Deficiency Records for Hearts and Hands, Post Acute Care and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Hearts and Hands, Post Acute Care and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-29 | 2023-08-04 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-29 | 2023-08-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-04-21 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-04-04 | 2023-04-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-06 | 2023-03-20 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-23 | 2022-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-23 | 2022-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-23 | 2022-04-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-23 | 2022-04-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-23 | 2022-04-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-23 | 2022-04-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-23 | 2022-04-19 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-02-23 | 2022-04-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-23 | 2022-04-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-23 | 2022-04-19 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-02-23 | 2022-04-19 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-23 | 2022-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-04-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-02-23 | 2022-04-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-23 | 2022-04-19 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-02-11 | 2022-03-03 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-02-23 | 2022-03-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-23 | 2022-03-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-23 | 2022-03-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-23 | 2022-03-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-21 | 2021-12-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-18 | 2021-08-26 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-28 | 2021-07-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-28 | 2021-07-01 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-24 | 2021-05-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-30 | 2021-04-27 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-03-30 | 2021-04-27 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-03-11 | 2021-04-09 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-11 | 2019-09-24 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-09-11 | 2019-09-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-11 | 2019-09-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-11 | 2019-09-24 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-07-17 | 2019-08-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-07-17 | 2019-08-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-17 | 2019-08-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-17 | 2019-08-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-17 | 2019-08-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-07-17 | 2019-08-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-17 | 2019-08-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-17 | 2019-08-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-17 | 2019-08-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-17 | 2019-08-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-17 | 2019-08-09 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-07-17 | 2019-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-17 | 2019-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-17 | 2019-08-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-07-17 | 2019-08-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-09-12 | 2018-10-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-12 | 2018-10-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-12 | 2018-10-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-12 | 2018-10-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-14 | 2018-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-14 | 2018-07-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-06-14 | 2018-07-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-14 | 2018-07-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-06-14 | 2018-07-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-06-14 | 2018-07-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-06-14 | 2018-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-14 | 2018-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-14 | 2018-07-07 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-06-14 | 2018-07-07 | N |
