Heritage Grove Estates

Inspectors wroteBased on record reviews and interviews, the facility failed to provide regular in-service education based on the outcome of performance reviews. This placed the residents at risk of impaired care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to sanitize multi-resident use equipment between resident use. Staff also failed to utilize adequate infection control measures when providing urinary catheter care for Resident (R) 15. The facility also failed to establish a water management program to prevent the growth of Legionella disease (Legionella is a bacterium which can cause pneumonia in vulnerable populations) and other water-borne pathogens.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the nurse aides received the required number of in-service training hours per year.

Inspectors wroteBased on interviews and record review, the facility failed to conduct a criminal background check as required for one facility employee. The employee was allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide Resident (R) 6, R8, and R44 and/or their representatives with a written notification of transfer for facility-initiated transfers and a bed hold policy upon transfer to the hospital. The facility further failed to notify the long-term care ombudsman (LTCO) of R6, R8, and R44's transfers to the hospital.

Inspectors wrote:Based on observation, record review, and interview, the facility failed to complete the Care Area Assessment (CAA), analysis of findings, related to a Comprehensive Minimum Data Set (MDS), for Resident (R) 30 and R31, in order to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to apply the standards of practice when staff recorded an incorrect opened date on Resident (R) 28 and R73 insulin pens in response to the survey.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 8's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). The facility failed to implement individualized interventions to prevent re-traumatization to R8.

Inspectors wroteBased on record review and interview, the facility failed to provide appropriate and adequate narcotic drug reconciliation when staff failed to accurately record controlled substance doses on the narcotic count record and further failed to immediately report a discrepancy in Resident (R) 60's count.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label Resident (R)1, R28, R39, and R73s insulin flex pens when initially opened for use.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the collaboration of care between Resident (R) 8 and R27's hospice provider and the facility which included the hospice provider contact information, the services the hospice provider would provide to the resident, the supplies, equipment and medications the hospice provider would provide for R8 The facility failed to ensure the hospice provider provided the current hospice plan of care (POC) for R8 and failed to ensure R27's most recent hospice certification and POC was provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift.

Inspectors wroteThe facility identified a census of 64 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision for cognately impaired Resident (R)1, a resident with a risk for elopement and falls, to prevent an elopement. On 01/26/25, R1 self-propelled in his wheelchair down a hallway to a locked door with a keypad. The door was not latched and R1 left the unit and proceeded out a set of double doors that exited the building. When R1 opened the double doors, an alarm sounded at the nurse ' s station, but the staff turned the alarm off without checking the door. Per interview and investigation, R1 exited the facility building at 05:58 AM and entered the Assisted Living (AL) building at 07:02 AM. The weather ranged from 22 degrees Fahrenheit (F) to 23 degrees F. [...]

Inspectors wroteThe facility identified a census of 57 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required communication training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 57 residents. Based on record review and interviews, the facility failed to ensure agency staff received the required resident's rights training. This placed the residents at risk for impaired care and decreased quality of life.

Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 41's dignity was maintained. This deficient practice placed R41 at risk for impaired dignity and decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure the oxygen tubing was stored in a sanitary manner to decrease exposure and contamination for Resident (R)41. This deficient practice placed R41 at increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 57 residents. The sample included 15 residents with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to ensure a form of communication was established between the facility and the dialysis center for Resident (R) 3. This deficient practice placed R3 at risk of potential adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 14 residents with two residents reviewed for pressure injuries. Based on observation, record review, and interview, the facility failed to ensure preventive measures were in place for Resident (R)40 who developed a facility acquired pressure injury to his coccyx (small triangular bone at the base of the spine) area and further failed to implement treatment orders, and routinely monitor the wound. R40's pressure injury evolved into a stage three (full thickness, extending into tissue beneath the skin) pressure ulcer. The facility further failed to ensure preventive measures were in place for R32 who developed a pressure injury to her left heel and further failed to monitor the wound routinely. This deficient practice placed her at risk of worsening and further development of skin related injuries.

Inspectors wroteThe facility reported a census of 56 residents. The sample included 14 residents with seven residents reviewed for accidents/hazards. Based on observation, record review, and interview, the facility to ensure Resident (R)41 remained free from avoidable accidents when staff left R41, who required one-to-one assistance, alone in the bathroom to perform hygiene tasks, which resulted in a fall for R41. As a result, R41 sustained a cut to the back of her head which required emergent treatment and surgical staples to close the wound. The facility further failed to identify and implement appropriate interventions, investigate for causal factors, and follow residents' plan of care to prevent avoidable accidents and falls. This placed those affected residents, R19, R28, R44, and R29, at risk for fall related injuries and complications.

Inspectors wroteThe facility reported a census of 56 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure the residents' plans of care were revised to include necessary information and interventions related to the residents care needs for Resident (R) 19, R41, R44, R29, R32 and R40. This deficient practice placed these residents at risk for uncommunicated care needs and inadequate care. Findings Included: [...]

Inspectors wroteThe facility identified a census of 57 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for Resident (R) 32 for terminal diagnosis and pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R32 at risk for inappropriate care planning and care needs.

Inspectors wroteThe facility identified a census of 56 residents. The sample included 14 residents with two reviewed for incontinence and or catheter (tube inserted into the bladder to drain urine) care. Based on observation, interviews, and record review the facility failed to fully assess, analyze findings, and develop a resident-centered toileting program and/or schedule which addressed Resident (R) 29's urine incontinence. The facility further failed to ensure R32 had current physician's order with a valid indication for an indwelling catheter which remained in place despite recurring urinary tract infections (UTI). This placed the residents at risk for incontinence and/or catheter related complications.

Inspectors wroteThe facility reported a census of 56 residents. The sample included 14 residents with 14 reviewed for nurse competency related assessment accuracy. Based on observation, record review, and interviews, the facility failed to ensure staff possessed the skills and knowledge necessary to ensure accuracy of fall assessments for Resident(s) (R) 41 and R44. This deficient practice placed both residents at risk for preventable falls and injuries due to unidentified risk factors. Findings Included: -The Medical Diagnosis section within R41's Electronic Medical Records (EMR) included diagnoses of unsteadiness on feet, macular degeneration (progressive deterioration of the retina), abnormalities of gait and mobility, vertebral fracture of lumbar region (broken bone of the spinal region), and dorsalgia (back pain). [...]

Inspectors wroteThe facility identified a census of 56 residents. The sample included 14 residents with five reviewed for unnecessary medications. Based on observation, interviews, and record review the facility failed ensure Resident (R) 29's remained free from antipsychotic (medication sued to treat major mental disorders) use when they failed to attempt a gradual dose reduction (GDR) for R29's antipsychotic she received for an inappropriate indication and failed to provide education and obtain informed consent regarding risk versus benefit for continued use of the antipsychotic. The facility further failed to monitor for side effects related to antipsychotic and antidepressant use. This placed R29 at increased risk for side effects and complications related to antipsychotic medication use.