Above 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 Heritage Hall-rich Creek during CMS and state inspections, most recent first.
The facility failed to provide sufficient staffing, leading to the dining room not being used for breakfast and inconsistently for evening meals. Residents and staff reported closures due to staffing shortages, with meals often served in residents' rooms. The facility's policy required nursing staff to assist in dining areas, but this was not observed.
A resident's MDS was inaccurately coded, marking side rails as a restraint instead of an enabler for positioning. The resident, with a history of multiple medical conditions, had side rails intended to aid in repositioning. An LPN acknowledged the error, but no further information was provided before the survey exit conference.
The facility staff failed to administer medications as ordered for two residents. One resident missed multiple medications during dialysis absences, while another did not receive the full course of an IV antibiotic. The facility's policy did not address medication scheduling for residents out for treatments, contributing to these deficiencies.
A resident with MRSA was not administered the antibiotic Doxycycline as prescribed due to its unavailability. The medication administration record indicated the doses were held, but the progress notes lacked clarification. An LPN confirmed the medication was not in the stat box, and the issue was later discussed with administrative staff. The physician was informed, and the antibiotic course was extended by one day.
A resident with severe cognitive impairment and psychiatric conditions was prescribed Geodan, an atypical antipsychotic. The facility failed to fully implement a pharmacist's recommendations for monitoring adverse metabolic effects, including timely lab tests and waist circumference measurements. The oversight was acknowledged by an LPN, and the facility's policies were reviewed, but adherence was lacking.
The facility failed to maintain a medication error rate below 5% during a medication pour and pass observation. An LPN did not apply a Lidoderm patch to a resident due to a lack of tape, resulting in a medication omission. Additionally, the same LPN could not administer ICaps MV Oral Tablet and cholecalciferol oral capsule to another resident as they were unavailable, leading to two more omissions. These errors contributed to the facility's non-compliance with the required medication error rate.
A resident with muscle wasting and a history of stroke was not provided with a two-handled cup with a lid and straw, as required by their care plan and physician's order. Despite the facility's policy to provide assistive devices based on assessments, the resident was observed without the necessary equipment during meals, and the dietary manager acknowledged the oversight.
The facility failed to maintain accurate clinical records for two residents. One resident's DDNR form was incomplete, lacking certification of decision-making capability. Another resident's physician order for a left upper extremity splint was inaccurately documented, leading to discrepancies in the splint's usage. Observations and staff interviews revealed the splint was not worn as prescribed, prompting a correction in the physician's order.
The facility's arbitration agreement failed to include explicit language about residents' right to rescind the agreement within 30 days of signing. Although the facility's policy requires informing residents of this right, the document provided to a resident lacked this information. The issue was acknowledged by the Admissions Director and discussed with facility leadership.
The facility's arbitration agreement failed to include a clause for selecting a convenient venue for both parties. This deficiency was confirmed by the Admissions Director and was not addressed in the facility's Arbitration Policy. The issue was discussed with the facility's administration and nursing leadership.
Staffing Shortages Affect Dining Room Utilization
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly in utilizing the dining room for meals. Observations and interviews revealed that the dining room was not used for breakfast and was inconsistently used for evening meals on two of the three units. Residents and staff reported that the dining room was closed on Sunday mornings and sometimes in the evenings due to staffing shortages. The Administrator acknowledged that the dining room was closed in the evenings when there was insufficient staff, although this occurred less frequently than before. Interviews with the Director of Nursing and other staff confirmed that breakfast was served in residents' rooms, and the dining room was not used for breakfast. Some residents expressed a preference for using the dining room, citing its larger size and better lighting. The facility's policy stated that nursing staff should assist in dining areas at all times, but this was not observed during the survey. The survey team did not receive additional information regarding this issue before the exit conference.
Inaccurate MDS Coding for Side Rail Use
Penalty
Summary
The facility staff failed to ensure an accurate assessment of a resident's status, specifically regarding the use of side rails. The Minimum Data Set (MDS) for a resident was inaccurately coded, indicating the side rails were used as a restraint when they were actually being used as an enabler for positioning. The resident had a history of Hemiplegia and Hemiparesis following a cerebral infarction, dementia, generalized muscle weakness, dysphagia, aphasia, and other conditions. The resident's care plan and clinical records indicated that the side rails were intended to aid in turning and repositioning, not as a restraint. The error was identified during a survey when a Licensed Practical Nurse (LPN) acknowledged that the coding was incorrect and stated that a modification should have been made. The survey team discussed the concern with the facility's administration and nursing staff, but no further information was provided before the exit conference. The inaccurate coding of the MDS was the primary deficiency noted in the report.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility staff failed to administer medications as ordered for two residents, leading to deficiencies in care. For Resident #100, the staff did not provide the prescribed medications during the resident's absence for dialysis on two occasions. The medications missed included essential drugs such as Lasix, sitagliptin, and spironolactone, among others. The facility's policy on medication administration did not address how to handle medication schedules when residents are out for treatments like dialysis. The Director of Nursing acknowledged that the medications could have been scheduled outside of dialysis times, but this was not done. For Resident #88, the facility staff failed to administer the full course of an IV antibiotic, Ciprofloxacin, as ordered by the medical provider. The resident, who had diagnoses including rhabdomyolysis, dementia, and a stage 4 pressure ulcer, was supposed to receive 112 doses of the antibiotic but only received 111. The discrepancy was noted, but no further information was provided to the survey team before the exit conference. This oversight in medication administration was discussed with the facility's administrative staff.
Failure to Administer Antibiotic Due to Unavailability
Penalty
Summary
The facility staff failed to ensure that the antibiotic Doxycycline was available for administration to a resident diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection, a history of urinary tract infection, and aphasia. The resident's clinical record included a provider order for Doxycycline Hyclate, to be administered twice daily until a specified date. However, a review of the medication administration record revealed that on a particular day, both doses were marked with a code indicating the medication was held, but the progress notes did not clarify the reason for this code. During an interview, an LPN stated that the medication was not available for administration and was not present in the stat box. The issue was discussed with administrative staff, and the Director of Nursing later provided the survey team with a copy of the facility's policy on ordering medications, which included contacting the provider pharmacy in emergencies. Another LPN confirmed that the physician was informed of the missed doses, and the antibiotic course was extended by one day to compensate for the missed administration.
Failure to Implement Pharmacist's Medication Review Recommendations
Penalty
Summary
The facility staff failed to act upon a medication regimen review for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including dementia and major depressive disorder. The pharmacist's recommendation, approved by the medical director, suggested monitoring for adverse metabolic effects due to the use of the atypical antipsychotic Geodan. This included conducting specific lab tests and monitoring BMI and waist circumference at specified intervals. However, the facility did not fully implement these recommendations. Lab work was conducted over a month after the recommendation and less than three months post-initiation of therapy, and there were no records of waist circumference measurements. Only one note regarding BMI was found, documented by the Registered Dietician. During the survey, the Unit Manager, an LPN, acknowledged the oversight, indicating a misunderstanding of the recommendation's timeline. The Director of Nursing provided several policies related to medication regimen reviews, but the surveyor found that the facility did not adhere to these policies in this case. The deficiency was discussed with the facility's administration and nursing leadership, but no additional information was provided to the survey team before the exit conference.
Medication Error Rate Exceeds 5% Due to Omissions
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5% during a medication pour and pass observation. On March 13, 2024, a surveyor observed three nurses administering medications to six residents, resulting in 26 opportunities for medication administration. During this observation, an LPN prepared morning medications for a resident who had a physician order for a Lidoderm external patch to be applied to the posterior neck for pain. However, the nurse did not have tape available to apply the patch and intended to return later. By 2 PM, the resident had left for an appointment, and a hold order was entered for the patch, resulting in a medication omission. Additionally, the same LPN prepared morning medications for another resident who had physician orders for ICaps MV Oral Tablet and cholecalciferol oral capsule. Neither medication was available in the medication cart, and the nurse planned to check the storage room later. By 2 PM, the medications were still unavailable, and a hold order was entered, resulting in two more medication omissions. These omissions contributed to the facility's failure to maintain the required medication error rate.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility staff failed to provide special eating equipment for a resident who required it, as observed during a survey. The resident, who had a history of muscle wasting, atrophy, and a cerebrovascular accident, was noted to have functional limitations in the range of motion in both upper extremities and required supervision or assistance with eating. Despite a physician's order and a care plan specifying the use of a two-handled cup with a lid and straw, the resident was observed on multiple occasions without the necessary adaptive equipment during meals. The dietary manager confirmed that the resident was supposed to receive built-up utensils and a two-handled cup, but these were not provided during the survey observations. The facility's policy on assistive devices and equipment indicated that such devices should be provided based on comprehensive assessments, yet the resident did not receive the required equipment. This deficiency was communicated to the facility's administration and nursing leadership, but no further information was provided to the survey team before the exit conference.
Incomplete DDNR and Inaccurate Documentation of Splint Use
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for two residents. For Resident #11, the Durable Do Not Resuscitate (DDNR) form was incomplete, with Sections #1 and #2 left blank. This resident had multiple diagnoses, including hemiplegia, hemiparesis following cerebral infarction, dysphagia, muscle wasting and atrophy, anxiety, and depression. The DDNR, dated 02/13/23, did not indicate whether the resident was capable or incapable of making an informed decision, nor did it provide further certification if the resident was deemed incapable. This issue was identified during a review with administrative staff, but no additional information was provided to the survey team before the exit conference. For Resident #8, the facility staff failed to accurately document a physician's order for a left upper extremity (LUE) splint. Observations revealed that the resident was not wearing the splint as prescribed, and there was a discrepancy between the physician's order and the actual practice. The order stated the splint should be worn six hours daily, six times per week, but staff interviews indicated the resident wore it for only two hours daily. The Assistant Director of Nursing (ADON) later provided a new physician order, correcting the previous entry to state the splint should be worn up to six hours daily. However, this correction was made after the surveyor's observations and interviews.
Arbitration Agreement Lacks Rescindment Clause
Penalty
Summary
The facility staff failed to ensure that the arbitration agreement provided to residents included explicit language about the right to rescind the agreement within 30 calendar days of signing. During the survey, it was found that the facility's AGREEMENT TO ARBITRATE document did not contain this necessary information. A signed arbitration agreement for one of the sampled residents was reviewed, and it was confirmed that the document lacked explicit language regarding the right to rescind. The Admissions Director acknowledged the absence of this language in the document, although they mentioned that the right to rescind is verbally discussed at the time of signing. The facility's Arbitration Policy, effective from October 2022, mandates that admissions personnel must inform residents or their representatives about the right to rescind the agreement within 30 days. However, this policy was not reflected in the actual arbitration document provided to residents. The issue was discussed with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Consultant, and Regional MDS Nurse during the survey, highlighting the discrepancy between the policy and the documentation provided to residents.
Arbitration Agreement Lacks Venue Selection Clause
Penalty
Summary
The facility staff failed to ensure that the arbitration agreement included a provision for selecting a venue that would be convenient for both parties involved. This deficiency was identified during a review of the facility's AGREEMENT TO ARBITRATE document, which was signed by one of the sampled residents. The document did not address the selection of a venue, and this omission was confirmed by the facility's Admissions Director during an interview with the surveyor. Additionally, the facility's Arbitration Policy, effective since October 24, 2022, also lacked guidance on venue selection. The issue was discussed with the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Nurse Consultant, and Regional MDS Nurse during a meeting with the survey team.
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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 Rich Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lindside Healthcare Center | 11.2 mi | ★★★★★ | 24 | 0 |
| Princeton Health Care Center | 16.2 mi | ★★★★★ | 10 | 0 |
| Summers Healthcare Center | 17.7 mi | ★★★★★ | 27 | 1 |
| Glenwood Healthcare Center | 18.3 mi | ★★★★★ | 0 | 0 |
| Main Street Care | 19.6 mi | ★★★★★ | 7 | 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.