Deficiency Records for Heritage Manor Nursing and Rehab Center
Updated as of July 01, 2021
This is not the most recent data for Heritage Manor Nursing and Rehab Center. For the most recent information, click here.
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 safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-10 | 2021-04-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-26 | 2021-02-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-11-04 | 2020-12-11 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-07-24 | 2020-08-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-03-12 | 2020-05-06 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2020-01-02 | 2020-02-28 | Y |
| 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 | 2019-09-13 | 2019-11-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-13 | 2019-11-22 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-09-13 | 2019-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-22 | 2019-11-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-22 | 2019-11-15 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-13 | 2019-11-08 | 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 | 2019-09-13 | 2019-11-08 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-13 | 2019-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-17 | 2019-11-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-17 | 2019-11-06 | Y |
| 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 | 2019-10-17 | 2019-11-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-20 | 2019-10-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-20 | 2019-10-28 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-09-20 | 2019-10-28 | 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 | 2019-09-20 | 2019-10-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-20 | 2019-10-28 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-20 | 2019-10-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-09-20 | 2019-10-28 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-09-20 | 2019-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-20 | 2019-10-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-20 | 2019-10-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-20 | 2019-10-28 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-20 | 2019-10-28 | 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 | 2019-09-20 | 2019-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-20 | 2019-10-28 | 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 | 2019-09-20 | 2019-10-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-20 | 2019-10-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-20 | 2019-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-20 | 2019-10-28 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-09-20 | 2019-10-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-09-20 | 2019-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-20 | 2019-10-28 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-09-20 | 2019-10-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-20 | 2019-10-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-20 | 2019-10-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-12-03 | 2019-01-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-03 | 2019-01-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-03 | 2019-01-04 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-24 | 2018-11-28 | 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 | 2018-10-24 | 2018-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-10-24 | 2018-11-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-24 | 2018-11-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-24 | 2018-11-26 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-10-24 | 2018-11-26 | 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 | 2018-10-24 | 2018-11-26 | 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 | 2018-10-24 | 2018-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-24 | 2018-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-24 | 2018-11-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-10-24 | 2018-11-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-10-24 | 2018-11-26 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-08-02 | 2017-10-02 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-08-02 | 2017-10-02 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-08-02 | 2017-10-02 | 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 | 2017-07-31 | 2017-09-01 | 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 | 2017-07-31 | 2017-09-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-07-31 | 2017-09-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2017-07-31 | 2017-09-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-07-31 | 2017-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-31 | 2017-09-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-07-31 | 2017-09-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-07-31 | 2017-09-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-07-31 | 2017-09-01 | N |
| 1) Protect current or future residents from giving up their Medicaid or Medicare benefits; or 2) follow federal rules for admissions. | Health | 2017-08-02 | 2017-08-30 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-08-02 | 2017-08-30 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-02 | 2017-08-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-08-02 | 2017-08-30 | N |
| Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. | Health | 2017-08-02 | 2017-08-30 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-08-02 | 2017-08-30 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2017-08-02 | 2017-08-30 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-02 | 2017-08-30 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-02 | 2017-08-30 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-02 | 2017-08-30 | N |
| Keep all essential equipment working safely. | Health | 2017-08-02 | 2017-08-30 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2017-08-02 | 2017-08-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-08-02 | 2017-08-30 | N |
