Heritage House at the Market

Facility failed to assess the ability of Resident 6 to independently manage medications, despite the resident using a nebulizer and inhaler.

Negotiated Service Agreements (NSAs) for Residents 3, 5, and 6 failed to include necessary care plans for blood thinner management and diabetic management.

Facility failed to notify physicians or evaluate the clinical impact of medication refusals for 5 of 5 sampled residents (Residents 1, 2, 3, 5, and 7).

Facility failed to ensure staff were screened for tuberculosis within three days of employment.

1 of 3 sampled staff members (Staff B) did not have documentation of a Tuberculosis screening test within three days of hire, potentially exposing 55 residents.

The facility failed to maintain carpet cleanliness and safety in 3 of 3 sampled resident apartments (Residents 5, 9, and 10), with instances of heavy staining, urine odor, and a wood scrap with a nail at the entrance.

In the dining room outside of kitchen entrance, the sprinkler head was loaded.

The report had deficiencies noted and the fire alarm panel had an active trouble signal.

The facility was unable to provide the heat test report.

Deficiencies found on report; recall on elevator had not been performed due to other elevator issues.

Facility failed to document a plan to monitor and address potential side effects for 3 residents on anticoagulant/aspirin therapy.

Facility failed to store TB testing records on-site.

Facility failed to ensure 5 of 7 sampled residents or their representatives signed their Assessment/Negotiated Service Plan (A/NSA).

Facility failed to maintain a current MTSW/CLIA waiver certificate and failed to display results of the previous full inspection.

Facility failed to ensure safe medication administration systems; missing vital signs, signatures, and documentation of meds (missed/refused/held) for multiple residents.

The facility failed to retain and have available for review a Resident Service Plan (RSP) for one resident.

Power strip plugged into another power strip in the Executive office.

Annual inspection of fire-resistance-rated construction paperwork not provided.

Penetrations found in the ceiling in the main hall outside the 3rd floor storage, in the gift shop, and in the PPE room.

Stairwell door on the second floor will not latch.

Quarterly inspection paperwork for sprinkler system not provided.

Missing documentation for Safety Team deficiencies and system above the deep fryer (Gaylord 19046) needing testing/replacement.

Sensitivity testing documentation not provided.

Carbon Monoxide Alarms and Detectors testing and maintenance documentation not provided.

Emergency lighting not working by room 310 (3rd floor stairwell), room 02 (2nd floor), and in the sun room.

Fire alarm circuit breaker in the electrical room is missing the required locking device.

Fire/smoke damper 4-year inspection paperwork not provided.

Fire door annual inspection paperwork not provided.

Facility cannot provide documentation for twelve planned and unannounced fire drills in the previous 12 months.

Facility failed to keep required personnel documentation on-site for 2 of 5 sampled staff (background checks unavailable for review).

Facility failed to ensure background checks were completed as terms of employment for 2 of 5 sampled staff.

Facility failed to ensure employees maintained updated CPR and First Aid training for 2 of 5 sampled staff.

Facility failed to maintain hot water temperatures between 105 F and 120 F in 2 common restrooms; temperatures measured 59.3 F and 60.1 F.