Heritage Hill Senior Community.

“The home failed to report an incident involving a missing piece of jewelry from a resident within the required 24-hour timeframe to the Department. The resident was sent to the hospital wearing 4 pieces of jewelry and returned with only 3, but the incident was not timely reported to DHS.”

“The home failed to obtain written resident signatures for cash disbursements. Two residents received cash disbursements ($20 and $10) without obtaining their signatures on receipts.”

“Staff member did not have a criminal background check completed upon hiring date.”

“A drainpipe in the Secured Dementia Unit courtyard walkway was raised approximately ¾ inch, creating a tripping hazard.”

“The laundry room exit door was locked and required a key to open, creating an obstructed egress route.”

“The exterior fire extinguisher located near the designated smoking area had an inspection tag that was not dated to indicate the year and month of last inspection and expiration date.”

“Resident #3 self-administers medications and stores medications in their room. A bottle of Nystatin Powder was stored on the resident's bathroom sink countertop, unsecured, while the resident's unlocked bedroom door was unattended.”

“Staff member was verbally abusive to a resident who was resisting being cleaned up after incontinence, using derogatory language and telling the resident they were 'acting like a child' and 'full of poop/shit.' This violated the requirement that residents be treated with dignity and respect.”

“A resident was not treated with dignity and respect when another resident was found inappropriately touching the resident's stomach and genital area in the resident's room. The affected resident requested the other resident leave and asked staff for assistance. Both residents were reported to be embarrassed about the incident.”

“A resident grabbed another resident by the face and punched them multiple times, and later struck another resident over the head with a glass vase, causing it to shatter and resulting in approximately a 1 inch laceration. The facility failed to prevent resident-to-resident abuse.”

“A resident was treated without dignity and respect when staff placed a pillow on another resident's head. The resident attempted unsuccessfully to remove the pillow. No injuries resulted from the incident.”

“Resident agreements for in-room video monitoring and voice-controlled electronic devices (Appendix A) were not signed or dated by residents or their responsible parties for six residents (#1-6).”

“During fire drills conducted from December 2023 through April 2024, the designated staff person did not immediately notify staff that a fire drill was being conducted and that Resident #7, who was actively dying, should not be evacuated. This is a repeated violation.”

“Staff person C screamed loudly at Resident #8, saying "I don't know why you just won't cooperate and pick up your feet!" and Resident #8 repeatedly screamed "Get away from me!", demonstrating that the resident was not treated with dignity and respect. This is a repeated violation.”

“The administrator did not complete at least 12 hours of their required annual administrator training hours in person during the 2023-24 training year.”

“A volunteer staff person did not complete required trainings on the emergency medical plan and reporting of reportable incidents within 40 hours of their start date.”

“The home did not have first aid kits that were easily accessible to all staff. One first aid kit was in a locked medication room that not all staff could access, and another first aid kit in the kitchen was bolted to the wall and could not be removed.”

“Staff Person A administered medications to residents without having completed the Department-approved Medication Administration training on multiple dates.”

“In January 2024, a resident was administered medical marijuana for chronic pain. The home does not allow the use of medical marijuana in the facility and did not have a written policy regarding medical marijuana use.”

“Resident #1 was discharged from the facility but did not receive an itemized written account of their funds and refund within 30 days of discharge as required.”

“Resident #2 and Resident #3 were not evacuated during fire drills conducted on specified dates because they were actively dying. The designated staff member did not immediately go to their rooms and notify staff that it was a fire drill and the residents should not be evacuated.”

“For Resident #2 and Resident #3 during fire drills, the home did not include the hospice agency license and documentation of the home's consideration of relocation of the resident's bedrooms with the fire drill logs as required.”

“Resident #4 indicated that Staff Member A was not always respectful toward them and would often yell and raise their voice at the resident, violating the requirement to treat residents with dignity and respect.”

“Hot water temperature in Room 28 measured 125.2°F, 125.4°F, and 125.1°F, exceeding the maximum allowable temperature of 120°F.”

“Two boxes of Cream of Wheat hot cereal with an expiration date of 6/23/2023 (both outdated) were found in the kitchen, one open and one unopened.”