A list of the most recent deficiencies for The Laurels of Mt. Pleasant. 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? |
|---|---|---|---|---|
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-26 | 2023-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-26 | 2023-08-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-02 | 2023-06-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-15 | 2022-07-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-15 | 2022-07-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-15 | 2022-07-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-21 | 2022-07-01 | 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 | 2022-06-21 | 2022-07-01 | 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 | 2022-06-21 | 2022-07-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-21 | 2022-07-01 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-06-21 | 2022-07-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-21 | 2022-07-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-21 | 2022-07-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-23 | 2022-06-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-23 | 2022-06-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-23 | 2022-06-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-23 | 2022-06-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-23 | 2022-06-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-05 | 2022-02-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-03 | 2021-10-04 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-03 | 2021-10-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-03 | 2020-03-04 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2020-02-03 | 2020-03-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-02-03 | 2020-03-04 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-02-03 | 2020-03-04 | 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 | 2020-02-03 | 2020-03-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-03 | 2020-03-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-02-03 | 2020-03-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-02-03 | 2020-03-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-02-03 | 2020-03-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-02-03 | 2020-03-04 | N |
| Respond appropriately to all alleged violations. | Health | 2020-02-03 | 2020-03-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-03 | 2020-03-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-03 | 2020-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-03 | 2020-03-04 | 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 | 2020-02-03 | 2020-03-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-03 | 2020-03-04 | 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 | 2020-02-03 | 2020-03-04 | N |
| Post nurse staffing information every day. | Health | 2020-02-03 | 2020-03-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-03 | 2020-03-04 | 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 | 2020-02-03 | 2020-03-04 | 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 | 2020-02-03 | 2020-03-04 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2020-02-03 | 2020-03-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-03 | 2020-03-04 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-02-03 | 2020-03-04 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-02-03 | 2020-03-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-03 | 2020-03-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-27 | 2020-03-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-01-27 | 2020-03-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-01-27 | 2020-03-04 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-01-27 | 2020-03-04 | N |
