Deficiency Records for Heritage Villa Care and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Heritage Villa Care 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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-09-22 | 2023-11-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-22 | 2023-11-02 | 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 | 2023-09-22 | 2023-11-02 | 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 | 2023-09-22 | 2023-11-02 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-22 | 2023-11-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-22 | 2023-11-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-22 | 2023-11-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-22 | 2023-11-02 | 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 | 2023-09-22 | 2023-11-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-22 | 2023-11-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-22 | 2023-11-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-11-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-22 | 2023-11-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-22 | 2023-11-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-20 | 2022-07-25 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-04-28 | 2021-07-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-28 | 2021-07-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-04-28 | 2021-07-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-04-28 | 2021-07-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-28 | 2021-07-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-28 | 2021-07-07 | 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 | 2021-04-28 | 2021-07-07 | N |
| Provide activities to meet all resident's needs. | Health | 2021-04-28 | 2021-07-07 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-04-28 | 2021-07-07 | 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 | 2021-04-28 | 2021-07-07 | 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 | 2021-04-28 | 2021-07-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-28 | 2021-07-07 | 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 | 2021-04-28 | 2021-07-07 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-04-28 | 2021-07-07 | 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 | 2021-04-28 | 2021-07-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-28 | 2021-07-07 | 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 | 2021-04-28 | 2021-07-07 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2021-04-28 | 2021-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-28 | 2021-07-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-28 | 2021-07-07 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-04-28 | 2021-07-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-04-28 | 2021-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-07-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-28 | 2021-07-07 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-28 | 2021-07-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-28 | 2021-07-07 | Y |
| 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 | 2021-04-28 | 2021-07-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-28 | 2021-07-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-28 | 2021-07-07 | 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 | 2021-04-28 | 2021-07-07 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-28 | 2021-07-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-17 | 2021-06-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-03-17 | 2021-06-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-17 | 2021-04-19 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-05 | 2019-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-05 | 2019-03-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-05 | 2019-03-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-05 | 2019-03-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-05 | 2019-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-05 | 2019-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-29 | 2019-03-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-04-11 | 2018-05-25 | 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 | 2018-04-11 | 2018-05-04 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-04-11 | 2018-05-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-11 | 2018-05-04 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-04-11 | 2018-05-04 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-04-11 | 2018-05-04 | N |
