Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Heritage Healthcare during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including diabetes, a femur fracture, CKD, and a non-traumatic subarachnoid hemorrhage, had PRN oxycodone ordered for pain. During a narcotic count between two RNs, two oxycodone cards and corresponding narcotic log sheets were present, but at the next shift’s count one oxycodone card and its log sheet were missing. One RN reported the resident had needed pain medication overnight and then left without signing the narcotic count. The DON later confirmed the card and log sheet were missing, with only the card top found in the disposal box and the pharmacy verifying that five oxycodone tablets were unaccounted for, while the resident did not recall receiving a pain pill at the reported time.
Food items in the kitchen were found without dates received, including multiple pre-packaged and canned items. A reach-in refrigerator was observed at 60 F, and temp logs were incomplete across multiple shifts. The Dietary Mgr stated food should be labeled when placed on shelves and refrigerator temps should be logged twice daily at or below 41 F.
Pureed Foods Not Prepared Per Recipe: A dietary staff member prepared pureed hamburger patties and peas without using the recipe, adding unmeasured water to the patties and milk to the peas to reach the desired consistency. He stated he was unsure whether puree recipes existed and usually thinned foods with broth or water. The Dietary Manager said the puree recipes were in the regular recipe book and should have been followed, and the facility policy required food service associates to follow provided recipes.
Facility environment not maintained in safe, clean, and structurally sound condition. Surveyors observed missing and peeling paint, scuff marks, chipped door trim, and holes in multiple resident rooms and utility areas, affecting 8 of 33 rooms reviewed. The ED acknowledged the peeling paint, holes, and scuff marks, while a CNA said one room’s walls had been damaged for over a year and a resident said holes had just been patched.
A resident with COPD, CKD, DM, CVA, cognitive communication deficit, and a gastrostomy was transferred to the hospital and later admitted to the ICU with aspiration pneumonia. The facility did not document that the resident or the resident's representative received written notice of the reason for the transfer or the facility's bed-hold policy; the ED stated those documents were given to the EMT instead.
A resident with diagnoses including mild intellectual disabilities, dementia, depression, PTSD, anxiety, and bipolar disorder did not have a PASARR Level I completed on or before admission. The record showed an antidepressant order and that the initial PASARR screening was not completed until months later. The ED acknowledged the PASARR was not completed in the correct time frame.
A resident with atrial fibrillation, CAD, HTN, and a history of MI had orders for carvedilol and diltiazem ER with hold parameters for SBP under 100 or HR under 60. The MAR showed both meds were administered multiple times when the resident’s HR was below the ordered threshold, and an RN and the DON stated the meds should not have been given outside the physician-ordered parameters.
Missed Quarterly Smoking Safety Evaluations: A resident with COPD, AFib, anxiety, MDD, a right AKA, HTN, and vascular dementia had a care plan noting noncompliance with the smoking policy, including smoking in his room and pocketing cigarette butts. The EMR lacked quarterly smoking safety evaluations for the prior year, with the last documented assessment in 1/2023; a later evaluation found he had not shown the ability to smoke safely without supervision and had poor safety awareness. The ED stated the quarterly evaluations were not noticed as missing and should have been completed.
A resident, who was cognitively intact, was moved to a smaller room without being given the option to remain in his original room after completing rehabilitation therapy. The new room lacked adequate bathroom facilities, and the resident was not informed of his right to refuse the transfer. The Executive Director later acknowledged that the resident should have been given a choice.
The facility failed to properly store and label medications across four medication carts, leading to deficiencies. Observations revealed oral medications mixed with topical ones, cleaning supplies stored with medications, and expired or unlabeled medications. Interviews with QMAs highlighted a lack of awareness regarding proper storage practices, indicating systemic issues with medication management.
A facility failed to thoroughly investigate allegations of a CNA working while impaired, potentially affecting residents' well-being. Resident B reported concerns about the CNA's behavior, including smelling alcohol and inappropriate proximity. The investigation lacked comprehensive staff interviews, resident statements, and documentation of emotional impact. The facility's policy requires thorough evidence collection, but the investigation was incomplete and delayed.
A facility failed to submit a discharge MDS assessment for a resident, resulting in a delay of over 120 days since the last assessment. The resident had multiple medical conditions, and while the admission MDS was submitted, the discharge assessment remained pending. The MDS Coordinator admitted the oversight, and the Administrator confirmed reliance on the RAI manual without a specific facility policy.
A facility failed to resubmit a PASARR for a resident after a new mental health diagnosis and medication were added. The resident, initially evaluated with no mental health issues, was later diagnosed with mild major depressive disorder and prescribed sertraline. Despite these changes, the facility did not complete another PASARR, as required by their policy. The oversight was acknowledged by the Social Services Director.
A resident with multiple pressure ulcers was not turned every two hours as ordered, particularly during evening and night shifts. Despite a care plan and physician's order, CNA task records showed missing documentation of required repositioning. The resident expressed concerns about the lack of consistent care, and facility staff acknowledged the issue but lacked a specific policy to prevent pressure ulcers.
A resident with end-stage renal disease and other health conditions missed a dialysis session due to the facility's failure to arrange transportation, resulting in hospitalization for fluid overload and respiratory failure. The facility was responsible for transportation arrangements but failed to inform the resident until the last minute, leading to severe health complications.
A facility failed to follow proper procedures before using bed rails for a resident who used them for mobility assistance. The facility did not obtain a physician's order, conduct a side rail assessment, or secure signed consent. Additionally, no alternatives were documented, and the care plan did not include the use of side rails. The facility's policy requires these steps to prevent safety hazards, but they were not followed.
A facility failed to conduct an annual gradual dose reduction (GDR) for a resident's anti-depressant and antipsychotic medications. The resident, who was observed to be in good spirits and engaged, had not had a GDR for bupropion since 2020 due to COVID-19, and no further recommendations were made until 2024. Similarly, the last GDR for olanzapine was in 2023, with no subsequent recommendations. The facility's administrator acknowledged the oversight, noting the absence of pharmacy requests for GDRs during monthly reviews.
The facility failed to notify physicians of high blood glucose levels for two residents and did not provide a Broda chair for a hospice resident as ordered. One resident had multiple blood sugar readings over 400 without physician notification, while another had similar readings with only one notification. Additionally, a hospice resident did not receive a Broda chair due to missed approval, despite it being ordered upon hospice admission.
The facility failed to follow physician's orders for indwelling urinary catheters for two residents. One resident's catheter was not changed as needed, leading to improper management of hematuria without physician notification. Another resident's catheter was not secured, resulting in leakage and dislodgement. The facility's policy on catheter management was not adhered to, contributing to these deficiencies.
Misappropriation of Resident Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a card of oxycodone and its corresponding narcotic log sheet went missing from the medication supply. RN 2 reported that during the narcotic count at 10:00 p.m., there were two narcotic cards and log sheets for the resident’s oxycodone. When RN 2 returned for her next shift at 6:00 a.m. and completed another narcotic count with RN 3, one oxycodone card and its narcotic log sheet for the resident were no longer present. RN 3 stated that the resident had required pain medication during the night and then left the facility without signing to indicate the narcotic count was completed and accurate. The DON’s review confirmed that the medication card and documentation sheet for the resident’s oxycodone were missing, with only the top of the narcotic card found in the medication disposal box and no pills present. The pharmacy verified that a card containing five oxycodone tablets for the resident was missing. The resident, who had diagnoses including diabetes mellitus, a fracture of the lower end of the left femur, chronic kidney disease, and non-traumatic subarachnoid hemorrhage, had an order for oxycodone HCL IR 5 mg every 6 hours as needed for pain and reported not being aware of the missing medications or recalling receiving a pain pill at 2:00 a.m. on the date in question. These findings supported that the resident’s narcotic medications were not kept free from potential theft or wrongful use by an employee.
Food Storage and Temperature Monitoring Deficiencies
Penalty
Summary
Food items in the kitchen were found without the date received on their labels during the initial kitchen tour. The unlabeled items included six packages of gravy mix, three containers of cream of wheat, eight bags of brown sugar, four packages of brownie mix, one can of sauerkraut, one can of peas, one can of marinara sauce, and one can of cheddar cheese sauce. During interview, the dietary staff member stated items were dated when put away and then labeled with the date opened when used, while the Dietary Manager later stated the items should have been labeled with the date received when removed from the shipping box and placed on the shelves. The reach-in refrigerator was observed at 60 degrees Fahrenheit during the kitchen tour and remained at 60 degrees Fahrenheit during a follow-up visit later that day. The dietary staff member stated the temperature should not have been 60 degrees Fahrenheit and called maintenance. Record review showed the temperature logs for the reach-in refrigerator were missing day-shift entries on multiple dates in July and missing evening-shift entries on two dates. The Dietary Manager stated the logs should have been completed twice daily on each shift, and the refrigerator/freezer temperature log indicated the refrigerator temperature should be at or below 41 degrees Fahrenheit and that problems should be reported immediately to the Director of Food and Nutrition Services or Maintenance.
Pureed Foods Not Prepared Per Recipe
Penalty
Summary
The facility failed to ensure pureed foods were prepared according to the recipe so that nutritive value, flavor, and appearance were conserved for 5 of 5 residents reviewed for a pureed diet. During observation, a dietary staff member added 5 cooked and seasoned hamburger patties to a food processor, added an unmeasured amount of water, and mixed the food to a pudding consistency without referring to a recipe. He also reported that he was unsure whether a puree recipe existed and did not know where it was located, stating that he usually thinned foods with broth or water. During the same observation, the staff member stated he had already prepared peas by adding 5 servings to a blender and using milk to thin them to the desired consistency. The Dietary Manager later stated that the puree recipes were stored in the regular recipe book and should have been followed. The recipe for pureed beef patties directed staff to prepare the food according to the regular recipe, process it until smooth, and reheat it to at least 165F for 15 seconds. The recipe for peas directed staff to drain the peas, process them until smooth and to an applesauce consistency, and reheat them to at least 165F for 15 seconds. The facility policy stated that recipes are provided by the Director of Food and Nutrition Services and followed by food service associates.
Facility Environment Not Maintained in Safe, Clean, and Structurally Sound Condition
Penalty
Summary
The facility failed to ensure the facility and resident rooms were maintained in a safe, clean, and structurally sound condition for 8 of 33 rooms reviewed for environment, including rooms 16, 23, 18, 21, 32, 36, and 103. During an observation on 7/30/25 beginning at 12:21 p.m., surveyors noted multiple environmental issues: a large area of missing paint under the window in one room, peeled paint under a window and by a bathroom door in another room, black scuff marks and missing paint on the lower portion of a wall in another room, black scuff marks on the bottom of a door, scuff marks and chipped paint on a door trim, peeling paint on the eye washing station door trim, peeling paint on the soiled utility room door trim, chipped paint and scuff marks on another door trim, chipped paint on another door trim, and several small holes on a wall above a dresser in another room. During an environmental tour on 8/5/25 at 2:09 p.m., the Executive Director stated there was peeling paint, holes, and scuff marks on the walls. During interviews, a CNA stated the walls in one room had been messed up for over a year, and a resident stated someone had just patched some holes. The facility policy titled Plant Operations - General Policy, last reviewed on 5/15/25, stated that a safe, clean, and structurally sound environment shall be achieved in the facility through the development and implementation of the Plant Operation Program, personnel training, and evaluation of goals in the department.
Failure to Provide Written Transfer and Bed-Hold Notice
Penalty
Summary
The facility failed to ensure that Resident 3 and the resident's representative received written notification of the facility's bed-hold policy and the reason for the resident's transfer and discharge to the hospital. Resident 3's clinical record was reviewed and showed diagnoses including chronic obstructive pulmonary disorder, chronic kidney disease, diabetes mellitus, cerebral infarction, cognitive communication deficit, and gastrostomy. A nursing progress note documented that the hospital called the facility and reported Resident 3 had been admitted to the ICU with aspiration pneumonia. There was no documentation in the electronic medical record showing that the resident or the resident's representative was provided written information about the reason for the transfer to the hospital or the facility's bed-hold policy. During interview, the Executive Director stated that the bed-hold policy and the transfer and discharge summary were provided to the Emergency Medical Team rather than to the resident or the resident's representative. The facility policy stated that written transfer/discharge notice and bed-hold information are to be provided to the resident or responsible party in accordance with federal regulations.
Delayed PASARR Level I Screening Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed on or prior to admission for one resident. Resident 10 had diagnoses including mild intellectual disabilities, dementia, depression, PTSD, anxiety, and bipolar disorder, and was admitted to the facility on an unspecified date. The clinical record showed a physician's order dated 1/15/25 for duloxetine 30 mg once daily, and the initial PASARR Level I was not completed until 6/26/25. During interview, the Executive Director stated the PASARR was not completed in the correct time frame. The facility policy indicated potential admissions are to be screened for possible serious mental disorders and that the initial PASARR Level I is completed prior to admission to a nursing facility.
Failure to Follow Hold Parameters for Cardiac Medications
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident 5, who had diagnoses including atrial fibrillation, atherosclerotic heart disease, presence of a coronary angioplasty implant and graft, and occlusion and stenosis of the carotid artery. The care plan identified altered cardiovascular status related to coronary artery disease, atrial fibrillation, hypertension, and a history of myocardial infarction, and included administering medications as ordered. Physician orders directed staff to administer carvedilol 6.25 mg twice daily and diltiazem ER 180 mg twice daily, with both medications to be held if systolic blood pressure was less than 100 or heart rate was less than 60. The MAR showed that carvedilol and diltiazem were administered on multiple occasions when the resident’s heart rate was below the ordered hold parameter. Diltiazem was given with heart rates of 58, 59, 43, and 56, and carvedilol was given with heart rates of 59, 58, 43, 43, and 59. During interviews, an RN stated medications should not be given outside physician-ordered parameters and should be held with notification to the physician when parameters were not met. The DON also stated Resident 5’s carvedilol and diltiazem should not have been administered outside of the physician’s ordered parameters.
Missed Quarterly Smoking Safety Evaluations
Penalty
Summary
The facility failed to ensure smoking evaluations were completed quarterly to assess a resident’s capabilities and deficits related to smoking safety. Resident 23 had diagnoses including chronic obstructive pulmonary disorder, atrial fibrillation, anxiety disorder, major depressive disorder, right above-the-knee amputation, hypertension, and vascular dementia. The resident’s care plan, dated 4/13/23, stated he was non-compliant with the smoking policy, smoked in his room and/or pocketed his cigarette butts, and interventions included instructing him on smoking risks, the facility smoking policy, and proper disposal of cigarette butts. The electronic medical record did not contain smoking safety evaluations for 2024, and the last documented smoking evaluation was in 1/2023. A quarterly smoking safety evaluation was completed on 8/1/25 after the start of the survey and indicated Resident 23 had not demonstrated the ability to safely smoke without supervision and had exhibited poor safety awareness when smoking. During interview, the Executive Director stated the facility had not noticed the smoking safety evaluations were not completed quarterly and acknowledged they should have been completed.
Resident's Right to Refuse Room Transfer Not Upheld
Penalty
Summary
The facility failed to protect a resident's right to refuse a non-requested room transfer, resulting in a deficiency. Resident C, who was cognitively intact with a BIMS score of 13 out of 15, was moved from his original room after completing rehabilitation therapy. Despite not experiencing a change in payor source, the resident was transferred to a smaller room without being given the option to remain in his initial room, which better accommodated his needs. The new room lacked adequate bathroom facilities, forcing the resident to use a bedside commode. Interviews with the resident and staff revealed that the resident was upset about the move and was not provided a choice to stay in his original room. The Executive Director acknowledged that the resident should have been given the option to remain in his previous room or be moved to a different room within the facility. This oversight was identified during a complaint investigation, highlighting the facility's failure to ensure the resident's rights were upheld.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across four medication carts, leading to several deficiencies. During observations, it was noted that oral medications were not separated from topical medications and eye drops, and cleaning supplies were stored alongside medications. Specifically, medication cart 1 contained unlabeled medication cups and a nebulizer machine, while cart 2 had ear wax removal drops improperly stored next to oral tablets and sanitizer wipes next to oral medications. Additionally, cart 3 had oral medications stored next to eye drops without a divider, and cart 4 contained expired glucose gel. The facility's policy on medication storage and expiration was not adhered to, as evidenced by the presence of expired and improperly labeled medications. Opened medications were not dated, and over-the-counter medications lacked necessary labeling information. Interviews with Qualified Medical Assistants (QMAs) revealed a lack of awareness regarding proper storage practices, such as the need to store ointments in treatment carts and the correct expiration period for eye drops. These observations indicate a systemic issue with medication management within the facility.
Failure to Investigate Allegations of Impaired Staff
Penalty
Summary
The facility failed to thoroughly investigate allegations of a staff member, CNA 12, working while impaired, which potentially affected residents' physical or emotional well-being. The incident was initially reported through social media by Resident B, who expressed concerns about a male staff member's behavior, including smelling alcohol on his breath and inappropriate proximity. The facility's investigation did not include the allegation of inappropriate touching, and the investigation documents lacked comprehensive staff interviews and resident statements. The investigation was delayed, with the full investigation requested multiple times before being provided. Staff statements indicated that CNA 12 exhibited signs of impairment, such as slurred speech and difficulty walking, and admitted to drinking on the job. However, the investigation did not document the emotional impact on Resident B or include a psychosocial assessment. Additionally, the facility's investigation did not clarify the number of residents CNA 12 interacted with or the extent of their care. The facility's policy on abuse investigations requires thorough evidence collection and interviews with all relevant parties, but the investigation lacked completeness. The incident was not reported until it was posted on social media, and the facility did not document any follow-up with Resident B by social services. The investigation did not include a review of the psychiatric Nurse Practitioner's notes, which indicated Resident B's increased depression due to her mother's passing, nor did it provide emotional support or counseling to the resident during the investigation.
Failure to Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to submit a discharge Minimum Data Set (MDS) assessment for a resident upon discharge, resulting in a delay of more than 120 days since the last submitted assessment. The resident, who had a range of medical conditions including hypo-osmolality, hyponatremia, alcohol abuse, pneumonia, cystitis, dysphagia, and protein calorie nutrition, was admitted with an MDS assessment dated and submitted on 2/9/24. However, the discharge MDS assessment dated 5/1/24 was pending and not submitted. During interviews, the MDS Coordinator acknowledged that the discharge assessment should have been completed and submitted, and the Administrator noted that the facility used the RAI manual but did not have a specific facility policy in place.
Failure to Resubmit PASARR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to resubmit a PASARR (Preadmission Screening and Resident Review) for a resident after a new mental health diagnosis and medication were added. Resident 70, who was initially evaluated with no mental health diagnosis or medications, was later diagnosed with mild major depressive disorder on February 2, 2024, and prescribed sertraline, an antidepressant, on February 3, 2024. Despite these changes, the facility did not complete another PASARR for the resident, as confirmed by the Social Services Director during an interview. The facility's current policy on PASARR, reviewed on September 25, 2023, states that any resident with a newly evident or possible serious mental disorder must be referred for review. However, this policy was not followed in the case of Resident 70, as the additional diagnosis and medication were not addressed with a new PASARR. The oversight was acknowledged by the Social Services Director, who indicated that the resident should have undergone another PASARR, but it was missed.
Failure to Reposition Resident Every Two Hours
Penalty
Summary
The facility failed to adhere to a physician's order to turn and reposition a resident every two hours to promote healing and prevent future pressure injuries. The resident, who was paralyzed from the waist down and had limited mobility, had multiple diagnoses including stage 3 and 4 pressure ulcers. Despite a care plan initiated to address these needs, the facility did not consistently perform the required turning and repositioning, as evidenced by missing documentation in the CNA task records over several days. The resident expressed concerns during interviews, indicating that she was not turned every two hours as required, particularly during evening and night shifts. She reported having to use her call light to request assistance, which was contrary to her preference of being woken up every two hours to be turned. The resident had chronic pressure wounds and emphasized the importance of regular turning to prevent new wounds and promote healing. Interviews with facility staff, including the Social Services Director and the DON, revealed that the issue of not turning the resident every two hours was known and had been discussed in care plan meetings. The DON acknowledged the ongoing concern and had attempted to address it by re-educating CNAs. However, the facility lacked a specific policy for preventing pressure ulcers or routine turning of residents, which contributed to the deficiency.
Failure to Provide Dialysis Transportation Leads to Hospitalization
Penalty
Summary
The facility failed to ensure transportation was available for a resident requiring dialysis, leading to a hospitalization. Resident 18, who has a medical history including dependence on renal dialysis, type 2 diabetes mellitus, end-stage renal disease, congestive heart failure, and amputations, was unable to attend a scheduled dialysis session due to a transportation issue. The facility did not inform the resident of the lack of transportation until the last minute, resulting in the resident missing dialysis on a Saturday. The absence of transportation led to the resident experiencing severe health issues, including fluid overload, pulmonary edema, congestive heart failure, and acute respiratory failure with hypoxia. The resident had to call 911 due to difficulty breathing and was subsequently hospitalized. The facility's agreement with the dialysis provider indicated that the facility was responsible for arranging suitable transportation, but a miscommunication led to the failure to secure transportation on the required day.
Failure to Follow Procedures for Bed Rail Use
Penalty
Summary
The facility failed to ensure proper procedures were followed before the use of bed rails for a resident, identified as Resident D, who was reviewed for accident hazards. The resident used the side rails for mobility assistance while in bed, as observed during multiple instances. However, the facility did not obtain a physician's order for the use of the side rails, nor did they conduct a side rail assessment. Additionally, there was no signed consent for the use of the side rails, and the facility did not document any appropriate alternatives attempted prior to the installation of the side rails. The care plan for Resident D also did not include the use of the side rails. The facility's policy on the safe and effective use of bed rails, which was last revised in December 2022, requires an assessment for risk of entrapment, a review of risks and benefits with the resident or their representative, and informed consent prior to the installation of bed rails. The policy also mandates documentation of alternatives to bed rail use and how these alternatives did not meet the resident's assessed needs. Despite these requirements, the facility did not adhere to these procedures, as indicated by the Administrator's admission that they missed obtaining an order or assessment for the use of the side rails and that they obtained blanket consent from all residents, regardless of their need for side rails.
Failure to Conduct Annual Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to conduct an annual gradual dose reduction (GDR) for an anti-depressant and an antipsychotic medication for a resident, identified as Resident J, who was reviewed for unnecessary medications. Despite the resident's positive demeanor and engagement during observations, the facility did not address the need for a GDR for bupropion, an anti-depressant prescribed since 2020, and olanzapine, an antipsychotic prescribed in 2023. The last GDR for bupropion was contraindicated in March 2020 due to COVID-19 circumstances, and no further GDR recommendations were made between June 2023 and July 2024. Similarly, the last GDR for olanzapine was conducted in April 2023, with no subsequent recommendations made. The facility's administrator acknowledged the oversight, indicating that no GDR requests from the pharmacy were found during monthly reviews for bupropion, and the last GDR for olanzapine was in April 2023. The administrator admitted that the contraindication for bupropion was not revisited since the initial decision in 2020. The facility's policy on unnecessary medication, last reviewed in August 2023, emphasizes the importance of ensuring medications are necessary for treating the resident's assessed condition and supports the use of GDR to manage symptoms with the lowest effective dose or discontinuation if possible.
Failure to Notify Physician and Provide Ordered Equipment
Penalty
Summary
The facility failed to notify the physician of blood glucose levels that exceeded the parameters set by the physician for three residents. Resident L had multiple instances of blood sugar readings over 400, with values reaching as high as 531, yet there were no records of the physician being notified of these elevated levels. This oversight was confirmed by the facility's administrator, who acknowledged the absence of any call-outs to the physician regarding these high blood sugar readings. Similarly, Resident C experienced blood sugar levels in the 400 and 500 range, but the facility only notified the physician once, despite multiple readings exceeding the threshold of 400. The resident's family member expressed concern over the lack of intervention, such as adjusting insulin, to address these high readings. The clinical records corroborated that the physician was only informed of the elevated blood sugar on one occasion, despite several instances of high readings. Additionally, the facility did not follow up on a hospice order for a Broda chair for Resident 136, who was on hospice care and had a history of hemiplegia and hemiparesis. The resident was observed lying in bed on multiple occasions without the Broda chair, which was ordered upon admission to hospice. The hospice RN confirmed that the chair was expected to be provided, but due to changes in hospice leadership, the approval was missed. This lack of coordination resulted in the resident not receiving the necessary equipment to support her mobility and comfort needs.
Failure to Follow Physician's Orders for Indwelling Catheters
Penalty
Summary
The facility failed to follow physician's orders for indwelling urinary catheters for two residents, Resident C and Resident H. Resident C's family member reported that the resident's catheter needed to be changed on the day of discharge, but the staff did not comply. The clinical record showed that Resident C had obstructive uropathy and an indwelling urinary catheter, with orders to change the catheter for infection, obstruction, or when the closed system was compromised. On one occasion, Resident C experienced hematuria, and the catheter was improperly managed without notifying the physician. The Director of Nursing indicated that the facility did not notify the physician unless there was a significant amount of blood. Resident H was observed with a Foley catheter in a dignity bag, and the clinical record indicated issues with catheter leakage and dislodgement. The catheter was not secured to prevent pulling or dislodgement, and there was no documentation of a device used to secure the catheter. The facility's policy required the catheter to be anchored to prevent tension, which was not adhered to in Resident H's case. These deficiencies were related to a complaint investigation.
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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 West Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Indiana Veterans Home | 1 mi | ★★★★★ | 4 | 0 |
| Westminster Village - West Lafayette | 1 mi | ★★★★★ | 6 | 1 |
| Cumberland Pointe Health Campus | 1.1 mi | ★★★★★ | 0 | 0 |
| University Place Health Center And Assisted Living | 2.4 mi | ★★★★★ | 5 | 0 |
| Saint Anthony Rehab And Nursing Center | 2.8 mi | ★★★★★ | 5 | 0 |
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