A list of the most recent deficiencies for Holiday Heights Healthcare. 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 maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-13 | 2023-10-18 | 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 | 2023-09-13 | 2023-10-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-13 | 2023-10-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-13 | 2023-10-18 | 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 | 2023-09-13 | 2023-10-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-13 | 2023-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-13 | 2023-10-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-13 | 2023-10-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-09-13 | 2023-10-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-09-13 | 2023-10-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-13 | 2023-10-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-09-13 | 2023-10-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-29 | 2023-08-09 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-29 | 2023-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-29 | 2023-08-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-04 | 2022-03-21 | 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 | 2022-01-04 | 2022-03-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-04 | 2022-03-21 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-04 | 2022-03-17 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-01-11 | 2022-02-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-11 | 2022-02-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-01-11 | 2022-02-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-11 | 2022-02-16 | 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 | 2020-01-30 | 2020-02-29 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-01-28 | 2020-02-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-01-28 | 2020-02-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-01-28 | 2020-02-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-01-28 | 2020-02-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-28 | 2020-02-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-01-28 | 2020-02-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-28 | 2020-02-29 | N |
