Inspection Reports for
Heritage Assisted Living and Memory Care

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: the ventilation hood filtration system in the commercial kitchen had a 4 inch gap between filter panels, allowing grease laden vapors to bypass the filtration system increasing the risk of a grease fire.

.405.01.a Electrical installations and equipment: a multi-plug adapter was used to power an oxygen concentrator and other devices in Room 29, and an extension cord was used to power a miniature refrigerator in Room 48; both are prohibited.

.405.02.c Prohibited applications: a relocatable power tap was used to power a miniature refrigerator in Room 9, which is prohibited.

.405.03 Medical gases: storage of 20 E-cylinder liquid oxygen cylinders, approximately 460-500 cubic feet, was observed within a singular smoke compartment; oxygen cylinder storage must comply with NFPA 99, Chapter 11, Sections 11.3.5 to 11.3.5.1.

.630.03 Developmental Disability: nine of ten staff did not have developmental disability training, although the facility provides services for residents with developmental disabilities; the administrator stated the training had not been completed yet.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: facility lacked documentation of periodic staff training on oxygen safety and emergency plans, and failed to document replacement and sensitivity testing of smoke detectors.

.155.01 Relocation agreements: the facility had only one relocation agreement instead of the required two, and the existing agreement was undated and could not be verified as updated annually.

.405.01 Electrical installations and equipment: three electrical panels in the basement were obstructed with storage items.

.405.01.a Electrical installations and equipment: an extension cord was in use in the garden room and nursing office.

.405.02.c Prohibited applications: a refrigerator and an ice maker were plugged into relocatable power taps in the RA station/office and resident room #42.

.155.03 Emergency generators: the facility could not produce documentation for weekly inspections, monthly load tests, or battery conductivity testing in the past 12 months.

.260.05.f Linen and laundry facilities and services: both laundry rooms had damaged flooring that was no longer washable.

.215.07 Notification to Adult Protection and Law Enforcement: the administrator failed to report an allegation of exploitation after Resident #6 informed her two thousand dollars was missing from their room during the first week of November 2021.

.215.08.b Investigation within Thirty Days: the administrator did not conduct an investigation within 30 days after Resident #6 reported missing two thousand dollars and did not complete a thorough investigation.

.250.14 Call System: the facility utilized a two-way intercom call system allowing staff to listen to residents in their rooms without their knowledge, breaching residents' privacy rights.

.260.06 Housekeeping and Maintenance Services: the facility was not maintained in a clean, safe and orderly manor with rusty furniture, raised sidewalks, dirty toilets, stained carpets, soiled trash bins, dust and grime, water deposits, peeling surfaces, scratched doors and desks (previously cited 7/10/2020).

.305.06 Self-Administered Medication: residents #2 and #5 self-injected insulin without nurse assessments to ensure safety; Resident #5 changed insulin dose without assessment.

.330.04.c.vii Resident Care Records: the facility did not document all change of condition assessments for residents with nausea, redness, soreness, and vomiting despite nurse assessments.

.330.06.a Behavior Documentation: the facility did not evaluate Resident #6's behaviors of yelling, cursing, or refusing showers.

.330.06.b Behavior Documentation: the facility did not develop a behavior plan with specific interventions for Resident #6's behaviors.

.600.04.a Sufficient Personnel: the administrator did not schedule sufficient personnel to meet residents' needs, resulting in long wait times for call lights, delayed medication, and unmet service agreements; the facility was short staffed and struggling to hire more staff.

.330.04 Resident care records: the facility did not ensure staff documentation was completed, including missing documentation of self-harm behaviors and communications with family and hospice prior to an immediate discharge.

.260.06 Housekeeping Services and Equipment: the building was not maintained in a clean, safe and orderly manner with issues including strong urine odor, dirty toilets, debris on floors, insect complaints, improper storage of oxygen tubing, damaged handrails, stained carpets and mattresses, littered patios with trip hazards, unstable air conditioning units, and unsafe equipment outside.

.300.02 Licensed Nurse: the facility did not ensure a licensed nurse was available at all times to assess residents experiencing a change of condition, resulting in delayed assessments and an inpatient hospital stay for a resident diagnosed with COVID-19.

.600.04.a Sufficient Personnel: the facility did not employ and schedule sufficient personnel to provide care during all hours, resulting in unmet resident needs such as assistance with bathing, unanswered call lights, unclean rooms, and incomplete care tasks as documented in service agreements.