Deficiency Records for Heritage Health Services
Updated as of May 01, 2024
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Deficiency Records for Heritage Health Services
A list of the most recent deficiencies for Heritage Health Services. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Heritage Health Services. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-06 | 2024-03-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-06 | 2024-03-04 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2024-02-06 | 2024-03-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-02-06 | 2024-03-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-06 | 2024-03-04 | 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 | 2024-02-06 | 2024-03-04 | 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 | 2024-02-06 | 2024-03-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-06 | 2024-03-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-06 | 2024-03-04 | 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 | 2024-02-06 | 2024-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-06 | 2024-03-04 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-02-06 | 2024-03-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-06 | 2024-03-04 | 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 | 2024-02-06 | 2024-03-04 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-05 | 2024-03-04 | 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 | 2024-02-05 | 2024-03-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-05 | 2024-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-08 | 2023-12-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-26 | 2023-03-10 | 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 | 2023-01-26 | 2023-03-10 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-26 | 2023-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-03-10 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-01-25 | 2023-03-10 | 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 | 2023-01-25 | 2023-03-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-25 | 2023-03-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-12 | 2021-11-10 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-12 | 2021-11-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-12 | 2021-11-10 | 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 | 2021-10-12 | 2021-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-12 | 2021-11-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-12 | 2021-11-10 | 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 | 2021-10-12 | 2021-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-12 | 2021-11-10 | N |
| Dispose of garbage and refuse properly. | Health | 2021-10-12 | 2021-11-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-10-12 | 2021-11-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-12 | 2021-11-10 | 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 | 2021-10-12 | 2021-11-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-10-12 | 2021-11-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-24 | 2021-07-23 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-06-24 | 2021-07-23 | Y |
| 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 | 2021-06-24 | 2021-07-23 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-06-24 | 2021-07-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-24 | 2021-07-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-24 | 2021-07-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-24 | 2021-07-23 | 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 | 2021-06-24 | 2021-07-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-24 | 2021-07-23 | Y |
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