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Deficiency Records for Heritage Center
A list of the most recent deficiencies for Heritage 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 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-03-27 | 2024-06-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-27 | 2024-06-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-27 | 2024-04-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-27 | 2024-04-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-03-27 | 2024-04-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-27 | 2024-04-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-27 | 2024-04-30 | 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 | 2024-03-27 | 2024-04-30 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-27 | 2024-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-27 | 2024-04-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-27 | 2024-04-30 | 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 | 2024-03-27 | 2024-04-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-27 | 2024-04-30 | N |
| Post nurse staffing information every day. | Health | 2024-03-27 | 2024-04-30 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-27 | 2024-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-27 | 2024-04-30 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-03-27 | 2024-04-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-03-27 | 2024-04-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-03-27 | 2024-04-30 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-27 | 2024-04-30 | 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 | 2024-03-27 | 2024-04-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-27 | 2024-04-30 | Y |
| 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 | 2024-03-27 | 2024-04-30 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-03-27 | 2024-04-30 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-20 | 2024-04-10 | 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 | 2024-03-20 | 2024-04-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-20 | 2024-04-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-25 | 2023-11-02 | Y |
| 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 | 2023-09-25 | 2023-11-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-11 | 2023-10-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-11 | 2023-10-03 | 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 | 2023-04-19 | 2023-05-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-19 | 2023-05-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-19 | 2023-05-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-19 | 2023-05-16 | 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 | 2023-04-19 | 2023-05-16 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-19 | 2023-05-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-19 | 2023-05-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-09 | 2022-09-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-09 | 2022-09-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-09 | 2022-09-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-09 | 2022-09-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-09 | 2022-09-26 | N |
| 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 | 2022-08-10 | 2022-09-15 | 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 | 2022-08-10 | 2022-09-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-10 | 2022-09-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-10 | 2022-09-15 | 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 | 2022-08-10 | 2022-09-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-10 | 2022-09-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-10 | 2022-09-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-10 | 2022-09-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-10 | 2022-09-15 | 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 | 2022-08-10 | 2022-09-15 | N |
| Dispose of garbage and refuse properly. | Health | 2022-08-10 | 2022-09-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-10 | 2022-09-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-10 | 2022-09-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-10 | 2022-09-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-10 | 2022-09-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-10 | 2022-09-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-10 | 2022-09-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-10 | 2022-09-15 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-04-21 | 2021-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-21 | 2021-06-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-21 | 2021-05-27 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-04-21 | 2021-05-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-21 | 2021-05-27 | 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 | 2021-04-21 | 2021-05-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-21 | 2021-05-27 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2021-04-21 | 2021-05-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-04-21 | 2021-05-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-21 | 2021-05-27 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-21 | 2021-05-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-21 | 2021-05-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-21 | 2021-05-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-21 | 2021-05-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-21 | 2021-05-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-21 | 2021-05-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-21 | 2021-05-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-21 | 2021-05-27 | 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 | 2021-04-21 | 2021-05-27 | 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 | 2021-04-21 | 2021-05-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-21 | 2021-05-27 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-04-21 | 2021-05-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-21 | 2021-05-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-21 | 2021-05-20 | N |
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