Deficiency Records for Heritage Manor Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Heritage Manor Nursing and Rehab Center. 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? |
|---|---|---|---|---|
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-30 | 2023-12-11 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-10-30 | 2023-12-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-30 | 2023-12-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-30 | 2023-12-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-10-30 | 2023-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-30 | 2023-12-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-30 | 2023-12-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-30 | 2023-12-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-30 | 2023-12-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-30 | 2023-12-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-30 | 2023-12-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-30 | 2023-12-04 | 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 | 2023-10-30 | 2023-12-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-30 | 2023-12-04 | 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 | 2023-10-30 | 2023-12-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-30 | 2023-12-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-30 | 2023-12-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-30 | 2023-12-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-30 | 2023-12-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-30 | 2023-12-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-30 | 2023-12-04 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-10-30 | 2023-12-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-30 | 2023-12-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-01 | 2023-11-24 | 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 | 2022-11-17 | 2023-01-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-17 | 2023-01-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-17 | 2023-01-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-17 | 2023-01-03 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-11-22 | 2022-12-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-22 | 2022-12-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-22 | 2022-12-23 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-11-22 | 2022-12-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-22 | 2022-12-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-22 | 2022-12-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-22 | 2022-12-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-09 | 2022-09-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-10 | 2022-06-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-10 | 2022-06-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-10 | 2022-06-16 | Y |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-07-30 | 2021-12-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-11-18 | 2021-12-27 | Y |
| 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 | 2021-11-18 | 2021-12-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-18 | 2021-12-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-18 | 2021-12-27 | Y |
| Keep all essential equipment working safely. | Health | 2021-11-18 | 2021-12-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-18 | 2021-12-27 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-30 | 2021-11-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-30 | 2021-10-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-30 | 2021-10-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-30 | 2021-10-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-30 | 2021-09-03 | 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 | 2021-07-30 | 2021-09-03 | 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 | 2021-07-30 | 2021-09-03 | 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 | 2021-07-30 | 2021-09-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-30 | 2021-09-03 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-27 | 2021-09-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-27 | 2021-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-27 | 2021-09-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-27 | 2021-09-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-27 | 2021-09-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-27 | 2021-09-01 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-27 | 2021-09-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-10 | 2021-04-16 | Y |
