A list of the most recent deficiencies for Locust Ridge Healthcare LLC. 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-30 | 2024-02-29 | 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 | 2024-01-30 | 2024-02-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-30 | 2024-02-29 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-01-31 | 2024-02-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-07 | 2023-12-22 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-12-07 | 2023-11-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-07 | 2023-11-29 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-12-07 | 2023-11-29 | Y |
| 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 | 2021-05-27 | 2021-07-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-27 | 2021-07-16 | 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 | 2021-05-27 | 2021-07-16 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2021-05-27 | 2021-07-16 | N |
| 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 | 2021-05-27 | 2021-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-27 | 2021-07-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-27 | 2021-07-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-27 | 2021-07-16 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2021-05-27 | 2021-07-16 | 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 | 2021-06-02 | 2021-07-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-02 | 2021-07-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-02 | 2021-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-02 | 2021-07-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-02 | 2021-07-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-02 | 2021-07-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-02 | 2021-07-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-06-02 | 2021-07-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-06-02 | 2021-07-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-30 | 2021-03-31 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-02-21 | 2019-03-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-21 | 2019-03-27 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-02-21 | 2019-03-27 | 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 | 2019-02-21 | 2019-03-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-19 | 2019-03-27 | N |
