Deficiency Records for Laverna Manor Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Laverna Manor Health and Rehabilitation. 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 meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-07-05 | 2023-08-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-14 | 2023-04-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-10 | 2023-04-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-10 | 2023-03-06 | 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 | 2023-02-10 | 2023-03-06 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-02-10 | 2023-03-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-25 | 2022-10-28 | N |
| Use approved construction type or materials. | Fire Safety | 2022-08-25 | 2022-10-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-25 | 2022-10-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-25 | 2022-10-07 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-08-25 | 2022-10-07 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-08-25 | 2022-10-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-25 | 2022-10-07 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-08-25 | 2022-10-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-25 | 2022-10-07 | N |
| 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 | 2022-08-25 | 2022-10-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-25 | 2022-10-07 | N |
| Provide activities to meet all resident's needs. | Health | 2022-08-25 | 2022-10-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-25 | 2022-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-10-07 | N |
| 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 | 2022-08-25 | 2022-10-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-25 | 2022-10-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-25 | 2022-10-07 | 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 | 2022-08-25 | 2022-10-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-08-25 | 2022-10-07 | 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 | 2022-08-25 | 2022-10-07 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-08-25 | 2022-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-25 | 2022-10-07 | 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 | 2022-08-25 | 2022-10-07 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-08-25 | 2022-10-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-08-25 | 2022-10-07 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-08-25 | 2022-10-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-08-25 | 2022-10-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-25 | 2022-10-07 | 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 | 2022-08-25 | 2022-10-07 | Y |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-08-25 | 2022-10-07 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-25 | 2022-10-07 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-25 | 2022-10-07 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-25 | 2022-10-07 | 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 | 2022-08-25 | 2022-10-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-25 | 2022-10-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-17 | 2022-03-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-17 | 2022-03-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-09 | 2022-03-20 | 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 | 2022-02-09 | 2022-03-20 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-02-09 | 2022-03-20 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-02-09 | 2022-03-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-09 | 2022-03-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-13 | 2020-01-24 | 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 | 2019-12-13 | 2020-01-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-13 | 2020-01-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-13 | 2020-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-13 | 2020-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-13 | 2020-01-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-12-13 | 2020-01-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-12-13 | 2020-01-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-13 | 2020-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-13 | 2020-01-24 | 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 | 2019-12-13 | 2020-01-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-13 | 2020-01-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-01-10 | 2019-03-07 | 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 | 2019-01-10 | 2019-03-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-10 | 2019-03-07 | N |
| 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 | 2019-01-10 | 2019-03-07 | 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 | 2019-01-10 | 2019-03-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-10 | 2019-03-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-10 | 2019-03-07 | 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 | 2019-01-10 | 2019-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-10 | 2019-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-10 | 2019-03-07 | N |
| Meet other general requirements. | Fire Safety | 2019-01-10 | 2019-03-07 | N |
| Use approved construction type or materials. | Fire Safety | 2019-01-10 | 2019-03-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-01-10 | 2019-03-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-10 | 2019-03-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-10 | 2019-03-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-10 | 2019-03-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-01-10 | 2019-03-07 | N |
