Deficiency Records for Heritage Hills Living and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Heritage Hills Living and Rehabilitation 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? |
|---|---|---|---|---|
| Have power receptacles that are properly grounded. | Fire Safety | 2023-11-30 | 2023-12-05 | 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 | 2023-10-12 | 2023-11-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-11-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-10 | 2023-09-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-08-10 | 2023-09-28 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-10 | 2023-09-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-10 | 2023-09-28 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-08-10 | 2023-09-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-10 | 2023-09-28 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-08-10 | 2023-09-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-10 | 2023-09-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-10 | 2023-09-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-10 | 2023-09-28 | 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 | 2023-08-10 | 2023-09-28 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-10 | 2023-09-28 | 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 | 2023-08-10 | 2023-09-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-10 | 2023-09-28 | 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 | 2023-08-10 | 2023-09-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-10 | 2023-09-28 | 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 | 2023-08-10 | 2023-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-09-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-09-28 | 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 | 2023-08-10 | 2023-09-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-10 | 2023-09-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-09-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-09-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-14 | 2022-12-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-02 | 2022-11-21 | N |
| 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 | 2022-09-02 | 2022-10-07 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-09-29 | 2022-09-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-02 | 2022-09-23 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-02 | 2022-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-02 | 2022-09-23 | 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 | 2022-09-02 | 2022-09-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-02 | 2022-09-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-02 | 2022-09-23 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-09-02 | 2022-09-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-02 | 2022-09-23 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-02 | 2022-09-23 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-08-31 | 2022-09-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-08-31 | 2022-09-23 | 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 | 2022-08-31 | 2022-09-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-31 | 2022-09-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-31 | 2022-09-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-08-31 | 2022-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-31 | 2022-09-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-31 | 2022-09-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-13 | 2021-07-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-13 | 2021-07-01 | 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 | 2021-05-13 | 2021-07-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-13 | 2021-07-01 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-05-13 | 2021-07-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-13 | 2021-07-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-05-11 | 2021-07-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-11 | 2021-07-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-11 | 2021-07-01 | 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 | 2021-05-11 | 2021-07-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-11 | 2021-07-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-05-11 | 2021-07-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-11 | 2021-07-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-11 | 2021-07-01 | N |
