Heritage Suites

The facility failed to ensure one of five sampled residents was tested for tuberculosis disease in compliance with public health guidelines. Specifically, Resident #4 had a 1st step TB skin test on record but lacked the required 2nd step screening.

The facility failed to ensure healthcare referral and follow-up to meet the routine health care needs of a resident. Resident #4 attended his own medical appointments to obtain physician orders, and the facility failed to document required daily monitoring for blood sugar, feet checks, and urination.

The facility failed to ensure that one of five sampled residents was tested for tuberculosis disease in compliance with required guidelines. Specifically, Resident #4 did not have documentation of a required second-step TB skin screening in their medical record following their initial negative test.

The facility failed to ensure that emergency call pendants for 2 of 2 sampled residents were working properly. Pressing the pendants did not consistently alert staff through the pager system, resulting in significant delays in response to resident needs.

The facility failed to maintain fire safety, electrical, mechanical, and plumbing equipment in a safe and operating condition. Specifically, the watch pendants used by residents to call for staff assistance were not working properly, as pressing the pendants failed to consistently alert staff through the pager system.

The facility failed to maintain a clean and orderly kitchen area protected from contamination. Observations revealed grease and food particle buildup on the gas stove, ovens, deep fryers, and meat slicer, as well as dirt accumulation on floors and walls. Additionally, dead cockroaches were found in the food preparation area, and staff indicated a lack of a formal cleaning schedule.

The facility failed to administer medications as ordered for one resident during medication passes. Specifically, the resident did not receive prescribed insulin doses despite blood sugar readings falling within the facility's established sliding scale range.

The facility failed to ensure that medication administration was in accordance with physician orders. Specifically, a resident's Lasix medication was discontinued on the MAR in August 2016, but was not transcribed on subsequent MARs through December 2016, resulting in the resident not receiving the medication. This led to visible swelling in the resident's feet and legs and increased shortness of breath.