Inspection Reports for Heritage Court Assisted Living

The inspection was conducted as an investigation of Complaints 125771-C and 125821-C regarding the condition and maintenance of the assisted living facility.

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 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 inspection was conducted to investigate complaints 125296-C, 125298-C, and incident 125301-I regarding Heritage Court Assisted Living.

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 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.

The inspection was conducted as part of the investigation of Complaint #116338-C and the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.

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 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 was conducted as part of an investigation of Complaint #108248-C regarding regulatory insufficiency related to service plans.

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.

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.

Investigation of Incident #104031-I and Complaint #104726-C at Pine Acres Assisted Living.

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

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

The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program, including investigation of Incident #100877-1 and a recertification visit.

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.

The inspection was conducted as an investigation of Complaint #89462-C and included an onsite infection control survey.

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.

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.

A recertification visit was conducted to determine compliance with certification for an Assisted Living Program.

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.

A recertification visit was conducted to determine compliance with certification for an Assisted Living Program. Complaint #73227-C was also investigated.

No regulatory insufficiencies were identified during the recertification and complaint investigation.

Complaint #73227-C was investigated and found to have no regulatory insufficiencies.

The inspection was conducted as an investigation of Incident 62640-I related to medication administration concerns at Heritage Court Assisted Living.

The investigation revealed multiple failures in following medication administration policies, including missing signatures and documentation errors for medications given to three tenants. The Program's medication policy was not consistently followed as confirmed by the Register Nurse.

Investigation of Incident 62640-I found substantiated concerns regarding medication administration errors and policy non-compliance.

The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification of an Assisted Living Program.

No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, including the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans.

The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and regulatory compliance of Heritage Court Assisted Living in response to previously identified regulatory insufficiencies.

The report found regulatory insufficiencies in the areas of Medications, Evaluations, Service Plans, and Nurse Review. The Plan of Correction submitted by the facility was accepted by the Department of Inspections and Appeals.

The visit was conducted as a Final Recertification Monitoring Evaluation to review the Plan of Correction submitted in response to a Preliminary Recertification Monitoring Evaluation Report for Heritage Court Assisted Living.

The program had no regulatory insufficiencies during this certification period. However, medication administration deficiencies were noted, including failure to maintain adequate medication supplies and incomplete documentation of medication administration and physician notification.

A complaint investigation on-site visit was conducted at Heritage Court on June 23, 2010, to investigate allegations related to tenant care and service plan compliance.

The investigation found regulatory insufficiencies in evaluation of tenant functional, cognitive, and health status, and service plan updates. No negligent care was found related to the complaint allegation of a tenant fracture after transfer.

Complaint Allegation: It was alleged a tenant transferred to another facility and upon admission was diagnosed with a fracture of the superior pubic ramus. The investigation found no negligent care related to this allegation.

The visit was a monitoring evaluation conducted as part of the recertification process for Heritage Court Assisted Living to review the Plan of Correction and assess compliance with regulatory requirements.

The evaluation found regulatory insufficiencies related to the program's failure to complete functional and health evaluations within required timeframes and to develop and update individualized service plans accordingly. No substantiated regulatory insufficiencies were noted during the recertification period.

The visit was a final recertification monitoring evaluation conducted to assess compliance with assisted living program regulations at Heritage Court Assisted Living.

The evaluation found that tenants were generally satisfied with the program, staff, and services. However, a regulatory insufficiency was identified related to the lack of consistent orientation and training for direct care staff on safe and sanitary food handling prior to handling food.

There were no substantiated complaints during this certification period.

An on-site monitoring evaluation was conducted to assess compliance with assisted living program regulations at Heritage Court Assisted Living.

The evaluation found regulatory insufficiencies including failure to consistently evaluate tenants' functional, health, and cognitive status within 30 days of admission and upon status changes, and failure to develop service plans in consultation with tenants and a multidisciplinary team.

There are no substantiated complaints during this certification period.