Heritage Hall-Rich Creek

In the surveyor’s words

From the most serious findings on record at Heritage Hall-Rich Creek, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 9, 2021

  Based on observation, staff interview, and review of the manufacturer's instructions for the sanitizer, the facility failed to maintain the sanitizing solution used to sanitize food preparation counters and work surfaces at a level to effectively sanitize surfaces in accordance with the manufacturer's instructions. This had the potential to affect 112 of the 113 residents of the facility who receive food from the dietary department. The facility identified one resident who received nothing by mouth. Findings include: On 12/06/21 at 11:15 AM observation in the kitchen revealed there was a red container of sanitizing solution with a wiping cloth inside. The solution measured 50 parts per million (ppm) of Oasis 146 Multi-Quat Sanitizer. […]

• No harm, potential for more than minimal, patternF725Mar 14, 2024

  Based on observation, resident interview, staff interview, and facility document review, the facility staff failed to ensure they had sufficient staff to attain the highest practicable well-being. The dining room was not being utilized for breakfast and was not used consistently at the evening meal due to staffing issues on 2 of 3 Units, Unit 1 and Unit 2. The findings included: The facility staff were not utilizing the dining room at breakfast and did not consistently use the dining room for the evening meal due to staffing issues. On 03/12/24 at 1:20 p.m., during an interview with Resident #11 this resident stated the facility did not use the dining room on Sunday morning's and sometimes it was not used because the facility did not have enough help. […]

• No harm, potential for more than minimal, patternF761Dec 9, 2021

  Based on observation, staff interview and facility policy review, the facility failed to ensure medication/drugs were secured to prevent residents from potentially gaining access to them. This had the potential to affect 49 ambulatory residents in the facility with a census of 113. Findings include: On 12/06/21 at 4:00 PM a large (gallon size) white bag with medications marked Omnicare Pharmacy was sitting on the floor behind the nursing station. The top of the bag was sealed shut except for a three-inch portion large enough for the surveyor to get her hand in the bag. The bag remained behind the nursing station with no staff present from 4:00 PM through 4:26 PM. […]

• No harm, potential for more than minimal, isolatedF641Mar 14, 2024

  Based on staff interview and clinical record review, the facility staff failed to ensure a minimum data set (MDS) assessment accurately reflected the resident's status for 1 of 23 residents in the survey sample, Resident #53. The findings included: For Resident #53, the facility staff coded the resident's side rails on the 1/17/24 MDS as a restraint when they were being used as an enabler for positioning. Resident #53's diagnosis list indicated diagnoses, which included, but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction, Dementia, Generalized Muscle Weakness, Dysphagia, Aphasia, Other Specified Interstitial Pulmonary Diseases, and Type 2 Diabetes Mellitus. […]

• No harm, potential for more than minimal, isolatedF684Mar 14, 2024

  Based on staff interviews, facility document review, and clinical record review, the facility staff failed to follow medical provider medication orders for two (2) of 23 sampled residents (Resident #88 and Resident #100). The findings include: 1. The facility staff failed to provide Resident #100's medications as ordered by the medical provider. Resident #100's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/18/24, was signed as completed on 2/20/24. Resident #100 was assessed as able to make self understood and as able to understand others. Resident #100's Brief Interview for Mental Status (BIMS) summary score was documented as a 14 out of 15; this indicated intact and/or borderline cognition. […]