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Deficiency Records for Complete Care at Heritage LLC

View the most recent health deficiencies and inspection results for Complete Care at Heritage LLC. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Complete Care at Heritage LLC. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure each resident receives an accurate assessment. Health 2026-02-25 2026-03-31 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2026-02-25 2026-03-31 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2026-02-25 2026-03-31 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2026-02-25 2026-03-31 Y
Provide properly protected cooking facilities. Fire Safety 2025-09-16 2025-12-29 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2025-09-16 2025-12-29 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-09-16 2025-12-29 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2025-09-16 2025-12-29 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2025-09-16 2025-12-29 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2025-09-16 2025-12-29 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 2025-09-16 2025-12-29 N
Provide enough food/fluids to maintain a resident's health. Health 2025-09-16 2025-10-29 N
Ensure each resident receives an accurate assessment. Health 2025-09-16 2025-10-29 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2025-09-16 2025-10-29 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2025-09-16 2025-10-29 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2025-09-16 2025-10-29 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 2025-09-16 2025-10-29 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2025-09-16 2025-10-29 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2025-09-16 2025-10-29 N
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 2025-09-16 2025-10-29 N
Post nurse staffing information every day. Health 2025-09-16 2025-10-29 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 2025-09-16 2025-10-29 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2025-09-16 2025-10-29 N
Provide and implement an infection prevention and control program. Health 2025-09-16 2025-10-29 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2025-09-16 2025-10-29 N
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2025-09-16 2025-10-29 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2025-09-16 2025-10-29 N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2025-09-16 2025-10-29 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-09-16 2025-10-29 Y
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 2025-09-16 2025-10-29 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 2025-09-16 2025-10-29 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2025-09-16 2025-10-29 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2025-09-16 2025-10-29 N
Ensure that residents are free from significant medication errors. Health 2025-02-26 2025-05-02 Y
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 2023-08-22 2023-11-14 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-08-22 2023-11-14 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 2023-08-22 2023-11-14 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-08-22 2023-11-14 N
Provide and implement an infection prevention and control program. Health 2023-08-22 2023-11-14 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-22 2023-11-14 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 2023-08-22 2023-10-06 Y
Respond appropriately to all alleged violations. Health 2023-08-22 2023-10-06 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-08-22 2023-10-06 Y
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2023-08-22 2023-10-06 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-08-22 2023-10-06 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-08-22 2023-10-06 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-22 2023-10-06 Y
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 2023-08-22 2023-10-06 Y
Ensure that residents are free from significant medication errors. Health 2023-08-22 2023-10-06 Y
Develop, implement, and/or maintain an effective training program for all new and existing staff members. Health 2023-08-22 2023-10-06 Y
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Health 2023-08-22 2023-10-06 Y
Provide behavior health training consistent with the requirements and as determined by a facility assessment. Health 2023-08-22 2023-10-06 Y
Ensure medication error rates are not 5 percent or greater. Health 2023-08-22 2023-10-06 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-08-22 2023-10-06 N
Post nurse staffing information every day. Health 2023-08-22 2023-10-06 N
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Health 2023-08-22 2023-10-06 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-08-22 2023-10-06 N
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2023-08-22 2023-10-06 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-08-22 2023-10-06 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 2023-08-22 2023-10-06 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-08-22 2023-10-04 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-08-22 2023-10-04 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-08-22 2023-10-04 N
Provide properly protected cooking facilities. Fire Safety 2023-08-22 2023-09-10 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-08-22 2023-09-10 N
Have stairways and smokeproof enclosures used as exits that meet safety requirements. Fire Safety 2023-08-22 2023-09-10 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-08-22 2023-09-10 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-08-22 2023-09-10 N
Have proper medical gas storage and administration areas. Fire Safety 2023-08-22 2023-09-10 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-08-22 2023-09-10 N
Have proper medical gas storage and administration areas. Fire Safety 2019-01-22 2019-04-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-01-22 2019-04-15 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2019-01-22 2019-04-15 N
Provide and implement an infection prevention and control program. Health 2019-01-22 2019-03-08 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-01-22 2019-03-08 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2019-01-22 2019-03-08 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 2019-01-22 2019-03-08 N
Ensure medication error rates are not 5 percent or greater. Health 2019-01-22 2019-03-08 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2019-01-22 2019-03-08 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 2019-01-22 2019-03-08 N
Observe each nurse aide's job performance and give regular training. Health 2019-01-22 2019-03-08 N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Health 2019-01-22 2019-03-08 N
Provide enough food/fluids to maintain a resident's health. Health 2019-01-22 2019-03-08 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-01-22 2019-03-08 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-01-22 2019-03-08 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2019-01-22 2019-03-08 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-01-22 2019-03-08 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 2019-01-22 2019-03-08 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 2019-01-22 2019-03-08 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2019-01-22 2019-03-08 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-01-22 2019-03-08 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2026-02-25 Not Fixed Y

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