Deficiency Records for Heatherdowns Rehab and Residential Care Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Heatherdowns Rehab and Residential Care 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? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-02-28 | 2024-03-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-28 | 2024-03-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-11 | 2023-12-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-12-11 | 2023-12-29 | Y |
| 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 | 2023-12-11 | 2023-12-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-16 | 2023-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-16 | 2023-12-29 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-16 | 2023-12-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-10 | 2023-10-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-06 | 2023-03-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-06 | 2023-03-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-06 | 2023-03-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-06 | 2023-03-28 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-06 | 2023-03-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-06 | 2023-03-28 | 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 | 2023-03-06 | 2023-03-28 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-22 | 2022-10-21 | 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 | 2022-09-22 | 2022-10-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-22 | 2022-10-21 | 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 | 2022-09-22 | 2022-10-21 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-22 | 2022-10-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-22 | 2022-10-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-22 | 2022-10-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-22 | 2022-10-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-22 | 2022-10-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-22 | 2022-10-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-22 | 2022-10-21 | 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 | 2022-09-22 | 2022-10-21 | 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 | 2022-09-22 | 2022-10-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-22 | 2022-10-21 | 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 | 2022-09-20 | 2022-10-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-20 | 2022-10-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-20 | 2022-10-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-25 | 2022-06-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-25 | 2022-06-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-25 | 2022-06-20 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-05-25 | 2022-06-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-11 | 2022-03-25 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-03-03 | 2022-03-25 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-11-09 | 2021-11-16 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-11-09 | 2021-11-16 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-09 | 2021-11-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-09 | 2021-11-16 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-10-13 | 2021-11-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-13 | 2021-11-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-13 | 2021-11-16 | 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 | 2021-10-13 | 2021-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-13 | 2021-11-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-13 | 2021-11-16 | 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 | 2021-09-16 | 2021-11-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-01 | 2021-11-16 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-01 | 2021-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-07 | 2021-04-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-07 | 2021-04-30 | Y |
| 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 | 2019-09-12 | 2019-10-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-12 | 2019-10-18 | 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 | 2019-09-12 | 2019-10-18 | 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 | 2019-09-12 | 2019-10-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-09-12 | 2019-10-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-12 | 2019-10-18 | 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 | 2019-09-12 | 2019-10-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-12 | 2019-10-18 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-09-12 | 2019-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-10-18 | 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 | 2019-09-09 | 2019-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-09 | 2019-10-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-03 | 2018-07-31 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-07-03 | 2018-07-31 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-07-03 | 2018-07-31 | 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 | 2018-07-03 | 2018-07-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-07-03 | 2018-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-03 | 2018-07-31 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2018-07-03 | 2018-07-31 | 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 | 2018-07-03 | 2018-07-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-07-03 | 2018-07-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-07-03 | 2018-07-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-03 | 2018-07-31 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2018-07-03 | 2018-07-31 | N |
