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Deficiency Records for Heritage Square Health Care Center
A list of the most recent deficiencies for Heritage Square Health Care 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 Square Health Care 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? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-07-18 | 2024-08-30 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-07-18 | 2024-08-30 | 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 | 2024-07-18 | 2024-08-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-18 | 2024-08-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-18 | 2024-08-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-18 | 2024-08-30 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-07-18 | 2024-08-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-18 | 2024-08-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-18 | 2024-08-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-18 | 2024-08-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-18 | 2024-08-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-18 | 2024-08-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-18 | 2024-08-30 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-07-18 | 2024-08-30 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2024-07-25 | 2024-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-04-09 | 2024-05-03 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-04-09 | 2024-05-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-17 | 2024-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-17 | 2024-01-31 | Y |
| 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 | 2024-01-17 | 2024-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-06 | 2024-01-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-06 | 2024-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-19 | 2023-08-29 | Y |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-06-15 | 2023-08-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-19 | 2023-07-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-19 | 2023-07-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-06-19 | 2023-07-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-19 | 2023-07-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-19 | 2023-07-20 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-19 | 2023-07-20 | 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 | 2023-06-19 | 2023-07-20 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-19 | 2023-07-20 | 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 | 2023-06-19 | 2023-07-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-19 | 2023-07-20 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-19 | 2023-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-19 | 2023-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-19 | 2023-07-20 | Y |
| 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 | 2023-06-19 | 2023-07-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-19 | 2023-07-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-19 | 2023-07-20 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-19 | 2023-07-20 | 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 | 2023-06-19 | 2023-07-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-19 | 2023-07-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-15 | 2023-07-20 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-06-15 | 2023-07-20 | 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 | 2023-06-15 | 2023-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-15 | 2023-07-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-15 | 2023-07-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-15 | 2023-07-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-15 | 2023-07-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-06-15 | 2023-07-20 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-03-16 | 2022-04-14 | Y |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-03-16 | 2022-04-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-16 | 2022-04-14 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-03-16 | 2022-04-14 | 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 | 2022-03-16 | 2022-04-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-16 | 2022-04-14 | 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 | 2022-03-16 | 2022-04-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-16 | 2022-04-14 | Y |
| Use approved construction type or materials. | Fire Safety | 2022-03-15 | 2022-04-14 | 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 | 2022-03-15 | 2022-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-15 | 2022-04-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-15 | 2022-04-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-11 | 2020-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-11 | 2020-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-11 | 2020-01-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-11 | 2020-01-06 | N |
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