Heritage Hall-Rich Creek

Inspectors wroteBased on observation, resident interview, staff interview, and facility document review, the facility staff failed to ensure they had sufficient staff to attain the highest practicable well-being. The dining room was not being utilized for breakfast and was not used consistently at the evening meal due to staffing issues on 2 of 3 Units, Unit 1 and Unit 2.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a minimum data set (MDS) assessment accurately reflected the resident's status for 1 of 23 residents in the survey sample, Resident #53.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to follow medical provider medication orders for two (2) of 23 sampled residents (Resident #88 and Resident #100).

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to ensure medications were available for administration for 1 of 20 current residents, Resident #29.

Inspectors wroteBased on staff interview, clinical record review and facility document review, the facility staff failed to act upon a medication regimen review for 1 of 23 residents in the survey sample, resident #95.

Inspectors wroteBased on observation, staff interview, and clinical record review facility staff failed to maintain a medication error rate less than 5% during medication pour and pass observation. The surveyor observed medication pour and pass. On 3/13/2024, the surveyor watched three nurses pass medications to six residents for a combined total of 26 opportunities. Nurses' technique and hand hygiene were appropriate to the task. At 8:26 AM, the surveyor observed LPN #7 prepare morning medications for Resident #66. The resident had a physician order for a Lidoderm external patch 5% apply to posterior neck in the morning for pain. The nurse stated there was no tape on the medication cart, so would return to apply the patch later, after some tape had been found. [...]

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide special eating equipment for 1 of 23 residents in the survey sample, Resident #8.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 2 of 20 current residents, Resident #11 and #8.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure the facility's arbitration agreement addressed residents' right to rescind the agreement within 30 calendar days of signing the agreement.

Inspectors wroteBased on staff interviews, facility document review, and clinical record review, the facility staff failed to ensure the facility's arbitration agreement addressed the selection of a venue that would be convenient to both parties.

Inspectors wroteBased on observation, staff interview, and review of the manufacturer's instructions for the sanitizer, the facility failed to maintain the sanitizing solution used to sanitize food preparation counters and work surfaces at a level to effectively sanitize surfaces in accordance with the manufacturer's instructions. This had the potential to affect 112 of the 113 residents of the facility who receive food from the dietary department. The facility identified one resident who received nothing by mouth.

Inspectors wroteBased on observation, staff interview and facility policy review, the facility failed to ensure medication/drugs were secured to prevent residents from potentially gaining access to them. This had the potential to affect 49 ambulatory residents in the facility with a census of 113.

Inspectors wroteBased on, clinical record review, staff interview, observation, resident interview, and facility document review, the facility staff failed to ensure a hazard free environment for 1 of 29 residents, Resident #36.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide appropriate treatment and services for care of a resident with a clinically justified indwelling catheter when the indwelling Foley catheters were not anchored for 3 of 29 residents (Resident #104, Resident #34, and Resident #69).

Inspectors wrote3. The facility staff failed to store a nebulizer mask in a plastic bag for Resident #108. Resident #108 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to stroke, anxiety disorder and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/15/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 12 out of a possible score of 15. Resident #108 was also coded as requiring limited supervision of 1 staff member for dressing, extensive assistance of 1 staff member for personal hygiene and being totally dependent on 1 staff member for bathing. During the initial tour of the facility on 1/23/19 at 12:33 pm, the surveyor observed Resident #108's nebulizer mask sitting on the table bedside of the bed. The mask was not stored in a plastic bag. [...]

Inspectors wroteBased on observation and staff interview, the facility staff failed to discard expired medications on 1 of 3 medication carts inspected. On 1/25/19 at 11:00 AM, the surveyor checked the medication cart on Side 2 for expired medications. The surveyor found 3 containers of artificial tears with expiration date 12/2018. The containers were labeled with the names of 3 unsampled residents. Medication administration records indicated that the 3 residents had received the medications daily in the 24 days after the expiration date. The nurse was informed of the concern and pulled the eye drops from the cart and went to the supply room for replacements. The director of nursing and administrator were notified of the issue on 1/25/19.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for 1 of 29 residents (Resident #117).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide the receiving provider with the appropriate information to include basis for the transfer, contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advanced Directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information including a copy of the resident's discharge summary and failed to document information provided to the receiving provider for 10 of 29 residents (Resident #267, Resident #104, Resident #83, Resident #90, Resident #36, Resident #115, Resident #218, Resident #19, Resident #25, and Resident #69).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide written notice of transfer/discharge to include the effective date of transfer or discharge; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; [...]

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to provide to the resident and the resident representative at the time of transfer/discharge written notice which specifies the duration of the bed-hold policy for 8 of 29 residents (Resident #104, Resident #83, Resident #90, Resident #36, Resident #115, Resident #218, Resident #25 and Resident #69).