A list of the most recent deficiencies for Leonardville Nursing Home. 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 | 2023-07-19 | 2023-08-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-19 | 2023-08-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-19 | 2023-08-24 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-07-19 | 2023-08-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-26 | 2023-08-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-26 | 2023-08-17 | 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 | 2023-06-19 | 2023-07-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-19 | 2023-07-18 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-06-19 | 2023-07-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-24 | 2023-04-21 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-02 | 2021-12-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-02 | 2021-12-02 | 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 | 2021-10-13 | 2021-11-17 | 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 | 2021-10-13 | 2021-11-17 | 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 | 2021-10-13 | 2021-11-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-03 | 2020-01-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-03 | 2020-01-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-03 | 2020-01-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-03 | 2020-01-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-03 | 2020-01-02 | N |
