Inspection Reports for
Heritage Woods

Emergency call response: During May, June and July 2025, there were 14 emergency call response times over the 7-minute limit, and documentation of hourly safety checks was missing or incomplete.

Memory care unit: Physical hazards were identified including operable and unsecured heating elements, unsecured cleaning chemicals accessible by residents, an emergency door alarm not audible from all areas, and windows that could be opened bypassing blockers.

Resident care plans: Two resident records were missing a physician evaluation required prior to moving into the residence.

Quality assurance program: Missing or incomplete components of the quality assurance and performance improvement program were noted, including missing documentation of target dates and responsible persons for follow-up action and observations of medication management issues (repeat finding).

Controlled medication handling: The controlled substance policy was incomplete and documentation of controlled substance counts by staff was inconsistent on multiple dates in June, July and August 2025.

Resident progress notes: Documentation of significant occurrences in progress notes was missing for four residents, including events reported to AGE.

Recordkeeping: Four personnel records were missing documentation of a signed job description (repeat finding).

Staff training: Documentation of general orientation was missing in four staff records and biannual SAMM and skills evaluations were not consistently documented for all personal care staff (repeat finding).