Facility profile · CCN 215135
Complete Care At Heritage Llc
70 federal citations on record , including 2 at the Immediate Jeopardy level, and 2 federal enforcement actions totaling $129,919.
Record summary
Federal record · Q1 202670
Total citations
49
Last 3 years
3
Actual harm+
2
Federal penalties
$129,919
Total fines
2
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
70 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Sep 16, 2025 | F697 | Provide safe, appropriate pain management for a resident who requires such services. | D | Complaint |
| Sep 16, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Complaint |
| Sep 16, 2025 | F947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D | Standard |
| Sep 16, 2025 | F925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | E | Standard |
| Sep 16, 2025 | F887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | D | Standard |
| Sep 16, 2025 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Sep 16, 2025 | F880 | Provide and implement an infection prevention and control program. | E | Standard |
| Sep 16, 2025 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Sep 16, 2025 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard |
| Sep 16, 2025 | F732 | Post nurse staffing information every day. | C | Standard |
| Sep 16, 2025 | F726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | E | Standard |
| Sep 16, 2025 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | E | Standard |
| Sep 16, 2025 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Sep 16, 2025 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Standard |
| Sep 16, 2025 | F676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Standard |
| Sep 16, 2025 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard |
| Sep 16, 2025 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D | Standard |
| Sep 16, 2025 | F641 | Ensure each resident receives an accurate assessment. | D | Standard |
| Sep 16, 2025 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Standard |
| Sep 16, 2025 | F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E | Standard |
| Sep 16, 2025 | F578 | 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. | D | Standard |
| Sep 16, 2025 | F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Complaint |
| Feb 26, 2025 | F760 | Ensure that residents are free from significant medication errors. | J | Complaint |
| Aug 22, 2023 | F949 | Provide behavior health training consistent with the requirements and as determined by a facility assessment. | D | Complaint |
| Aug 22, 2023 | F947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E | Complaint |
| Aug 22, 2023 | F940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | D | Complaint |
| Aug 22, 2023 | F760 | Ensure that residents are free from significant medication errors. | D | Complaint |
| Aug 22, 2023 | F700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | D | Complaint |
| Aug 22, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | Complaint |
| Aug 22, 2023 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E | Complaint |
| Aug 22, 2023 | F657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E | Complaint |
| Aug 22, 2023 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Aug 22, 2023 | F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D | Complaint |
| Aug 22, 2023 | F604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D | Complaint |
| Aug 22, 2023 | F600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | Complaint |
| Aug 22, 2023 | F580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D | Complaint |
| Aug 22, 2023 | F925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | D | Standard |
| Aug 22, 2023 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Aug 22, 2023 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | Standard |
| Aug 22, 2023 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D | Standard |
| Aug 22, 2023 | F759 | Ensure medication error rates are not 5 percent or greater. | E | Standard |
| Aug 22, 2023 | F758 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D | Standard |
| Aug 22, 2023 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E | Standard |
| Aug 22, 2023 | F732 | Post nurse staffing information every day. | D | Standard |
| Aug 22, 2023 | F728 | Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | D | Standard |
| Aug 22, 2023 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard |
| Aug 22, 2023 | F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E | Standard |
| Aug 22, 2023 | F557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | D | Standard |
| Aug 22, 2023 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard |
| Apr 14, 2023 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Complaint |
| Apr 14, 2023 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Complaint |
| Apr 14, 2023 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| Jan 22, 2019 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Jan 22, 2019 | F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D | Standard |
| Jan 22, 2019 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Jan 22, 2019 | F761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D | Standard |
| Jan 22, 2019 | F759 | Ensure medication error rates are not 5 percent or greater. | D | Standard |
| Jan 22, 2019 | F757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D | Standard |
| Jan 22, 2019 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Jan 22, 2019 | F730 | Observe each nurse aide's job performance and give regular training. | D | Standard |
| Jan 22, 2019 | F711 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | D | Standard |
| Jan 22, 2019 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Standard |
| Jan 22, 2019 | F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D | Standard |
| Jan 22, 2019 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | Standard |
| Jan 22, 2019 | F676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | D | Standard |
| Jan 22, 2019 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Jan 22, 2019 | F625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D | Standard |
| Jan 22, 2019 | F584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D | Standard |
| Jan 22, 2019 | F561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D | Standard |
| Jan 22, 2019 | F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | Standard |
Federal enforcement history
Federal regulators have imposed 2 enforcement actions against this facility, including 2 civil money penalties totaling $129,919 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Feb 26, 2025 | Fine | $60,132 | — |
| Aug 22, 2023 | Fine | $69,787 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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