Heritage Health Care Center

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Construction Deficiencies

Install a two-hour-resistant firewall separation.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Based on a review of the facility's Emergency Preparedness Plan, record review, and staff interview, the facility failed to participate in required emergency drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to all 61 residents, plus staff, during an emergency.

Based on record review and staff interview, the facility failed to ensure that their Emergency Preparedness plan incorporated documentation to include the emergency and standby power systems. Failure to implement the emergency and standby power systems plan during an emergency could lead to harm.

Based on observations during the tour conducted on March 18, 2026, the facility failed to ensure that a restraint chain was properly installed on the kitchen oven to protect the gas connection. Failure to protect connections on appliances that are on casters or wheels can result in a rupture of gas or electric connections, resulting in a risk to all residents and staff in the event of fire.  Â

Based on observation and staff interviews, the facility failed to ensure that the electrical breaker for the fire alarm system had visual markings to distinguish it from other breakers. Failure to properly identify/mark the fire alarm system could lead to harm to all 61residents and staff in an emergency.Â

Based on observation and interview, the facility failed to provide corridor doors in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.6, 19.3.6.3, and 19.3.6.3.10. This deficient practice could affect approximately 12 of the 61 residents.Â

Based on observation, the facility failed to properly fill penetrations of the fire/smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the fire/ smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients and staff in the affected area at the time of a fire.

Based on observation, the facility failed to provide a protective guard on light bulbs located throughout the facility. Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on a record review and interviews, the facility failed to provide the required documentation for its fire drills per NFPA 101. Failing to properly document the fire drills in accordance with the life safety code, sign-in sheets identifying all individuals that participated in the drills may result in untrained staff, which could lead to harm of all residents in the event of a fire.Â

 Based on record review and staff interviews, the facility failed to provide documentation of the emergency generator's required maintenance. Failure to properly maintain and document routine emergency generator maintenance could lead to harm of residents and staff in the event of an emergency.

Based on the interview, review of the clinical record, and review of facility policy and procedure, the administrator failed to ensure that policies and procedures for physical health services and behavioral health services are established, documented, and implemented to protect the health and safety of a resident that cover resident screening, admission, transport, transfer, discharge planning, and discharge for 2 of 5 sampled residents (Residents #36, #2) related to PASARR (Preadmission Screening and Resident Review) screening and referral. The deficient practice could result in residents' medically related social and emotional needs not being met.

Based on clinical record reviews, facility documentation, staff interviews, and policy review, if an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse, neglect or exploitation has occurred on the premises or while a resident (#32) is receiving services from a nursing care institution's employee or personnel member, an administrator shall:R9-10-403.F.2. Report the suspected abuse, neglect, or exploitation of the resident as follows:R9-10-403.F.2.a. For a resident 18 years of age or older, according to A.R.S. § 46-454; Â

Based on review of clinical records, staff interviews, facility documentation, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) guidance, and facility policy, the director of nursing shall ensure that as soon as possible but not more than 24 hours a nurse notifies a resident's attending physician has a significant change in condition for two sampled residents (#4 and #36). Â

Based on clinical record review, interviews, facility documentation, and policy review, the director of nursing failed to ensure that: an unnecessary drug is not administered to a resident (#36). Â

Based on observations, staff interviews, and policy review, the administrator failed to ensure that if a nursing care institution contracts with a food establishment to prepare and deliver food to the nursing care institution: the nursing care institution is able to store, refrigerate, and reheat food to meet the dietary needs of the resident.Â

Based on clinical record review, interviews, facility documentation, and policy review, the facility administrator shall ensure that policies and procedures are established, documented and implemented to protect the health and safety of a resident that cover health care directives for two residents (Residents #5, #22).Â

Violation cited

Violation cited

Violation cited

Violation cited