Heritage Mills Personal Care Center.

“Medication records were not properly maintained. One resident's medication was recorded at incorrect frequency (one tablet daily instead of twice daily), another resident's prescribed medication was not included on the MAR, and a third resident's nasal spray order was not included on the MAR for March 2026.”

“A resident's refusal of prescribed medication was not reported to the prescriber or physician within 24 hours as required.”

“The facility did not follow prescriber's orders in three instances: one resident's prescribed medication was administered only daily instead of twice daily; a topical cream was not administered due to unavailability in the medication cart; and a resident's heart rate was not documented prior to administration of a medication with heart rate parameters.”

“Medication errors were not immediately reported to the resident, the resident's designated person, and the prescriber as required.”

“A resident's initial assessment was not updated when the resident's living arrangements changed from part-time to full-time residence at the facility, and the assessment did not reflect the associated changes in medication administration needs.”

“Staff failed to report multiple incidents of resident abuse, including threats between residents and verbal abuse, to the Area Agency on Aging as required by the Older Adult Protective Services Act.”

“Facility failed to report multiple incidents of resident abuse and threats to the Department's personal care home regional office or complaint hotline within 24 hours as required.”

“Facility failed to maintain individual count sheets for narcotic medications, and failed to use a second count sheet for witness verification. Additionally, there are no individual count sheets for the overflow narcotics and no signatures to verify that staff are counting the medications at the change of every shift.”

“Residents requiring hygienic assistance with toileting and incontinence management were found multiple times with briefs soaked through to furniture, with briefs deteriorating. Staff was not meeting residents' ADL needs as indicated in their Resident Assessment and Support Plans.”

“Staff person told a resident they were being a 'pain in the a**', upsetting the resident who reported to family and other staff that they were hated and unliked at the facility. Resident was not treated with dignity and respect.”

“A cleaning cart on the second floor contained 2 spray bottles without manufacturer's labels; the liquid was identified as OdorBan by housekeeping staff. Poisonous materials were not stored in original, labeled containers.”

“Staff were observed utilizing vaping devices inside the building on Friday, and multiple staff reported witnessing other staff using vaping pens inside the facility. The facility has a designated smoking area outside in the parking lot, and staff were not following the fire safety policy and procedures.”

“A ladder was being stored in stairwell 2, blocking immediate egress in the event of an emergency.”

“A resident refused a prescribed daily medication for constipation 20 times, and the prescribing physician was not notified of the resident's continued refusal.”

“A resident prescribed medication for pain was administered an incorrect dose instead of the prescribed dose.”

“A resident was admitted to the secured dementia unit without a diagnosis of Alzheimer's disease or other dementia documented in their medical evaluation.”

“A resident in the secured dementia care unit was not assessed annually for the continuing need for the secured dementia care unit.”

“Staff Member A completed initial Medication Administration Training and semiannual audit but did not complete required semiannual Medication Administration Record Review by the due date.”