Deficiency Records for Heritage Rehab and Living Ctr
Updated as of March 01, 2022
This is not the most recent data for Heritage Rehab and Living Ctr. For the most recent information, click here.
A list of the most recent deficiencies for Heritage Rehab and Living Ctr. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-22 | 2021-12-17 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-08-10 | 2021-10-12 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-08-10 | 2021-09-27 | 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 | 2021-08-10 | 2021-09-27 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-10 | 2021-09-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-10 | 2021-09-27 | 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 | 2021-08-10 | 2021-09-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-10 | 2021-09-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-10 | 2021-09-24 | 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 | 2021-08-10 | 2021-09-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-10 | 2021-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-07-07 | 2020-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-15 | 2020-10-07 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-07-17 | 2020-09-01 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-07-07 | 2020-08-31 | 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 | 2020-07-17 | 2020-08-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-07-17 | 2020-08-31 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-07-17 | 2020-08-31 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-07-17 | 2020-08-27 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-07-17 | 2020-08-27 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-07-07 | 2020-08-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-07-07 | 2020-08-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-07-07 | 2020-08-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-07-17 | 2020-08-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-07-17 | 2020-07-17 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-07-17 | 2020-07-17 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-07-17 | 2020-07-17 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2020-07-17 | 2020-06-11 | Y |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2020-07-17 | 2020-06-11 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-07-17 | 2020-06-11 | Y |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2020-07-17 | 2020-06-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-17 | 2019-11-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-10 | 2019-08-13 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-07-10 | 2019-08-13 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-07-10 | 2019-08-13 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-07-10 | 2019-08-13 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-07-10 | 2019-08-12 | N |
| Meet other general requirements. | Fire Safety | 2019-07-10 | 2019-08-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-07-10 | 2019-08-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-10 | 2019-08-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-07-18 | 2018-08-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-07-19 | 2018-08-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-07-19 | 2018-08-09 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-07-19 | 2018-08-09 | N |
