Heritage Manor Assisted Living LLC.

“Based on observation and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if staff were unaware of the egress of a resident from the facility. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a bell system placed on the back door of the facility. However, the Compliance Officer was able to open the back door without causing the alert to make noise to alert employees of egress. 2. In an interview, E1 and E4 acknowledged the means of exiting the facility did not control or alert employees of the egress of a resident from the facility at the time of the inspection.”

“Based on interview and record review, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of three residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. In an interview, E2 reported all residents received medication administration services. 2. A review of R2's medical record revealed a signed medication order dated September 20, 2024. The order included "Cyanocobalamin 1000 MCG/ML INJ... Inject 1ML intramuscularly every month...Bring labeled vial to clinic to have nurse administer injection." 3. A review of R2's medical record revealed R2's Medical Administration Record (MAR) sheet. The MARs sheet revealed Cyanocobalamin had not been administered this month. However, in an interview, E2 reported E2 had administered the medication to R2 on December 7, 2024 and forgot to document it. 4. A review of E2's personnel record revealed no documentation of a nursing license. 5. In an interview, E2 and E4 acknowledged medication was not administered in compliance with an order and documented.”

“Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the front door of the facility had an alternative locking mechanism screwed in towards the top of the door. The Compliance Officer tried to lock the door using the deadbolt on the door, but the deadbolt would not fully turn. 2. During an environmental inspection of the facility, the Compliance Officer observed the back yard gate allowing access to the front of the house. The latch for the gate was broken off and the gate would open without any resistance. 3. In an interview, E2 and E4 acknowledged the front door and the backyard gate posed a risk to health and safety of the residents.”

“Based on observation and interview, the manager failed to ensure a toxic material stored by the facility was stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the following in unlocked cabinets in the kitchen, accessible to residents: -"Great Value" dishwasher gel; -"Great Value" disinfectant spray; -"RMR-86" mold and mildew stain remover; -"Great Value" glass cleaner; -"Great Value" multi-purpose cleaner; -"Greased Lightning" cleaner and degreaser; and -"Easy-Off" grill cleaner. 2. In an interview, E1 and E4 acknowledged toxic materials stored by the facility were not stored in a locked area and inaccessible to residents.”