Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Center, The during CMS and state inspections, most recent first.
The facility did not fully complete required dialysis communication records for two residents with end-stage renal disease and other chronic conditions. Documentation lapses included missing pre- and post-dialysis weights, vital signs, and access site checks, despite facility policy and contract requirements. The DON confirmed the forms were not completed as required.
A resident with End Stage Renal Disease and other chronic conditions was ordered and received hemodialysis treatments as documented in the medical record and care plan. However, the admission MDS assessment did not accurately reflect the dialysis treatments received, as confirmed by the Clinical Reimbursement Specialist during record review.
A resident with multiple chronic conditions and a permacath for dialysis did not have a comprehensive care plan addressing the vascular access site or Enhanced Barrier Precautions, as required by facility policy. The omission was confirmed by the DON after review of the resident's records and observation.
Surveyors observed that expired Heparin lock flush syringes were present and accessible in a medication storage room. Both the SDC and DON confirmed that these expired IV medications should have been discarded according to facility policy, but were instead available for use.
A resident with cognitive impairment and swallowing difficulties, who had a physician order and care plan for a divided plate at meals, was observed being served food on a regular plate during multiple meals. Staff and leadership confirmed the need for the assistive device and acknowledged it was not provided as required.
A resident with multiple chronic conditions and moderate cognitive impairment was found to have three expired, unopened nutritional shakes in their personal refrigerator. Facility policy required weekly checks and removal of expired food items, but staff interviews revealed confusion about responsibility for this task, and the DON confirmed the expired items should have been discarded.
A resident with end stage renal disease and a permacath for dialysis had their access site assessments inaccurately documented by LPNs, who recorded assessments for a shunt site instead of the actual permacath. Although staff assessed the correct site, the MAR did not accurately reflect the care provided, as confirmed by the DON.
Staff failed to provide hand hygiene assistance before meals to three residents who required help, did not use required PPE (gown and gloves) during feeding tube care for a resident on Enhanced Barrier Precautions, and improperly stored an ice scoop during meal service, leaving ice exposed to potential contamination.
The facility failed to maintain sanitary kitchen equipment, affecting 118 of 120 residents. Observations revealed dried food debris on oven doors and handles, and the convection oven's control panel. The CDM confirmed the unsanitary conditions, which violated the facility's cleaning policy.
The facility failed to provide a homelike environment during dining, as observed in two dining rooms where residents were served meals on brown plastic trays. Interviews with staff confirmed this practice, which contradicted the facility's policy on creating a homelike atmosphere. The Certified Dietary Manager and Administrator were unaware of the importance of this aspect of meal service.
The facility failed to revise the care plan for a resident receiving enteral feeding, resulting in a discrepancy between the physician's order and the care provided. The resident's care plan was not updated to reflect changes in the feeding rate and water flush volume, as confirmed by the DON and observed during a survey.
The facility failed to provide adequate personal hygiene care for a resident with moderate cognitive impairment, who was observed multiple times with dirty fingernails and facial hair. Despite staff performing regular checks, the resident's hygiene needs were not met, as confirmed by interviews with staff and the resident's daughter.
The facility failed to follow a physician's order to keep a resident's legs elevated to treat edema. Despite the order, the resident was observed multiple times with her legs not elevated, and staff confirmed the lack of compliance.
The facility failed to follow a physician's order for enteral feeding for a resident with a history of severe malnutrition and other health issues. The resident was supposed to receive a water flush of 150 ml every 4 hours but was only receiving 60 ml. This discrepancy was confirmed by nursing staff and the DON, although the resident did not experience any harm.
The facility failed to ensure necessary emergency equipment was available at the bedside for a resident with a tracheostomy. Despite the resident's care plan and physician's orders indicating the need for tracheostomy care and suctioning, the required suction tubing, canister, and ambu bag were not present in the room. This deficiency was confirmed by an LPN and the DON.
The facility failed to properly store medications in one of six medication carts. An LPN was found with mislabeled insulin pens for two residents and a Heparin Lock Syringe stored improperly in an open toothette box. The DON confirmed that the insulin pens should be discarded and new ones ordered, and that the Heparin Lock Syringe should not have been stored with oral care items.
The facility failed to notify the physician in a timely manner regarding abnormal lab results for a resident with multiple diagnoses. A urine specimen collected and sent for analysis showed a urinary tract infection, but the results were not reviewed or communicated to the primary care provider until three days later. The Medical Director and Director of Nursing confirmed the delay.
Incomplete Dialysis Communication Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that dialysis communication records were fully completed for two residents who required dialysis services. According to the facility's contract and policy, staff are responsible for maintaining complete records and ensuring ongoing communication and coordination with dialysis providers. For both residents, who had significant medical histories including end-stage renal disease, diabetes, and other chronic conditions, the PRE/POST DIALYSIS COMMUNICATION forms were found to be incomplete on multiple occasions. Missing documentation included vital information such as pre- and post-dialysis weights, vital signs, changes at the dialysis access site, and staff signatures. Medical record reviews showed that these documentation lapses occurred repeatedly over the course of a month for both residents, despite facility policies requiring thorough completion of these forms. During an interview, the DON confirmed that the forms were not completed in their entirety as required. The incomplete records were directly observed in the residents' files, and the deficiency was acknowledged by facility leadership.
Failure to Accurately Complete MDS Assessment for Dialysis Treatment
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident who was admitted with multiple diagnoses, including End Stage Renal Disease (ESRD), Chronic Obstructive Pulmonary Disease, Diabetes, Vascular Dementia, and mobility issues. Medical records and the Medication Administration Record (MAR) indicated that the resident was ordered and received hemodialysis treatments on specific days following admission. The resident's comprehensive care plan also documented dialysis related to ESRD. However, the admission MDS assessment did not reflect that the resident received dialysis treatments while at the facility. This discrepancy was confirmed by the Clinical Reimbursement Specialist during a review of the medical record and the MDS assessment.
Failure to Develop Comprehensive Care Plan for Resident with Permacath and EBP Needs
Penalty
Summary
The facility failed to develop a person-centered, comprehensive care plan for one resident who was admitted with multiple complex medical conditions, including Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, Congestive Heart Failure, End Stage Renal Disease, and Muscle Weakness. The resident had a permacath inserted in the right chest for dialysis treatment, which was documented in the nursing admission assessment. Facility policy required the development and implementation of a comprehensive care plan for each resident, including measurable objectives to address all identified medical and nursing needs. Despite these requirements, review of the resident's comprehensive care plan revealed that it did not address the presence of the permacath or the need for Enhanced Barrier Precautions (EBP), both of which were indicated by facility policy for residents with indwelling medical devices. The resident was observed with a clean and dry permacath site, and received dialysis three times per week. The DON confirmed that the care plan should have included the vascular access and EBP, and acknowledged that the facility failed to do so for this resident.
Expired IV Medications Found in Medication Storage Room
Penalty
Summary
The facility failed to ensure that expired intravenous (IV) medications were discarded and not available for resident use, as required by facility policy and professional standards. During an observation in one of the medication storage rooms, surveyors found thirty-one syringes of Heparin lock flush with expiration dates that had already passed. Both the Staff Development Coordinator and the Director of Nursing confirmed that these expired IV medications were present and accessible for use, and acknowledged that such medications should have been discarded according to the expiration date listed on the syringes. The facility's policy specifies that licensed nurses are responsible for checking expiration dates, but this process was not followed, resulting in expired medications being available in the medication storage area.
Failure to Provide Ordered Assistive Eating Device
Penalty
Summary
The facility failed to provide a required assistive meal device, specifically a divided plate, for a resident with significant medical needs. The resident had a history of metabolic encephalopathy, malnutrition, dysphagia, and cognitive communication deficit, and was assessed as cognitively impaired. Medical records, care plans, and a communication order all indicated that the resident required a divided plate at every meal to support independent eating. The resident's meal information card also specified the need for a divided plate. Despite these documented requirements, observations on two separate occasions showed that the resident was served meals on a regular plate rather than the prescribed divided plate. Staff interviews confirmed that the resident needed the divided plate to promote independence with meals, and facility leadership acknowledged that the assistive device was not provided as ordered during the observed meals.
Failure to Remove Expired Food from Resident Refrigerator
Penalty
Summary
Facility staff failed to follow the established policy regarding the weekly inspection and removal of expired food items from residents' personal refrigerators. According to the facility's policy, staff are required to check individual food items in residents' refrigerators weekly and promptly discard any expired items. During an observation, three unopened nutritional shakes with an expiration date of 9/26/2022 were found in a resident's personal refrigerator, indicating that the required weekly checks were not performed as outlined in the policy. The resident involved had multiple diagnoses, including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Right Heart Failure, Alzheimer's Disease, and Dementia, and was assessed as having moderate cognitive impairment. Interviews with staff revealed uncertainty about who was responsible for checking the refrigerators, with the LPN unsure of the process and the DON stating that housekeeping was primarily responsible for weekly checks. The DON confirmed that the expired nutritional shakes should have been discarded according to facility policy.
Inaccurate Documentation of Dialysis Access Site Assessments
Penalty
Summary
The facility failed to ensure that the medical record for a resident receiving dialysis was complete and accurate, specifically regarding documentation of dialysis access site assessments. The resident was admitted with diagnoses including dependence on renal dialysis and end stage renal disease, and had a permacath in the right upper chest for dialysis access. Facility policy required accurate recordkeeping, and physician orders directed staff to assess the dialysis access site for thrill, bruit, and bleeding every shift. However, review of the Medication Administration Record (MAR) showed that LPNs documented assessments of a 'shunt site' for thrill and bruit, even though the resident did not have a shunt but rather a permacath. Interviews with the LPNs revealed that they were aware the resident's dialysis access was a permacath and that they assessed the site for signs of bleeding and infection, but they failed to accurately document these assessments in the MAR, instead recording assessments for a shunt site. The Director of Nursing confirmed that the documentation did not accurately reflect the assessments performed on the resident's actual dialysis access site during the specified period.
Deficiencies in Hand Hygiene, PPE Use, and Sanitary Practices During Meal Service
Penalty
Summary
The facility failed to provide hand hygiene assistance prior to meals for three residents on one of four units observed during meal tray distribution. Specifically, staff delivered meal trays to residents who required assistance or supervision with activities of daily living, including eating and personal hygiene, without offering hand sanitizer or assisting them to wash their hands. Staff interviews confirmed that hand hygiene should have been offered, but was not provided to these residents before meals. Additionally, the facility did not ensure proper use of Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP) due to a feeding tube. During a high-contact care activity involving the management of a feeding tube, a registered nurse wore gloves but did not don a gown as required by facility policy and posted signage. There was also a lack of appropriate signage indicating the need for EBP at the time of the observation, and staff were not initially aware of the correct PPE requirements for this resident. The facility also failed to maintain sanitary conditions during meal service related to the handling and storage of the ice scoop used for resident drinks. A certified nursing assistant placed the ice scoop directly into the ice storage container instead of the designated holder, preventing the container lid from closing and exposing the ice to potential contamination. Staff interviews confirmed the improper storage of the ice scoop and acknowledged the failure to follow facility procedures for maintaining a sanitary environment.
Failure to Maintain Sanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain sanitary kitchen equipment, which had the potential to affect 118 of 120 residents. During an initial kitchen observation, the Certified Dietary Manager (CDM) noted a thin layer of dried brown/black food debris on top of both oven doors and on the handle of the left oven door. Additionally, the convection oven had multiple spatters of dried brown food debris on the front control panel. The CDM confirmed the unsanitary condition of the equipment during an interview. The facility's policy, revised on 12/17/2021, mandates that the Director of Food and Nutrition Services develop a cleaning schedule to ensure cleanliness and sanitation at all times, which was not adhered to in this instance.
Failure to Provide a Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment during dining in two of the four dining rooms observed. During an observation, it was noted that Certified Nursing Assistants (CNAs) and the Activities Director (AD) delivered meal trays to residents, leaving the dishes of food, beverages, and silverware on brown plastic trays on the tables. Interviews with CNA #2, CNA #3, and the AD confirmed that it was typical for meals to be left on the trays, as it was believed to make it easier for the residents. This practice was observed in both the main dining room and the 100 hall day room, where residents ate their meals directly from the trays and consumed milk directly from the cartons. The facility's policy on Resident Dining Services, revised on 4/26/23, indicated that food should be served in a safe, clean, and homelike environment, which was not adhered to in these instances. Further interviews with the Certified Dietary Manager (CDM) and the Administrator revealed a lack of awareness and discussion regarding the importance of a homelike atmosphere during meal service. The CDM stated that meals had always been served on trays and did not recall any discussions about creating a homelike environment. The Administrator also indicated that he would need to review the facility's policy on dining and meal service before commenting on the practice of leaving food on trays. These findings highlight a systemic issue in the facility's approach to dining services, failing to align with their policy and the residents' right to a homelike environment.
Failure to Revise Enteral Feeding Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident who was receiving enteral feeding. The resident, who had a history of malignant neoplasm of the larynx, chronic obstructive pulmonary disease, and dysphagia, was admitted with a care plan that included specific instructions for enteral feeding. However, the care plan was not updated to reflect a physician's order change, which specified a different rate and volume for the feeding and water flushes. This discrepancy was observed during a survey, where the resident was receiving Jevity 1.5 at 60 ml/hour with a water flush of 60 ml every 4 hours, contrary to the physician's order of 60 ml/hour with a 150 ml water flush every 4 hours. Interviews with the LPN and the DON confirmed that the care plan had not been revised to match the updated physician's order. The LPN described the procedure she followed when administering tube feeding, which included checking the resident's order and the PEG site, but the care plan still reflected outdated instructions. The DON acknowledged that it was her expectation for staff to follow the physician's orders and confirmed that the care plan should have been revised to reflect the changes in the enteral feeding instructions.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for Resident #62, who had moderate cognitive impairment and required limited assistance for dressing, toileting, and personal hygiene. Despite the facility's policy mandating care and services for bathing, dressing, grooming, and oral care, Resident #62 was observed multiple times with dirty fingernails and facial hair on her chin. The resident's fingernails had a brown substance caked under them, and facial hair was present on her chin during observations on 2/26/2024 and 2/27/2024. Interviews with staff and the resident's daughter confirmed the lack of proper hygiene care. CNA #1 stated that she performed incontinence and general cleanliness checks every two hours, yet the resident's fingernails remained dirty. The Director of Nursing (DON) acknowledged that staff were expected to keep residents' fingernails clean and remove facial hair from female residents. Despite these expectations, the facility failed to meet the hygiene needs of Resident #62, as evidenced by the repeated observations of dirty fingernails and facial hair.
Failure to Follow Physician's Order for Edema Treatment
Penalty
Summary
The facility failed to follow a physician's order for the treatment of edema for one resident. Resident #21, who has severe cognitive impairment and uses a wheelchair for ambulation, was observed multiple times with her legs not elevated as per the physician's order dated 4/9/2023. The order specified that the resident's legs should be kept elevated when out of bed every shift. However, during observations on 2/27/2024 and 2/28/2024, the resident was seen with her legs hanging down and feet on the floor, both in her room and in the day room. Licensed Practical Nurse (LPN) #6 and the Director of Nursing (DON) confirmed that the resident's legs were not elevated and that there was no equipment on the specialized wheelchair to facilitate leg elevation. The DON acknowledged that the staff was not following the physician's orders, as it was her expectation for the staff to adhere to the prescribed treatment plan. This failure to follow the physician's order was identified during the review of the facility policy, medical records, and through direct observation and interviews with the staff.
Failure to Follow Physician's Order for Enteral Feeding
Penalty
Summary
The facility failed to follow a physician's order for enteral feeding for Resident #79. The resident, who had a history of malignant neoplasm of the larynx, chronic obstructive pulmonary disease, and dysphagia, was admitted with a care plan indicating a risk for weight fluctuation and severe malnutrition. The physician's order specified that the resident should receive Jevity 1.5 at 60 ml/hour for 22 hours with a water flush of 150 ml every 4 hours. However, observations on multiple occasions revealed that the resident was receiving a water flush of only 60 ml every 4 hours, contrary to the physician's order. This discrepancy was confirmed by RN #1 and the Director of Nursing (DON), who acknowledged that the nursing staff had not adhered to the prescribed orders for tube feeding. During an interview, the Medical Doctor confirmed that the resident had not experienced any harm, dehydration, or associated symptoms due to the incorrect water flush rate. The resident remained at baseline with no hypotensive episodes. Despite this, the failure to follow the physician's order for enteral feeding represents a deficiency in the facility's adherence to proper medication administration protocols, as outlined in their policy dated 8/24/2023.
Failure to Provide Necessary Emergency Equipment for Tracheostomy Care
Penalty
Summary
The facility failed to ensure necessary emergency equipment was immediately available at the bedside for a resident with a tracheostomy. The facility's policy required that each resident with a tracheostomy have emergency supplies, including a manual resuscitator and mask (ambu bag) and suction equipment, at the bedside. However, during an observation, it was noted that Resident #79, who had a tracheostomy, did not have the complete suction tubing, canister, or ambu bag in the room. This was confirmed by an LPN and the Director of Nursing (DON), who acknowledged that the required emergency supplies were not available at the bedside. Resident #79 was admitted with diagnoses including a personal history of malignant neoplasm of the larynx, chronic obstructive pulmonary disease, and dysphagia. The resident's care plan and physician's orders indicated the need for tracheostomy care and suctioning as necessary. Despite these requirements, the necessary emergency equipment was not present in the resident's room during the surveyor's observation, leading to a deficiency in providing safe and appropriate respiratory care for the resident.
Improper Medication Storage
Penalty
Summary
The facility failed to properly store medications in one of six medication carts. During an observation, an LPN was found to have an insulin pen for Resident #39 in a plastic bag with a prescription label, but the pen itself also had a label for Resident #105. Additionally, Resident #105's insulin pen did not have a label on it. The LPN acknowledged the issue and stated she would report it to her supervisor. Further inspection of the cart revealed a Heparin Lock Syringe stored improperly in an open toothette box, which the LPN also acknowledged as incorrect storage. In a telephone interview, another LPN confirmed that she administered insulin to both residents and checked the insulin pen against the Medication Administration Record (MAR) and the label to ensure they matched. The Director of Nursing (DON) stated that the insulin pens should be discarded and new ones ordered, and confirmed that the Heparin Lock Syringe should not have been stored with oral care items. The facility's policy mandates that external use medications and biologicals be stored separately from internal use medications and biologicals, which was not followed in this instance.
Delayed Notification of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding abnormal laboratory results for one resident. Resident #39, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease, Vascular Dementia, Type 2 Diabetes Mellitus, Hypertension, Hemiplegia and Hemiparesis, Repeated Falls, and Adult Failure to Thrive, was admitted to the facility. A urine specimen was collected on 2/18/2024 and sent for urinalysis, culture, and sensitivity. The results, received on 2/23/2024, indicated a urinary tract infection, but there was no documentation that a provider had reviewed the report on the same day it was received. On 2/26/2024, an LPN discovered that the report had not been sent to the primary care provider and subsequently notified the Nurse Practitioner, who then ordered an antibiotic. The Medical Director confirmed that there was no negative outcome for the resident due to the delay, but expressed that he would have expected to be notified of the results on the day they were received. The Director of Nursing confirmed that the notification of the abnormal lab result to the physician or nurse practitioner was delayed by three days.
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Illustrative
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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 Morristown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Morristown | 1.7 mi | ★★★★★ | 2 | 0 |
| Jefferson Park At White Pine | 11.1 mi | — | 1 | 0 |
| Ridgeview Terrace Of Life Care | 12.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Jefferson City | 13.1 mi | ★★★★★ | 0 | 0 |
| Jefferson City Health And Rehab Center | 13.4 mi | ★★★★★ | 0 | 0 |
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