A list of the most recent deficiencies for Heather Hill Healthcare 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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-23 | 2023-02-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-23 | 2023-02-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-16 | 2022-06-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-16 | 2022-06-07 | 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 | 2022-03-16 | 2022-06-07 | 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 | 2022-03-16 | 2022-06-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-16 | 2022-06-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-03-16 | 2022-06-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-16 | 2022-04-16 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-16 | 2022-04-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-16 | 2022-04-16 | N |
| 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 | 2022-03-16 | 2022-04-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-16 | 2022-04-16 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-16 | 2022-04-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-16 | 2022-04-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-01-15 | 2021-02-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-01-15 | 2021-02-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-01-15 | 2021-02-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-01-14 | 2021-02-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-01-14 | 2021-02-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-08-28 | 2019-09-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-28 | 2019-09-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-28 | 2019-09-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-30 | 2019-09-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-30 | 2019-09-27 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-08-30 | 2019-09-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-08-30 | 2019-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-30 | 2019-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-30 | 2019-09-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-30 | 2019-09-27 | N |
