Inspection Reports for
Heritage Court Assisted Living

The investigation was triggered by complaints 125771-C and 125821-C. The roof leaks and heating system issues were confirmed through tenant and staff interviews and observations. The roof leak issue has persisted for at least five years, and repairs have not been completed despite bids and tar application.

The facility failed to consistently maintain the building, with issues including roof leaks causing water to drip into the dining area, stained and damaged ceiling tiles, and unresolved heating system problems. These deficiencies potentially affected all 20 tenants.

The investigation involved complaints 125296-C, 125298-C, and incident 125301-I. No insufficiencies were found for complaint 121969-C. The cited deficiency was related to door alarm policy noncompliance. The facility asserted substantial compliance with corrective actions by 2/19/2025.

No regulatory insufficiencies were cited during complaint 121969-C. One regulatory insufficiency was cited for failure to follow program policies and procedures related to door alarms and staff response. The facility was found to be in substantial compliance as of 2/19/2025 after corrective actions.

The program failed to follow its door alarm policy by allowing the main entrance alarm to be turned off prior to the allowed time, which resulted in Tenant #1 leaving the facility unnoticed and requiring EMS intervention. Staff A admitted to turning off the alarm early and acknowledged the findings.

The visit was triggered by Complaint #116338-C. The complaint was found to be credible as evidenced by the deficiencies cited related to medication administration and record checks.

The inspection found regulatory insufficiencies related to medication administration and record checks. Specifically, the program failed to administer prescribed medications to tenants and failed to complete background checks for employees prior to hire.

The program failed to complete background checks prior to hire for 4 of 5 employees reviewed. A civil penalty was issued for this violation.

The investigation was triggered by Complaint #108248-C. The deficiency was substantiated based on interviews and record reviews showing failure to update service plans appropriately.

The program failed to update service plans as needed for 1 of 5 tenants reviewed, specifically Tenant #1, whose service plan did not include interventions for inappropriate sexual behaviors despite documented incidents.

Investigation of Incident #104031-I and Complaint #104726-C found no regulatory insufficiencies.

No regulatory insufficiencies were cited during the investigation of the incident and complaint.

Regulatory insufficiencies were cited related to program notification to the department and individualized service plans. Specifically, the program failed to notify the department timely of incidents and failed to develop individualized service plans reflecting tenant needs and preferences, including alcohol dependence and suicidal ideations.

Investigation of Complaint #89462-C found the program did not meet the requirement to conduct nurse reviews every 90 days for tenants receiving personal or health-related care, as evidenced by Tenant #1's file review.

The program failed to assess and document the health status of tenants every 90 days as required for 1 of 3 tenants reviewed. No regulatory insufficiencies were cited during the infection control survey.

The program failed to consistently ensure evaluations were completed with significant change for one of two tenants reviewed, specifically Tenant #1. The Registered Nurse confirmed failure to complete functional, cognitive, and health evaluations prior to Tenant #1's significant change.