Inspection Reports for
Heritage Living Center

The facility was found deficient in protecting resident rights, specifically regarding an unauthorized haircut causing psychosocial harm. The ice machine was not maintained in a clean and sanitary condition. Staffing shortages were documented on multiple weekend days, and infection control practices were not consistently followed during medication administration and catheter care.

The facility was found deficient in protecting resident rights, specifically regarding an unwanted haircut causing psychosocial harm to a resident. Additional deficiencies included failure to maintain a clean ice machine, inadequate weekend staffing levels, and lapses in infection prevention practices such as hand hygiene during medication administration and failure to follow Enhanced Barrier Precautions during catheter care.

The investigation was triggered by a complaint related to the death of Resident #1 by suicide. The complaint was substantiated with findings that the facility failed to adequately address the resident's behavioral health needs and suicide risk.

The facility failed to include the resident's suicide history in the Care Plan and did not train staff to identify or respond to behavioral health needs. Observations, interviews, and record reviews revealed the resident's prior suicide attempts were not adequately addressed, and staff were unaware of the resident's suicide risk. The resident was found deceased by hanging in their room, and the investigation confirmed minimal harm but significant deficiencies in behavioral health care and staff training.

The investigation was triggered by a complaint regarding the facility's failure to address the behavioral health needs of Resident #1, who had a history of suicide attempts and family history of suicide. The complaint was substantiated with findings that the resident's suicide history was not included in the Care Plan and staff were not trained to respond to such behavioral health needs.

The facility failed to include the resident's suicide history in the Care Plan and did not train staff to identify or respond to behavioral health needs. Resident #1, with a history of major depressive disorder and prior suicide attempts, was found deceased by hanging in their room. Multiple staff interviews and document reviews revealed gaps in communication and care planning related to the resident's behavioral health history.

The facility was found to have multiple deficiencies including failure to secure residents' electronic medical records, unsecured portable oxygen cylinders, unlocked medication carts, improper food handling and storage practices, and missing call light pull strings in resident bathrooms. These issues posed minimal harm or potential for actual harm to residents.

The facility was found deficient in securing residents' private health information on electronic devices, storing portable oxygen cylinders safely, locking medication carts when unattended, maintaining proper dietary hygiene and food safety, and ensuring bathroom call lights had functional pull strings for resident safety.

The complaint investigation found that Resident #1 had a chipped tooth caused by a mechanical lift, but the incident was not reported to the physician, family, or documented in incident reports or grievances. Staff interviews confirmed lack of proper reporting and notification procedures were followed.

The facility failed to ensure proper reporting and notification of an injury when Resident #1's tooth was chipped by a lift bar. Documentation reviews showed no incident report, progress notes, or grievance filed regarding the injury. Interviews with staff revealed lack of awareness and failure to complete required incident and accident reports.

The facility failed to ensure that the physician and family were notified after Resident #1 sustained a chipped tooth injury from a mechanical lift. The incident was not reported in the facility's incident documentation, progress notes, or grievance logs, and no Incident & Accident (I&A) report was completed as required by facility policy.

The facility failed to ensure proper placement checks of gastrostomy tubes prior to feeding, maintain safe and appetizing food temperatures, and follow proper food storage and employee hygiene practices, potentially affecting multiple residents.

The facility was found deficient in ensuring proper placement verification of feeding tubes prior to use, maintaining palatable and safe food temperatures during meal service, and adhering to food safety standards including proper storage and employee hand hygiene. These deficiencies posed minimal harm or potential for harm to residents.