A list of the most recent deficiencies for The Laurels of Sandy Creek. 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 nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-09-14 | 2023-10-02 | Y |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-14 | 2023-10-02 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-14 | 2023-06-05 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-03 | 2023-05-26 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-03 | 2023-05-26 | N |
Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-03 | 2023-05-26 | N |
Provide and implement an infection prevention and control program. | Health | 2023-05-03 | 2023-05-26 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-03 | 2023-05-26 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-03 | 2023-05-26 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-05-26 | Y |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-02 | 2023-05-04 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-02 | 2023-05-04 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-15 | 2022-09-16 | Y |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-30 | 2022-09-14 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-13 | 2022-07-27 | Y |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-07-13 | 2022-07-27 | Y |
Respond appropriately to all alleged violations. | Health | 2022-07-13 | 2022-07-27 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-14 | 2022-07-12 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-14 | 2022-07-12 | Y |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-14 | 2022-07-12 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-14 | 2022-07-12 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-04 | 2022-04-15 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-02-04 | 2022-04-15 | 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 | 2022-02-04 | 2022-03-07 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-04 | 2022-03-07 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-04 | 2022-03-07 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-02-04 | 2022-03-07 | 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 | 2022-02-04 | 2022-03-07 | N |
Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-02-04 | 2022-03-07 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-04 | 2022-03-07 | N |
Provide and implement an infection prevention and control program. | Health | 2022-02-04 | 2022-03-07 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-04 | 2022-03-07 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-04 | 2022-03-07 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-04 | 2022-03-07 | Y |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-04 | 2022-03-07 | Y |
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-02-04 | 2022-03-07 | Y |
Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-02-04 | 2022-03-04 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-03 | 2022-03-04 | 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 | 2022-02-03 | 2022-03-04 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-03 | 2022-03-04 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-02-03 | 2022-03-04 | N |
Provide a written emergency evacuation plan. | Fire Safety | 2022-02-03 | 2022-03-04 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-03 | 2022-03-04 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-03 | 2022-03-04 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-03 | 2022-03-04 | N |
Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-06-21 | 2021-07-31 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-21 | 2021-07-31 | 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 | 2021-06-21 | 2021-07-31 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-21 | 2021-07-31 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-21 | 2021-07-31 | 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 | 2021-06-21 | 2021-07-31 | Y |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-12-19 | 2020-01-12 | N |
Provide activities to meet all resident's needs. | Health | 2019-12-19 | 2020-01-12 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-19 | 2020-01-12 | N |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-19 | 2020-01-12 | 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 | 2019-12-19 | 2020-01-12 | N |
Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-12 | N |
Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2019-12-19 | 2020-01-12 | 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 | 2019-12-19 | 2020-01-12 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-19 | 2020-01-12 | N |