A list of the most recent deficiencies for Complete Care at Heritage LLC. 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 | 2023-08-22 | 2023-11-14 | 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 | 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 |
| 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 |
| 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 |
| 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 |
| Post nurse staffing information every day. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | Health | 2023-08-22 | 2023-10-06 | 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 |
| 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-20 | 2023-10-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-20 | 2023-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-20 | 2023-10-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-20 | 2023-09-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-20 | 2023-09-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-09-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-20 | 2023-09-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-20 | 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 | 2023-07-20 | 2023-09-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-20 | 2023-09-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-14 | 2023-05-19 | Y |
| 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 | 2023-04-14 | 2023-05-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-14 | 2023-05-19 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-31 | 2021-10-29 | 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 | 2021-08-31 | 2021-10-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-31 | 2021-10-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-31 | 2021-10-29 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-25 | 2019-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-25 | 2019-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-25 | 2019-04-15 | 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 |
| 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 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 |
| 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 |
| 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 |
| 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 enough food/fluids to maintain a resident's health. | 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 |
| Observe each nurse aide's job performance and give regular training. | 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 |
| Ensure each resident?s drug regimen must be free from unnecessary 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 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 |
| 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 |
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2019-01-22 | 2019-03-08 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-10-30 | 2017-11-20 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2017-10-30 | 2017-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-10-30 | 2017-11-20 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-09-22 | 2017-11-07 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-09-22 | 2017-11-07 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-09-22 | 2017-11-07 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-22 | 2017-11-07 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-09-22 | 2017-11-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-22 | 2017-11-07 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-22 | 2017-11-07 | N |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2017-09-22 | 2017-11-07 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-09-22 | 2017-11-07 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-09-22 | 2017-11-07 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-22 | 2017-11-07 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-09-22 | 2017-11-07 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-22 | 2017-11-07 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-09-22 | 2017-11-07 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-22 | 2017-11-07 | N |
