A list of the most recent deficiencies for Heritage Healthcare. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-04-27 | 2023-05-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-27 | 2023-05-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-27 | 2023-05-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-27 | 2023-05-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-09 | 2023-05-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-09 | 2023-05-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-06 | 2022-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-06 | 2022-06-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-05-05 | 2022-05-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-05 | 2022-05-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-05-05 | 2022-05-28 | 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 | 2022-05-05 | 2022-05-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-05 | 2022-05-28 | 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 | 2022-05-05 | 2022-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-05 | 2022-05-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-05-05 | 2022-05-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-05 | 2022-05-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-02 | 2022-03-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-02 | 2022-03-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-02 | 2022-03-22 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-02 | 2022-03-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Develop a communication plan. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Establish methods for sharing information. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-13 | 2019-07-25 | 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 | 2019-06-13 | 2019-07-25 | 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 | 2019-06-13 | 2019-07-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-06-13 | 2019-07-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-06-13 | 2019-07-25 | 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 | 2019-05-02 | 2019-07-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-02 | 2019-06-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-02 | 2019-06-01 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2019-05-02 | 2019-06-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-02 | 2019-06-01 | N |
| Protect a residents' right to refuse some types of non-requested transfers within the nursing home. | Health | 2019-05-02 | 2019-06-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-05-02 | 2019-06-01 | 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 | 2019-05-02 | 2019-06-01 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-05-02 | 2019-06-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-02 | 2019-06-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-02 | 2019-06-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-02 | 2019-06-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-05-02 | 2019-06-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-02 | 2019-06-01 | 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 | 2019-05-02 | 2019-06-01 | 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 | 2019-05-02 | 2019-06-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-02 | 2019-06-01 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-02 | 2019-06-01 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-05-02 | 2019-06-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-05-02 | 2019-06-01 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-05-02 | 2019-06-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-05-02 | 2019-06-01 | 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 | 2019-05-02 | 2019-06-01 | N |
| Provide or obtain dental services for each resident. | Health | 2019-05-02 | 2019-06-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-02 | 2019-06-01 | N |
