Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Health Services during CMS and state inspections, most recent first.
Surveyors observed improper food storage and labeling, with multiple open and undated food items in the kitchen's dry storage, cooler, and freezer. Staff failed to follow hand hygiene protocols, including handling plates and food without washing hands or using gloves, despite facility policies and FDA Food Code requirements. These practices had the potential to affect all residents in the facility.
The facility did not maintain complete infection surveillance logs, failed to monitor residents for infection symptoms, and did not ensure hand hygiene was performed before meals or during wound care. Staff and leadership confirmed missing data and lapses in infection tracking, and an LPN did not follow proper hand hygiene protocols during a dressing change for a resident with multiple medical conditions.
The facility did not ensure that the required QAPI committee members, including the Medical Director, DON, NHA, and Infection Preventionist, met at least quarterly as required. Attendance records were missing for several months, and when meetings did occur, not all required members were present or documented. Staff interviews confirmed the absence of meetings and incomplete documentation, impacting oversight of quality improvement activities.
Surveyors identified that five residents with various medical conditions were not offered or administered the PCV20 pneumococcal vaccine as required by facility policy and CDC guidelines. Staff interviews and record reviews confirmed the absence of documentation showing that the vaccine was offered, education was provided, or declination paperwork was completed, resulting in a deficiency related to vaccination practices.
A resident with moderate cognitive impairment and a legal Guardian was admitted to the facility, but the required protective placement and annual review documentation were not maintained in the medical record as mandated by state law. Although the facility communicated with the Guardian and attempted to obtain updates from the county and APS, there was no evidence of current protective placement or annual reviews, and the facility lacked a policy on guardianship and protective placement.
Staff did not follow the care plan for a resident with excoriation disorder and other medical conditions, which directed that incontinence briefs should not be used. Instead, staff were observed removing and reapplying an incontinence brief after wound care, despite documented instructions to use alternative clothing and interventions. The resident had multiple open and reddened areas on the buttocks, matching the area covered by the brief. The DON confirmed briefs should not be used but was unaware they were still in use.
The facility failed to adhere to infection control protocols, as staff did not use PPE during care for a resident on Enhanced Barrier Precautions and neglected proper hand hygiene during dressing changes. Additionally, catheter bags for two residents were observed in contact with the floor, contrary to facility policy. These actions indicate a lack of compliance with infection prevention measures.
A facility failed to provide licensed nurse coverage for 2.5 hours during a PM shift, affecting 23 residents. This led to missed blood glucose monitoring and medication administration for several residents, and one resident was sent to the ER without a nurse assessment. Seven full-code residents were left without CPR-certified staff. The absence of a licensed nurse and poor communication from management created immediate jeopardy.
The facility did not report an allegation of neglect when it was without a licensed nurse for 2.5 hours, affecting residents' medication and blood glucose monitoring. One resident was sent to the ER without a nurse assessment. The absence of a licensed nurse was confirmed, but the incident was not reported to the State Agency as required.
The facility did not adhere to its policies for preventing abuse and neglect by failing to conduct timely background checks for three staff members. Background checks for an LPN hired in 2017 were completed in 2019, and another LPN hired in 2018 had checks dated two years prior. A CNA hired in 2024 had outdated background information from 2023. The Business Manager confirmed these oversights, and no additional background information was available.
A resident received alprazolam without a valid physician's order due to a lapse in documentation and communication. The resident, with diagnoses including chronic pain syndrome and anxiety disorder, was administered the medication six times without a valid prescription. The facility's policy requires medication orders to be reviewed and confirmed prior to administration, but a verbal order to change the dosage was not documented in time, leading to the deficiency.
The facility failed to maintain accurate nurse staffing postings, affecting 23 residents. Discrepancies were found between staffing postings and payroll records, with periods lacking licensed nurse coverage. Staff interviews and facility investigation confirmed inaccuracies, and the Regional Manager was unsure of the cause.
Deficient Food Storage, Labeling, and Hand Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and served in a sanitary manner, as evidenced by multiple observations of improper food labeling, dating, and storage practices in the kitchen's dry storage, cooler, and freezer areas. Surveyors found numerous open and undated food items, including cereals, flour, dry milk, coconut flakes, and prepared foods such as cream of chicken, hot dogs, hard-boiled eggs, and orange juice mix. These items lacked required use-by dates or proper labeling, contrary to both the FDA Food Code and the facility's own policies, which mandate clear marking of preparation, opening, and use-by dates for all food items. In addition to food storage issues, staff did not consistently follow appropriate hand hygiene procedures in the kitchen and while serving food. During meal service, a staff member was observed handling residents' plates with bare hands and touching food serving utensils, then serving food on those plates without performing hand hygiene or using gloves as required. Another staff member was seen entering the kitchen, donning a beard restraint, and beginning kitchen tasks without washing hands, both after entering from outside and from the hallway. Interviews with staff confirmed a lack of adherence to hand hygiene protocols, despite awareness of the facility's policies. These deficiencies were observed during an initial kitchen tour and subsequent observations, and staff interviews confirmed that the facility's policies were not being followed. The improper storage, labeling, and handling of food, as well as lapses in hand hygiene, had the potential to affect all 25 residents residing in the facility.
Failure to Maintain Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by incomplete and missing infection surveillance logs, lack of monitoring for signs and symptoms of infection among residents, and failure to ensure proper hand hygiene practices. The infection surveillance line lists for both residents and staff were found to be incomplete, missing critical data such as start and end dates of infections, organism identification, symptoms, test tracking, and reporting to the Quality Assessment and Assurance (QAA) committee. The Director of Nursing (DON) and other leadership staff confirmed these deficiencies, noting that the absence of a dedicated Infection Preventionist (IP) and lack of proper training contributed to the inability to effectively track and manage infection data. During meal observations, staff did not offer or assist residents with hand hygiene prior to dining, nor did they provide verbal reminders. Multiple residents confirmed that hand hygiene was not offered before meals, and that hand wipes, which were previously available, were no longer provided. Staff present in the dining room, including the DON and other personnel, did not ensure that residents had the opportunity to clean their hands before eating, contrary to facility policy and CDC guidelines. Additionally, improper hand hygiene was observed during wound care for a resident with multiple medical conditions, including paraplegia and chronic skin-picking disorder. An LPN failed to perform hand hygiene at key moments during the dressing change process, such as after glove removal and before touching clean supplies or the treatment cart. Both the LPN and the DON acknowledged these missed hand hygiene opportunities, which were inconsistent with facility policy and best practices for infection control.
Failure to Ensure Required QAPI Committee Members Met Quarterly
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly, as mandated by their policy and regulatory requirements. Review of QAPI meeting attendance records from March 2024 through February 2025 revealed missing sign-in sheets for several months, specifically May, July, September, October, November, and December 2024. Additionally, when meetings did occur, not all required members were present; for example, the Medical Director, Director of Nursing, and Infection Preventionist were absent from various meetings, and there was insufficient documentation to confirm their participation, especially for those who attended remotely. The absence of the Executive Director/NHA in November and December 2024 was cited as the reason for no meetings during those months. Staff interviews confirmed the lack of complete attendance records and the inability to provide proof of required members' participation in the QAPI meetings. The facility's leadership acknowledged the difficulty in demonstrating compliance without proper documentation and could not locate the missing sign-in sheets. This deficiency had the potential to affect more than 4 of the 25 residents residing in the facility, as the QAPI committee is responsible for overseeing and improving quality of care.
Failure to Offer or Document PCV20 Vaccination for Multiple Residents
Penalty
Summary
Surveyors found that the facility failed to ensure that pneumococcal vaccinations, specifically the PCV20 vaccine, were offered or administered to five sampled residents as required by both facility policy and current CDC recommendations. The facility's policy mandates that all residents be assessed for pneumococcal immunization upon admission, and that vaccines be offered unless medically contraindicated or previously administered. However, record reviews for the five residents revealed that none had documentation indicating they were offered the PCV20 vaccine, nor was there evidence of education, offer, or declination paperwork in their medical records. The residents involved had various medical conditions, including paraplegia, epilepsy, congestive heart failure, dementia, chronic obstructive pulmonary disease, and a history of cerebral infarction. Some had moderate to severe cognitive impairment and court-appointed guardians, while others had intact cognition. Their immunization histories showed that they had received either PCV13 or PPSV23 vaccines in the past, making them due for the PCV20 vaccine according to CDC guidelines. Despite this, there was no documentation that the vaccine was offered or administered at the appropriate intervals. Interviews with facility staff, including the DON and the acting Infection Preventionist, confirmed that the facility was responsible for offering the PCV20 vaccine and maintaining records of administration or declination. However, the vaccination tracking sheets provided did not show that the PCV20 vaccine was offered to any of the five residents, and no supporting documentation was available. This lack of documentation and failure to follow policy led to the identified deficiency.
Failure to Ensure Protective Placement for Resident with Guardian
Penalty
Summary
The facility failed to ensure that protective placement was obtained for a resident with a legal Guardian when the resident's stay exceeded ninety days, as required by state statute. The resident was admitted with the consent of a legal Guardian and had diagnoses including paraplegia, epilepsy, and congestive heart failure, with a BIMS score indicating moderate cognitive impairment. The medical record included guardianship and protective placement documents from 1998 but did not contain the required annual reviews for protective placement to determine if the resident was in the least restrictive environment. The facility updated the Guardian on changes in the resident's condition and the Guardian made healthcare decisions, but there was no evidence of current protective placement documentation or annual reviews in the record. Staff interviews revealed that the facility typically receives annual review documents from the county, which are uploaded into the electronic medical record, but no recent documentation was found for this resident. The managed care organization had been contacting the county for updates on the protective placement order since the previous year, and a referral to Adult Protective Services was made. APS later informed the facility that the resident's protective placement had been discontinued by the court in 2003. The facility did not have a policy addressing guardianship and protective placement, and staff indicated that state regulations should be followed.
Failure to Follow Care Plan for Skin Integrity in Resident with Excoriation Disorder
Penalty
Summary
Staff failed to follow the care plan for a resident diagnosed with excoriation disorder and other medical conditions, which specifically directed that incontinence briefs should not be used due to the risk of moisture-related skin breakdown. Despite these instructions, during an observation, staff were seen removing an incontinence brief from the resident and then applying a clean one after wound care. The care plan and Kardex both indicated alternative interventions such as union suits, boxer shorts, long pants, tall socks, or wrapping the resident in a bath blanket to prevent self-trauma, but these were not implemented during the observed care. The resident had multiple open areas and redness on the bilateral buttocks, corresponding to the area covered by the incontinence brief. Staff interviews confirmed that the resident's skin condition had persisted for years and that various pharmacological and non-pharmacological interventions had been attempted to address itching and skin integrity. The DON verified that incontinence briefs should not be used for this resident due to moisture retention but was unaware that staff continued to use them. The failure to adhere to the care plan and use of incontinence briefs contributed to the ongoing impaired skin integrity observed.
Infection Control Deficiencies in PPE Use and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. Resident 1, who was on EBP due to wounds, was observed on two occasions where staff did not wear personal protective equipment (PPE) during care. Additionally, during a dressing change, staff did not perform hand hygiene between glove changes. The facility's policy required PPE for high-contact resident care activities, but staff were either unaware of the requirements or did not follow them. Furthermore, Resident 1's catheter bag was observed in contact with the floor, which was against the facility's policy. Resident 2, who had a condom catheter, was also observed with an uncovered catheter drainage bag in contact with the floor. Despite staff acknowledging that catheter bags should not be on the floor, the issue persisted. The Director of Nursing confirmed the expectations for PPE use and hand hygiene, as well as the requirement for catheter bags to be covered and not in contact with the floor. These observations indicate a lack of adherence to the facility's infection control policies, potentially increasing the risk of infection transmission among residents.
Lack of Licensed Nurse Coverage Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to provide adequate licensed nurse coverage for approximately 2.5 hours during a PM shift, which affected all 23 residents. An agency nurse left the facility without a replacement, leaving the residents without necessary medical care. This resulted in three residents not receiving blood glucose monitoring and 14 residents not receiving their medications as per physician orders. Additionally, one resident was transported to the emergency room without a nurse assessment. During this period, seven residents who were full-code status were left without CPR-certified nursing staff in the facility. The facility claimed that a CPR-certified Maintenance Manager was present, but they could not provide proof of certification. The absence of a licensed nurse meant that residents were at risk due to the lack of professional assessment of their healthcare needs. The situation was exacerbated by the lack of communication and response from facility management. Attempts to contact the Nursing Home Administrator, Scheduler, and on-call Unit Manager were unsuccessful, leading to a delay in addressing the staffing issue. The facility's investigation revealed that the AM shift nurses left without ensuring a PM shift nurse was present, and the medication cart keys were left unsecured, further compromising resident care.
Removal Plan
- Reeducated staff of the requirement to have a licensed nurse on duty.
- Reeducated nurses to remain on assignment until relieved by another nurse.
- Reeducated nursing staff that only licensed nursing staff have access to medication cart keys.
- Educated staffing agencies used by the facility of the responsibility of nurses to remain on assignment until another nurse arrives on duty.
- Clarified with staffing agencies used by the facility the need for notification when agency staff cancel shifts.
- Developed an agency nurse orientation packet that indicates nurses may not leave the facility until care is handed off to another nurse.
- Incorporated a process in which there is a designated charge nurse each shift when the DON is not in the facility. The charge nurse or DON will cover any shifts that do not have a nurse.
Failure to Report Neglect Due to Absence of Licensed Nurse
Penalty
Summary
The facility failed to report an allegation of neglect to the State Agency when it was without a licensed nurse for approximately 2.5 hours on a specific date. During this time, three residents did not receive blood glucose monitoring as per physician orders, and fourteen residents did not receive their medications in accordance with physician orders or the facility's policy. Additionally, one resident was transported to the emergency room without a nurse assessment to determine their medical needs. The incident was documented in a police report and an ambulance report, indicating that the facility was without staff for several hours, and an unresponsive resident was transported to the hospital. The facility's investigation confirmed the absence of a licensed nurse during the PM shift, and the Maintenance Manager had to call 911 for the unresponsive resident. The facility's policy required reporting such incidents to the State Agency within specified timeframes, but this was not done, leading to the deficiency.
Failure to Conduct Timely Background Checks for Staff
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, and exploitation by not conducting thorough and timely background checks for three staff members. The facility's policy, revised on 7/15/22, mandates background, reference, and credentials checks for potential employees and other associated personnel. However, the surveyor found that the facility did not complete these checks for LPN-K, LPN-I, and CNA-L before their hire dates. Specifically, LPN-K was hired in 2017, but the background checks were not completed until 2019. Similarly, LPN-I was hired in 2018, but the checks were dated two years prior, in 2016. CNA-L was hired in 2024, but the background information was from 2023, indicating a significant delay and potential oversight in the hiring process. During interviews, the Business Manager (BOM-E) confirmed that background checks should be completed before hiring, but could not explain the discrepancies for LPN-K and LPN-I. BOM-E also acknowledged that CNA-L should have completed a new Background Information Disclosure form before being hired, as there was a possibility of living out of state in the interim. The Regional Manager (RM-C) confirmed that no additional background check information was available for these staff members, highlighting a lapse in the facility's adherence to its own policies designed to protect residents from potential abuse and neglect.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the accurate administration of medications for a resident, identified as R2, who received alprazolam without a valid physician's order. R2, who had diagnoses including chronic pain syndrome, major depressive disorder, and anxiety disorder, was administered alprazolam six times between August 30, 2024, and September 3, 2024, despite the absence of a valid prescription. The facility's policy requires that medications be administered as prescribed and that medication orders be reviewed and confirmed prior to administration. The deficiency occurred when a verbal order to discontinue alprazolam 0.25 mg every 8 hours PRN was given on August 30, 2024, but the new order for alprazolam 0.25 mg every 12 hours PRN was not documented until September 3, 2024. The Director of Nursing (DON) was unable to locate the order for the change in dosage and confirmed the need for a new order. Despite this, the medication was administered without a valid script, as confirmed by the review of the resident's Medication Administration Records (MARs) and communication with the resident's physician's office.
Inaccurate Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the nurse staffing posting accurately reflected the number of nursing staff working in the facility, which had the potential to affect all 23 residents residing there on the specified date. The facility's policy required that nurse staffing information be readily available and updated to reflect actual hours worked by nursing staff, including adjustments for staff absences. However, discrepancies were found between the nurse staffing postings and payroll records for the date in question. Specifically, the postings did not accurately reflect the hours worked by RNs, LPNs, and CNAs across different shifts, and there were periods when no licensed nurse was present in the facility. Interviews with staff and a review of the facility's investigation revealed that a nurse did not report to work for the PM shift, and an LPN left early on the AM shift, leaving residents without a licensed nurse for a period. The payroll records indicated different staffing levels than those posted, with inaccuracies in the reported hours for RNs, LPNs, and CNAs. The Regional Manager confirmed the inaccuracies in the nurse staffing postings and was unsure why the payroll entries were also incorrect. These discrepancies indicate a failure to maintain accurate and up-to-date staffing information as required by the facility's policy.
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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 Port Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Samaritan Nursing And Rehab | 9.1 mi | — | 23 | 3 |
| Lasata Care Center | 10.6 mi | — | 8 | 0 |
| Cedarburg Health Services | 10.6 mi | — | 0 | 0 |
| Newcastle Place | 13.1 mi | — | 6 | 0 |
| Cedar Lake Health And Rehab Center | 14.9 mi | — | 2 | 0 |
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