A list of the most recent deficiencies for Heritage Hall-Leesburg. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-21 | 2022-11-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-09-21 | 2022-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-21 | 2022-11-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-21 | 2022-11-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-21 | 2022-11-05 | 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 | 2021-05-05 | 2021-06-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-05 | 2021-06-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-11 | 2021-05-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-11 | 2021-05-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-06 | 2019-12-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-09 | 2019-06-21 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-05-09 | 2019-06-21 | 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 | 2019-05-09 | 2019-06-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-09 | 2019-06-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-09 | 2019-06-21 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-05-09 | 2019-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-09 | 2019-06-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-05-09 | 2019-06-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-09 | 2019-06-21 | N |
