar, and drainage. The wound was found to be infected, requiring antibiotic treatment. The Director of Nursing (DON) was unable to explain how the wound on the resident's left Achilles occurred and acknowledged that the wound might have been left untreated and unchecked for 24 hours. The facility's policy on pressure injury prevention and management, which mandates daily assessment of all dressings and pressure injuries, was not adhered to. The facility did not provide a requested skin assessment or altered skin integrity policy, further indicating a lapse in following established protocols to prevent and manage pressure ulcers.
Inconsistent Implementation of Fall Prevention Measures
Penalty
Summary
The facility failed to ensure residents received consistent implementation of interventions to prevent falls for two residents. For Resident 115, the clinical record indicated multiple falls, with interventions such as bed and chair alarms, bed in the lowest position, and reminders to use the call light. However, these interventions were inconsistently applied, and care plans were not updated following each fall. Observations revealed that the chair alarm was not functioning, and staff confirmed that the cords were loose and had not been replaced despite requests. Additionally, the resident's family had raised concerns about the alarms not being plugged in during visits. Resident 86 also experienced multiple falls, with interventions such as bed/chair alarms, floor mats, and video monitoring. However, the video monitor was found facing the window and not in view of the resident, and the bed alarm was removed due to the resident's weight. The bed was not in the lowest position during an observation, and the RN had to lower it. The clinical record lacked documentation of new interventions following several falls, and the DON indicated that care plans were not updated due to the survey being in progress. The facility's policies required assessments and revisions of care plans to maintain a current profile of the resident, with weekly high-risk meetings to discuss potential significant changes. However, the facility failed to adhere to these policies, resulting in inconsistent implementation of fall prevention measures and inadequate supervision to prevent accidents.
Failure to Ensure Proper Care of PEG/G-Tube Feeding Tubing
Penalty
Summary
The facility failed to ensure the appropriate care of the PEG/G-tube feeding tubing for one resident. Observations on two consecutive days revealed that the resident's tube feeding container lacked a label indicating the formula, the date when the tubing was changed, and the initials of the nursing staff. The resident's clinical record indicated severe cognitive impairment and total dependence on care, with specific physician orders and care plan interventions requiring documentation of the date, rate, time, and initials on the feeding bag and tubing, and changing feeding supplies every 24 hours. Interviews with the Assistant Director of Nursing confirmed that tube feeding and tubing should be changed every 24 hours and that the bag should be labeled with the date, type, and flow rate. The Administrator provided the manufacturer's label and the facility's current policy, both indicating that the formula should not hang longer than 24 hours. Despite these guidelines, the facility did not comply with the required procedures, leading to the identified deficiency.
Failure to Ensure Proper Oxygen Administration and Equipment Labeling
Penalty
Summary
The facility failed to ensure proper labeling and administration of oxygen equipment for three residents, leading to potential respiratory complications. For Resident 10, an oxygen humidification water bottle dated 3/5/24 was observed without an oxygen storage bag on two separate occasions. The resident's clinical record indicated severe cognitive impairment and a need for extensive assistance, with physician orders to change oxygen tubing and supplies every Tuesday. However, the facility did not adhere to these orders, as evidenced by the undated storage bag and unchanged tubing. Resident 55's oxygen tubing was observed in an undated storage bag, contrary to the facility's policy of dating the storage bags. The resident's clinical record showed cognitive impairment and a need for extensive assistance, with physician orders to change oxygen tubing and supplies every Tuesday. Despite this, the facility failed to ensure the tubing was properly dated, and staff indicated that the oxygen people come every Tuesday to clean and maintain the concentrators, but did not date the tubing. Resident 11 experienced multiple instances of low oxygen saturation without proper notification to the physician. The resident's clinical record indicated chronic respiratory conditions and a dependence on supplemental oxygen. Despite active physician orders for continuous oxygen therapy and elevated head of bed, staff failed to maintain proper oxygen levels and did not notify the physician of the resident's altered condition. During an observation, staff transferred the resident without turning on the portable oxygen tank, leading to a temporary drop in oxygen saturation. The facility's policies on respiratory change and oxygen administration were not followed, contributing to the deficiencies observed.
Failure to Post Actual Shift Times of Nursing Staff
Penalty
Summary
The facility failed to post the actual shift times worked by licensed and unlicensed nursing staff directly responsible for resident care per shift daily for nine consecutive days. During an observation, the staff numbers posted at the Harbor nurses station did not include the actual shift times worked by nursing staff, only indicating partial shifts. The Administrator provided staff posting sheets for the reviewed dates, which included the date, census, and total hours each discipline was in the building but did not specify the actual shifts worked. The Administrator confirmed that the facility's nursing staffing sheet did not allow for determining which portion of a shift nursing staff worked. The facility's Posted Nurse Staffing policy, dated December 2023, required the posting of hours worked by nursing staff per shift, which was not adhered to.
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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.
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Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Park Nursing Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Parkview Care Center | 1.3 mi | ★★★★★ | 24 | 0 |
| Bethel Manor | 1.4 mi | ★★★★★ | 1 | 0 |
| Envive Of River City | 2 mi | ★★★★★ | 25 | 0 |
| Brickyard Healthcare - Woodbridge Care Center | 2 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 October 2026) and official state health department websites.