Heritage Place

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated Director of Nursing (DON) worked 40 hours a week. This failed practice had the potential to place all residents (based on a census of 44) at risk of not receiving quality nursing services due to a lack of oversight.

Inspectors wroteBased on observation and interview, the facility failed to ensure medical supplies were labeled appropriately and removed from storage if expired. These failed practices placed all residents (based on a census of 44) at risk for adverse effects or complications from use of the expired products.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored under proper sanitary conditions in the main kitchen and in the Sitka [NAME] unit. This failed practice placed all residents (based on a census of 44), who received food from both kitchens at risk for foodborne illness and communicable disease.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure pureed food was prepared to the appropriate consistency to meet 3 resident's (#6, #15, and #19 ) individual needs out of 3 residents on a pureed diet. This failed practice had the potential to place the residents at risk for aspiration and compromised nutritional intake.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure comprehensive care plans were revised to meet the changing needs of 3 residents (#'s 26, 31, and 33), out of 12 sampled residents. Specifically, the facility failed to revise care plans to reflect: 1) the use of a foot cradle for Resident #26; 2) a change in cognition and activities of daily living (ADLs) for Resident #31, and; 3) the use of enhanced barrier precautions (EBP) for Resident #33. This failed practice placed the residents at risk for less than the highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure consistent oral care was provided to 1 resident (# 31), out of 12 residents sampled. This failed practice had the potential to place the resident at risk of poor oral health outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete for 1 sampled resident (#33), out of 12 sampled residents. Specifically, physician signatures on written orders were not dated. This failed practice created incomplete medical records which placed the resident at risk for inconsistencies in treatment and care provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control procedures were properly implemented in the facility. Specifically, the Certified Nurse Assistants (CNAs) failed to change gloves and perform hand hygiene while providing personal cares, for 2 residents (#s 26 and 35), out of 2 residents observed for personal cares. This failed practice had the potential to place all residents at risk of contamination and transmission of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food safety. Specifically, the facility failed to ensure: 1) food was stored under proper sanitation and food handling practices in the main kitchen; 2) food was stored under proper sanitation and food handling practices on the Sitka [NAME] unit; and 3) the dishwasher water temperature was at appropriate temperature range, prior to washing dishes, for proper sanitation of all dishware and food service equipment. These failed practices had the potential of causing or spreading foodborne illness to all residents, based on a census of 43.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure: 1) a properly sized sling was used in transfers for 1 resident (#195), out of 12 sampled residents; and 2) neurological (or neuro) checks (assessments to determine if any neurological symptoms arose from potential head injuries) were performed after unwitnessed falls for 2 residents (#'s 18 and 20), out of 4 sampled residents for falls. These failed practices had the potential to: 1) cause pain and distress to the resident; and 2) delay treatment if the resident had a change in neurological status.

Inspectors wroteBased on record review and interview, the facility failed to adequately monitor the functional status of wander guard tags (a safety assistance device placed on a resident at risk for wandering and possible elopement. This device would trigger an alarm at any exit equipped with a wander guard sensor, alerting staff to a possible elopement attempt). Specifically, the facility used an outdated, obsolete tag battery tester, incapable of accurately indicating battery level status, for 1 Resident's (#30) tag device, out of 3 residents reviewed with wander guards, and which resulted in an elopement from the facility. This failed practice placed all residents with wander guard safety precautions (based on a census of 6) at risk for wander guard tag failure and possible elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medical products were removed from the medical supply storage areas. This failed practice placed all residents (based on a census of 43) at risk for adverse effects or complications from use of the expired products.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate competencies and skills sets were properly established for Resident Aides (RAs), Licensed Nurses (LNs), and Food Service Staff who prepared modified diets for Sitka [NAME] residents. Specifically, the facility failed to ensure: 1) the RAs and LNs, as well as food service staff, were trained to operate a Cuisinart chopper/grinder food processor used on the Sitka [NAME] unit for preparing modified diets; and 2) RAs and LNs had food worker cards to certify they were appropriately trained to prepare modified diets. These failed practices placed 3 unsampled Sitka [NAME] residents (#s 15, 21, and 38) who were on modified diets, and potentially future residents placed on modified diets, at risk for improper food preparation and food borne illnesses.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure infection control procedures were properly implemented. Specifically, the facility failed to: 1) ensure staff removed soiled gloves and performed hand hygiene after completing dirty tasks to clean tasks for 1 unsampled resident (#10), out of 3 residents (1 unsampled and 2 sampled) observed for residents' care; and 2) ensure soiled personal protective equipment (PPE) were disposed of safely for 1 unsampled resident (#44), out of 2 residents (1 unsampled and 1 sampled) observed for transmission-based precautions (TBP). These failed practices had the potential to affect all residents, based on a census of 51, for risk of the spread of the Covid-19 virus and other infectious diseases.

Inspectors wroteBased on record review and interview the facility failed to ensure the discharge status of resident (#55), out of 3 closed records reviewed, was updated. Specifically, the facility failed to update the discharge location of the resident. This failed practice provided inaccurate discharge information.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the comprehensive care plan was updated to meet the needs of 2 residents (#1 and #39) out of 13 sampled residents. This failed practice had the potential to cause an inconsistent provision of treatment and services.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide assistance with dining for 2 of 2 dining observations with Resident #1. This failed practice placed dependent residents at risk for potential harm from weight loss, hunger, dehydration, and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident environment was free of accidents and hazards. Specifically, the facility failed to: 1) assess and identify potential hazards before the installation of a wooden shelf in a resident room, above the resident's bed, for 1 resident (#4), out of 13 sampled residents; and 2) ensure staff monitored the temperature of reheated food for 1 unsampled resident (#40), out of 1 observation for reheated food. These failed practices placed all residents, based on a census of 51, at risk of having an avoidable accident such as a burn or other injury.

Inspectors wroteBased on record review and interview, the facility failed to ensure medication orders did not contain excessive dosing or duplicate drug therapy for 1 resident (#24) out of 5 sampled residents for unnecessary medications. Specifically, the facility failed to ensure: 1) scheduled and PRN (as needed) Tylenol orders were within the recommended daily maximum dose for the same resident; and 2) multiple PRN medications for pain had appropriate parameters for administration. These failed practices placed the resident at risk of receiving unnecessary medication, excessive dosage, or uncontrolled pain relief.