A list of the most recent deficiencies for Laurels of Defiance The. 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? |
|---|---|---|---|---|
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2023-11-08 | 2023-12-12 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-06 | 2023-05-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-06 | 2023-05-05 | N |
| 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 | 2023-04-06 | 2023-05-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-06 | 2023-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-06 | 2023-05-05 | 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 | 2023-04-06 | 2023-05-05 | 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 | 2023-04-06 | 2023-05-05 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-04-06 | 2023-05-05 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-06 | 2023-05-05 | 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 | 2023-04-04 | 2023-05-05 | N |
| Have correct number of accessible exits for each story. | Fire Safety | 2023-04-04 | 2023-05-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-04 | 2023-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-04 | 2023-05-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-04 | 2023-05-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-04 | 2023-05-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-04 | 2023-05-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-01 | 2022-04-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-04-01 | 2022-04-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-01 | 2022-04-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-01 | 2022-04-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-01 | 2022-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-21 | 2021-10-22 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2021-06-02 | 2021-06-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-05 | 2021-03-30 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-12-05 | 2020-01-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-05 | 2020-01-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-05 | 2020-01-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-05 | 2020-01-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-05 | 2020-01-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-03 | 2020-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-03 | 2020-01-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-03 | 2020-01-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-05 | 2019-06-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-18 | 2018-11-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-18 | 2018-11-27 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-18 | 2018-11-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-18 | 2018-11-27 | 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 | 2018-10-18 | 2018-11-27 | 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 | 2018-10-18 | 2018-11-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-18 | 2018-11-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-18 | 2018-11-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-18 | 2018-11-27 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-18 | 2018-11-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-18 | 2018-11-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-18 | 2018-11-27 | 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 | 2018-10-18 | 2018-11-27 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2018-10-18 | 2018-11-27 | 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 | 2018-10-18 | 2018-11-27 | 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 | 2018-10-18 | 2018-11-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-18 | 2018-11-27 | N |
