Deficiency Records for Heisinger Bluffs Healthcare Western Campus
Updated as of March 01, 2024
A list of the most recent deficiencies for Heisinger Bluffs Healthcare Western Campus. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-20 | 2023-08-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-20 | 2023-08-31 | 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 | 2023-07-20 | 2023-08-31 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-20 | 2023-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-08-31 | N |
| 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 | 2023-07-20 | 2023-08-31 | N |
| Post nurse staffing information every day. | Health | 2023-07-20 | 2023-08-31 | 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 | 2023-07-20 | 2023-08-31 | 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 | 2023-07-20 | 2023-08-31 | 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 | 2023-07-20 | 2023-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-20 | 2023-08-31 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-07-20 | 2023-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-08-31 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-07-20 | 2023-08-31 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-20 | 2023-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-20 | 2023-08-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-20 | 2023-08-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-20 | 2023-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-20 | 2023-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-20 | 2023-08-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-03 | 2023-04-14 | 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 | 2022-04-21 | 2022-05-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-21 | 2022-05-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-21 | 2022-05-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-21 | 2022-05-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-21 | 2022-05-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-21 | 2022-05-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-21 | 2022-05-19 | N |
