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Deficiency Records for Heritage Manor
A list of the most recent deficiencies for Heritage Manor. 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 Manor. 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 and implement an infection prevention and control program. | Health | 2024-07-03 | 2024-07-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-23 | 2024-05-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-04-12 | 2024-05-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-04-12 | 2024-05-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-12 | 2024-05-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-04-12 | 2024-05-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-12 | 2024-05-06 | 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 | 2024-04-12 | 2024-05-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-04-12 | 2024-05-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-04-12 | 2024-05-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-04-12 | 2024-05-06 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-04-12 | 2024-05-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-04-12 | 2024-05-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-12 | 2024-05-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-04-12 | 2024-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-04-12 | 2024-05-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-04-12 | 2024-05-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-04-12 | 2024-05-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-04-12 | 2024-05-06 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-04-15 | 2024-05-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-04-15 | 2024-05-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-04-15 | 2024-05-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-04-15 | 2024-05-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-04-15 | 2024-05-06 | 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 | 2024-04-15 | 2024-05-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-04-15 | 2024-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-03-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-21 | 2023-12-18 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-11-21 | 2023-12-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-14 | 2023-12-05 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-28 | 2023-05-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-28 | 2023-05-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-28 | 2023-05-30 | 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 | 2023-04-28 | 2023-05-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-28 | 2023-05-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-28 | 2023-05-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-28 | 2023-05-30 | 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 | 2023-04-28 | 2023-05-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-28 | 2023-05-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-28 | 2023-05-30 | 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 | 2023-04-28 | 2023-05-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-28 | 2023-05-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-28 | 2023-05-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-01 | 2023-05-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-21 | 2022-11-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-19 | 2022-09-16 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-19 | 2022-09-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-16 | 2022-03-31 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-08 | 2019-06-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-08 | 2019-06-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-05-08 | 2019-06-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-08 | 2019-06-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-08 | 2019-06-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-09 | 2019-06-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-09 | 2019-06-03 | 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 | 2019-06-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-09 | 2019-06-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-09 | 2019-06-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-05-09 | 2019-06-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-09 | 2019-06-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-09 | 2019-06-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-09 | 2019-06-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-05-09 | 2019-06-03 | 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 | 2019-05-09 | 2019-06-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-05-09 | 2019-06-03 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-05-09 | 2019-06-03 | 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 | 2019-06-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-09 | 2019-06-03 | N |
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