The Heights on Huebner

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 5 of 11 residents (Resident #6, Resident #9, Resident #46, Resident #68, and Resident #125) who were reviewed for resident assessments. 1. The facility failed to document Resident #6's use of scheduled pain medication and lack of use of anticonvulsant medication on the quarterly MDS assessment. 2. The facility failed to document Resident #9's use of anticonvulsant medication on the quarterly MDS assessment. 3. The facility failed to document Resident #46's use of antiplatelet medication on the quarterly MDS assessment. 4. The facility failed to document Resident #68's use of antiplatelet medication and hypoglycemic medication on the quarterly MDS assessment. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 4 (Resident #4, Resident #103, Resident #26, and Resident #144) of 22 residents reviewed for accidents and hazards.1. The facility failed to ensure Resident #144 and Resident #103 did not have a disposable razor in his room.2. The facility failed to ensure Resident #4 did not have prohibited chemical and topical products stored in her room.3. The facility failed to ensure Resident #26 did not have prohibited medications and flammable products stored in his room. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 8 residents (Residents #4) reviewed for medical records. 1. The facility failed to ensure Resident #4's medication consent form was missing the nurse signature required to witness on the original medication consent for her antidepressant medication venlafaxine and the replacement consent form did not include the medication name. 2. [...]

Inspectors wroteBased on observation, interview, 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 5 of 6 residents (Resident #7, Residents #97, Resident#34. Resident #144 and Resident #4) reviewed for infection control.1. The facility failed to ensure CNA D sanitized the pulse oximeter used between Resident #7 and Resident #97.2. The facility failed to ensure MA E sanitized the blood pressure cuff used between Resident #34 and Resident #144.3. The facility failed to ensure Resident #4's wound bed did not come in contact with a used bed sheet after it was cleaned while RN L was performing wound care. 4. The facility failed to ensure CNA J and CNA K did not hold Resident #4's catheter above bladder level. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident had the right to formulate an advance directive and determine the choice to receive or not receive cardiopulmonary resuscitation (CPR) for 1 (Resident #26) of 8 residents reviewed for resident rights. The facility failed to ensure Resident #26's out-of-hospital Do Not Resuscitate (OOH DNR) was complete and valid for use in an emergency. This failure could result in failure to honor the resident's wishes during a medical emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #148) reviewed for dialysis:The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #148. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 1 emergency care cart reviewed for storage of drugs. The facility failed to ensure the emergency cart did not have expired tracheostomy kits. This deficient practice could place residents at risk of adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. A bag of celery stalks was opened and undated in the refrigerator 2. A bag of sliced ham was opened in the refrigerator. 3. A bag of cereal was opened in the pantry. These failures could place residents who consume meals and snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interviews, observation, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 6 residents (Residents #1 and #2) reviewed for care plans, in that: Resident #1 and Resident #2's care plan was not updated to reflect their need of being fed at mealtimes. [...]

Inspectors wroteBased on observation, interview, 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 of 3 residents (Residents #1) reviewed for infection control. The facility failed to ensure LVN-A and CNA-B wore gowns while providing catheter care to Resident #1 who was on EBP. This failure could affect residents who required assistance with catheter care and could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions. (Resident #152) The facility failed to develop Resident #152's baseline care plan regarding the resident's BiPap (Bilevel Positive Airway Pressure - device that helps breathing) care for within 48 hours of admission on [DATE]. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 2 (Resident #152) reviewed for respiratory care. Resident #152 did not have physician's orders regarding the resident's BiPap (Bilevel Positive Airway Pressure - device that helps breathing) care when the resident was using the BiPap every night since admission on [DATE]. This failure could affect residents with a BiPap and could lead to lack of care as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 medication carts (treatment cart) reviewed for pharmacy services. There was one medication (Anasept Gel - antimicrobial skin and wound gel) expired on 09/14/2023 found inside the treatment cart on 10/31/2024. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (100 hall medication cart) reviewed for drug security. 100 Hall nurse's medication cart was left unattended, unlocked with the keys hanging from the lock outside the nurses' station with the drawers facing the outward and could be opened by anyone who passed by. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for that described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 8 residents (#5, #6 and #7) reviewed for care plans. 1. Resident #5's care plan did not indicate that she had a colostomy (a surgical opening for the colon in the abdomen). 2. Resident #6's care plan did not indicate that she had a foley catheter (a flexible tube that was inserted through the urethra and into the bladder to drain urine). 3. Resident #7's care plan did not indicate that he had a suprapubic catheter (a tube that was inserted through the lower abdomen and directly into the bladder in order to drain urine). [...]

Inspectors wroteBased on interview and record review the facility failed to implement their written policies and procedures for reporting all allegations involving abuse, neglect and injuries of an unknown source in accordance with the state law for 1 of 8 residents (Resident #61) reviewed for abuse and neglect. The facility did not provide the state agency with a provider investigation report within 5 working days. This failure could place residents at risk of injury abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (Resident #61) reviewed for abuse and neglect. The facility did not thoroughly investigate when Resident #61 was bitten by a visitors dog. This failure could place residents at risk for allegations of abuse or neglect not being thoroughly investigated by the facility and reported as required.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment of 1 of 24 residents (Resident # 78) reviewed for comprehensive person-centered care plans in that The facility failed to do a comprehensive assessment for Resident #78 that included a preference to receive medications in the dining room. This deficient practice could place residents at risk of receiving inadequate assessments not individualized to their care needs.