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Deficiency Records for Heritage Gardens Health and Rehabilitation Center
A list of the most recent deficiencies for Heritage Gardens Health and Rehabilitation Center. 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 Gardens Health 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-06 | 2023-11-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-20 | 2023-10-27 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2023-09-20 | 2023-10-27 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-20 | 2023-10-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-20 | 2023-10-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-20 | 2023-10-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-20 | 2023-10-27 | 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 | 2023-09-20 | 2023-10-27 | 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 | 2023-09-20 | 2023-10-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-20 | 2023-10-27 | N |
| Post nurse staffing information every day. | Health | 2023-09-20 | 2023-10-27 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-09-20 | 2023-10-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-10-27 | 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 | 2023-09-20 | 2023-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-20 | 2023-10-27 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Develop a communication plan. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-10-03 | 2023-10-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-20 | 2023-04-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-20 | 2023-04-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-07 | 2022-11-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-07 | 2022-11-25 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-08-29 | 2022-08-29 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-02-10 | 2022-03-09 | 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 | 2022-02-10 | 2022-03-09 | 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 | 2022-02-10 | 2022-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-10 | 2022-03-09 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-02-10 | 2022-03-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-10 | 2022-03-09 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-10 | 2022-03-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-10 | 2022-03-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-10 | 2022-03-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-10 | 2022-03-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-10 | 2022-03-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-01-27 | 2022-02-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-27 | 2022-02-22 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-01-27 | 2022-02-22 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-01-27 | 2022-02-22 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-01-27 | 2022-02-22 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-27 | 2022-02-22 | 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 | 2022-01-27 | 2022-02-22 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-27 | 2022-02-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-27 | 2022-02-22 | 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 | 2022-01-27 | 2022-02-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-27 | 2022-02-22 | Y |
| 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 | 2022-01-27 | 2022-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-02-22 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-27 | 2022-02-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-01-27 | 2022-02-22 | 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 | 2022-01-27 | 2022-02-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-22 | 2021-12-27 | 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 | 2020-03-17 | 2020-03-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-17 | 2020-03-18 | 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 | 2020-03-17 | 2020-03-18 | 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 | 2020-03-17 | 2020-03-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-17 | 2020-03-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-03-17 | 2020-03-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-02-11 | 2020-02-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-11 | 2020-02-18 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-02-11 | 2020-02-18 | N |
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