The Heights at Medical Center

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable, and homelike environment including a window that would open to allow fresh air in for 1 (Resident #54) of 1 observed for comfortable and homelike environment. The facility failed to ensure Resident #54's room window was not screwed shut and would be able to open when resident desired fresh air. This failure could place the residents at risk of feeling uncomfortable and could diminish quality of life.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for two residents (Resident #2 and Resident #76) of twenty-one residents reviewed for MDS assessments. 1. The facility failed to ensure Resident #2's annual MDS, dated [DATE], indicated the resident was receiving the services of the state level II PASRR due to his intellectual disability. 2. The facility failed to ensure Resident #76's quarterly MDS, dated [DATE], indicted the resident used a CPAP (Continuous Positive Airway Pressure) at hours of sleep due to his sleep apnea. These deficient practice could affect residents who receive care and could result in missed or inappropriate care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #51 and #60) of 4 residents reviewed for incontinence care. 1. When CNA-B was providing peri care to Resident #51, CNA-B cleaned the resident's genital area without separating the labia. 2. When CNA-C was providing peri care with urinary indwelling catheter to Resident #60, CNA-C did not clean entire scrotum. These failures could place residents who required incontinence care at risk for cross contamination and the development of urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Residents #36) of 1 Resident whose records were reviewed for oxygen use. The facility failed to ensure Resident #36's oxygen tubing was changed every week, and oxygen filter was checked and cleaned every week per the physician order. This deficient practice could affect any respiratory on oxygen therapy and could contribute to respiratory distress, infections, pneumonia and an overall decline in their physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. Cook failed to wear beard restraints while working in the kitchen. Dietary Aide did not properly wear hair restraints in a way that covered all their hair. This failure could place residents who receive food prepared in the facility's only kitchen by placing them at risk for food-borne illness and food contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #60) of 21 residents reviewed for infection control practices. LVN-A was administering medications via Resident #60's gastrostomy tube, LVN-A did not wear a gown while . Resident #60 had EBP (Enhanced Barrier Precautions) status. This deficient practice could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 8 residents (Resident #26) reviewed for MDS transmission. The facility failed to transmit a discharge MDS assessment to the CMS system for Resident 26 who discharged on 04/29/2025 within 14 days of the discharge date .This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on interview and record review, the facility failed to develop a discharge summary that included a post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, and the resident representative that included where the individual planned to reside, any arrangements that have been made for the resident's follow up care and any post discharge medical and non-medical services for 1 of 1 resident (Resident #1) reviewed for inappropriate discharge. The facility failed to ensure Resident #1 was given a proper discharge when the resident checked out on pass on 7/11/25 and did not return to the facility. This deficient practice could place residents at risk of being discharged and causing a disruption in their care and services and potential decline in health.

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plan of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 1 of 3 nursing staff (LVN A) reviewed for nursing services. LVN A did not notify the DON or the Administrator until Monday 7/14/25 when Resident #1 went out on pass on Friday 7/11/25, and the resident did not return. Resident #1 was scheduled to return to the facility on Saturday 7/12/25. [...]

Inspectors wroteBased on interviews, and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for since April 2024. The facility failed to have either a full-time dietitian or certified dietary manager on staff since April 2024. This failure could place the residents at risk of not receiving sufficient food and nutritional services, which could negative impact overall resident nutrition.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #9, Resident #40,and Resident #43) of nineteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #9, Resident #40, and Resident #43's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 8 (room [ROOM NUMBER], #103, #104, #106, #110, #113, #116, and facility shower room) of 12 rooms observed for environment. The facility failed to ensure Resident rooms #102, #103, #104, #106, #110, #113, #116, and facility shower room were clean and sanitized. The facility failed to ensure Resident room [ROOM NUMBER]'s floor was repaired of cracks to prevent accidents. These deficient practices could place residents at risk of living in an unclean, unsafe and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure food in the facility's refrigerator was labeled and dated according to guidelines. 2. The facility failed to ensure the ice machine in the kitchen area was thoroughly cleaned. 3. The facility failed to ensure food in the facility's freezer was labeled and dated according to guidelines. 4. The facility filed to ensure kitchen equipment in the kitchen area, was thoroughly cleaned. 5. The facility failed to ensure food in the facility's dry food area was labeled and dated according to guidelines. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #51) of 5 residents reviewed for dignity. The facility failed to ensure LVN A closed the door and provided privacy obtaining Resident #51's blood sugar. This failure could place the residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for two (Resident #40 and Resident #43) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #40's Quarterly MDS Assessment accurately reflected that Resident #40 still had his g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach). The facility failed to ensure Resident #43's Quarterly MDS Assessment accurately reflected that Resident #43 still had his g-tube. The facility failed to ensure Resident #'s 43's Quarterly MDS Assessment accurately reflected that Resident #43 had impairment to his right hand. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for two (Resident #40 and Resident #43) of eight residents reviewed for Care Plans. The facility failed to ensure Resident #40 and Resident #43 were care planned for their g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) not being used for nutrition but was still connected to the residents. This failure could place the residents at risk of not receiving necessary care and services.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Residents #26 and #63) of 2 residents reviewed for (ADLs) care provided to dependent residents. 1. The facility failed to ensure Resident #26 received scheduled showers reviewed for the past 30 days (06/16/24 - 07/16/24). 2. The facility failed to ensure Resident and #63 received scheduled showers reviewed for the past 30 days (06/16/24 - 07/16/24). These failures placed residents at risk of not receiving necessary services to maintain good personal hygiene and decreased self- esteem.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one (Resident #44) of twelve residents observed for incontinent care . The facility failed to ensure that CNA D did not wipe from front to back while providing incontinent care to Resident 44 on 07/16/24. These failures could place the residents at risk of cross-contamination and development of urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral (intake of food through a tube in the gastrointestinal tract) feeding for one (Resident #43) of four residents reviewed for gastrostomy tube management. The facility failed to ensure that Resident #43 had orders to observe the g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) even though it was not used by the resident. The facility failed to ensure that Resident #43 had order to flush and check the placement of the g-tube every shift. These failures could place residents who had g-tube at risk for having a clogged g-tube.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #1) of four residents reviewed for respiratory care. The facility failed to ensure that Resident #1's mask for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was properly stored. The facility failed to ensure that Resident #1's humidifier had water in it. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on interviews, and record reviews, the facility failed to assist a resident in obtaining routine dental care for one (Resident #31) of one resident reviewed for dental services. The facility failed to ensure assist Resident #31 with getting a dental appointment when requested by the responsible party in March 2024 This failure could place the resident at risk of not receiving required dental services to avoid complications with her eating.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one ( Resident #51) of twelve residents observed for infection control. The facility failed to ensure that LVN B and RA F changed their gloves and performed hand hygiene while providing incontinent care to Resident #51. This failure could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to personal privacy for 2 of 4 residents (Resident #2 and Resident #4) reviewed for dignity. 1. Resident #2's privacy curtain was not closed completely during wound care on 6/21/24. 2. Resident #4's privacy curtain was not closed completely during wound care on 6/22/24. These failures could affect residents by contributing to poor self-esteem and decreased self-worth and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 8 medication carts (the 100-hallway medication cart) reviewed for medication storage, The facility failed to ensure the 100-hallway medication cart was locked when it was left unattended in the common area in front of the nurses' station. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (RN A) reviewed for infection control. During Resident wound care, RN A failed to perform hand hygiene appropriately. This failure could affect residents and place them at risk for infection.

Inspectors wroteBased on interview and record review the facility failed to immediately consult with Resident #2's primary care physician when an incident involving the resident which results in injury and has the potential for requiring physician intervention for 1 of 11 residents (Resident #2) reviewed for resident rights. The facility failed to notify Resident #2's responsible party and ensure the MD was notified of an incident when Resident #2 fell on [DATE] at 1:30 AM which resulted in bruising to the left hand, slight discoloration began to form on the left thumb and a change in skin condition. An IJ was identified on 05/26/2024 at 12:52 PM. The IJ template was provided to the facility on [DATE] at 2:00 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 11 resident (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2 was not left without care after her initial fall on 03/08/24 at 1:30 AM until after a second fall on 03/08/24 at 6:30 AM which resulted in a left hip and left distal radius fracture. An IJ was identified on 05/26/2024 at 12:52 PM. The IJ template was provided to the facility on [DATE] at 2:00 PM. While the IJ was removed on 05/28/2024 at 2:05 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on fall prevention. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 11 resident (Resident #1) reviewed for accidents and hazards supervision. The facility failed to provide adequate supervision to prevent the elopement of Resident #1 between 01/28/2024 at 10:30 PM and in Resident #1 being found outside of the facility on 01/29/2024 at 3:06 AM. An IJ was identified on 05/26/2024 at 12:52 PM. The IJ template was provided to the facility on [DATE] at 2:00 PM. While the IJ was removed on 05/28/2024 at 2:05 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on supervision and elopement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility reviewed for resident rights. The facility failed to ensure all residents had the right to receive visitors between 7:00 PM and 7:00 AM. This deficient practice placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team for one (Resident #1) of one resident reviewed for revised Care Plan. The facility failed to ensure Resident #1's care plan was revised to reflect discontinued foley catheter. This failure could place the resident at risk of current needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for one (Resident #1) of one resident reviewed for hospice services. The facility failed to maintain required hospice forms and documentation to ensure Resident #1 received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review the facility failed to allow the resident to obtain a copy of the records upon request and upon two working days advance notice to the facility for 1 of 5 residents (Resident #1) whose records were reviewed in that: The facility failed to provide a Resident #1's RP with a copy of Resident #1's medical records after a request was submitted to the facility. This deficient practice could affect residents and could contribute to a delay in the due legal process for residents.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify a resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 residents (Resident #1) reviewed for notification of changes in that: The facility failed to ensure Resident #1's RP was notified when Resident #1 was transferred to a local hospital on 7/27/23. This deficient practice could place residents at risk of not having their family or legal representative notified when having a change of condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 of 6 residents (Residents #8 and 13) reviewed for gastrostomy tube management, in that: 1. Staff N failed to check the placement of Resident #8's gastrostomy tube prior to administering feeding. 2. Staff E failed to check the placement of Resident #13's gastrostomy tube prior to medication administration. These failures could place residents with gastrostomy tubes at risk of aspiration, medical complications, and a decline in health due to inappropriate gastrostomy tube care and management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide separately locked compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 medication rooms, in that, Controlled medications in the narcotic waste box were accessible to any employees who had the code for the medication room. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment; including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, with clean bed and bath linens that are in good condition, for 1 of 2 shower rooms (200-300 hall shower room), reviewed for a clean and homelike shower room, in that: The facility failed to ensure one of 2 facility shower rooms (200-300 hall shower room) did not present with a dirty shower bed, holes in the wall, a missing shower valve, and trash. This failure placed residents at risk for infections, injuries, and demoralization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The facility failed to ensure a bagged part of lettuce in the refrigerator dated 04/11/2023 and was not beyond the 72 hours discard time. 2. The facility failed to ensure the dietary aide did not bring rack of dirty meal trays through the kitchen during meal prep instead of the dishwashing room door. 3. The facility failed to ensure the cook while serving soup did not have gloved thumb inside the bowl resulting in soup touching thumb. These failures could place residents who received meals from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 resident (Resident #9) reviewed for privacy, in that: The facility failed to ensure CNA A and CNA B completely closed Resident #9's privacy curtain while providing catheter care and incontinent care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 18 residents (Residents #50) whose assessments were reviewed, in that: The facility failed to ensure Resident #50's Annual MDS assessment did not incorrectly document the resident as receiving an anticoagulant. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive person-centered care plan to reflect the current condition for 2 of 12 residents (Resident #36 and Resident #44) reviewed for care plan revisions 1. The facility failed to update Resident #36's care plan to only reflect the DNR code status and resolve Full Code status care plan. 2. The facility failed to update Resident #44's care plan to only reflect the DNR code status and resolve Full Code status care plan. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #9) reviewed for incontinent care, in that: The facility failed to ensure CNA A separated Resident #9's labia to clean between the labia during catheter and incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to 1 of 3 medication carts (200-hall medication cart) reviewed for medication storage, in that: The facility failed to ensure the 200-hall medication cart was not left unlocked, unattended, and presented with a medication atop. This failure placed residents at risk for misappropriation of property and /or injury by misapplication of drugs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #50) observed for accuracy of medical records in that: The facility failed to discontinue Resident #50 isolation precaution order. This deficient practice could place residents at risk for errors in care and treatment.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Resident #11) reviewed for infection control, in that: The facility failed to ensure LVN D and CNA I practiced glove changes and hand hygiene during incontinent care for Resident #11 This failure could place residents at risk for infections and health declines.