Deficiency Records for Louisburg Healthcare and Rehabilitation Center
Updated as of March 01, 2020
This is not the most recent data for Louisburg Healthcare and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Louisburg Healthcare and Rehabilitation 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-03 | 2019-09-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-03 | 2019-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-03 | 2019-09-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-23 | 2019-06-12 | 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 | 2019-05-23 | 2019-06-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-05-23 | 2019-06-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-23 | 2019-06-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-18 | 2019-04-19 | 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 | 2018-08-24 | 2018-09-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-08-24 | 2018-08-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-22 | 2018-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-22 | 2018-05-31 | 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 | 2018-04-19 | 2018-05-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-19 | 2018-05-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-19 | 2018-05-07 | 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 | 2018-04-19 | 2018-05-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-19 | 2018-05-07 | 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 ne | Health | 2018-04-19 | 2018-05-07 | N |
| Dispose of garbage and refuse properly. | Health | 2018-04-19 | 2018-05-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-02-14 | 2018-02-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-02-14 | 2018-02-06 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-26 | 2017-08-08 | Y |
| Add automatic sprinklers after major renovation. | Fire Safety | 2017-06-08 | 2017-07-23 | 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 | 2017-06-08 | 2017-07-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-06-08 | 2017-07-23 | N |
| Send unopened mail from residents and promptly deliver unopened mail to residents. | Health | 2017-05-11 | 2017-05-26 | N |
