Deficiency Records for Louisburg Healthcare and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Louisburg Healthcare and Rehab 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-08 | 2023-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-08 | 2023-11-30 | 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 | 2023-10-30 | 2023-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-30 | 2023-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-30 | 2023-11-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-30 | 2023-11-10 | N |
| 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 | 2023-10-30 | 2023-11-10 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-11-08 | 2023-11-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-08 | 2023-11-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-08 | 2023-11-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-08 | 2023-11-08 | 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 | 2023-07-11 | 2023-08-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-11 | 2023-08-18 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-11 | 2023-08-18 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-03-02 | 2022-03-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-10 | 2022-03-11 | 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 | 2022-03-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-10 | 2022-03-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-10 | 2022-03-11 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-02-10 | 2022-03-11 | 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 | 2022-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-10 | 2022-02-10 | 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 | 2022-01-05 | 2022-01-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-05 | 2022-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-05 | 2022-01-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-05 | 2022-01-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-05 | 2022-01-30 | 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 | 2022-01-05 | 2022-01-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-05 | 2022-01-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-05 | 2022-01-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-09 | 2021-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-18 | 2021-05-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-01 | 2021-02-26 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-02-20 | 2020-04-16 | 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 | 2020-02-20 | 2020-04-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-20 | 2020-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-20 | 2020-04-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-20 | 2020-04-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-20 | 2020-04-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-20 | 2020-04-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-20 | 2020-04-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-20 | 2020-04-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-03-12 | 2020-04-10 | N |
| 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 | 2020-03-12 | 2020-04-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-12 | 2020-04-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-03-12 | 2020-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-12 | 2020-04-10 | N |
