Deficiency Records for Heron Pointe Health and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Heron Pointe Health and Rehabilitation. 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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-01 | 2024-03-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-01 | 2024-03-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-01 | 2024-03-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-01 | 2024-03-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-01 | 2024-03-07 | 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 | 2024-02-01 | 2024-03-07 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-02-01 | 2024-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-01 | 2024-03-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-02-01 | 2024-03-07 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Develop a communication plan. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Establish methods for sharing information. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-29 | 2024-03-07 | N |
| Meet other general requirements. | Fire Safety | 2023-10-13 | 2023-11-22 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-07-27 | 2023-09-05 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-07-27 | 2023-09-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-07-27 | 2023-09-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-27 | 2023-09-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-27 | 2023-09-05 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-27 | 2023-09-05 | 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 | 2023-05-24 | 2023-05-24 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-18 | 2022-10-04 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-08-18 | 2022-10-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-08-18 | 2022-10-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-18 | 2022-10-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-18 | 2022-10-04 | 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 | 2022-08-18 | 2022-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-18 | 2022-10-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Develop a communication plan. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Establish methods for sharing information. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-16 | 2022-10-04 | 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 | 2022-08-16 | 2022-10-04 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-08-16 | 2022-10-04 | N |
| 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 | 2021-10-08 | 2021-09-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-11 | 2021-04-08 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-03-11 | 2021-04-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-11 | 2021-04-08 | 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 | 2021-03-11 | 2021-04-08 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-03-09 | 2021-04-08 | N |
