A list of the most recent deficiencies for The Laurels of Heath. 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 implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-01-30 | N |
| Provide activities to meet all resident's needs. | Health | 2024-01-11 | 2024-01-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-01-30 | 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 | 2024-01-11 | 2024-01-30 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-11 | 2024-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-11 | 2024-01-30 | 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 | 2024-01-11 | 2024-01-30 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-01-11 | 2024-01-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-11 | 2024-01-30 | Y |
| 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 | 2024-01-09 | 2024-01-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-09 | 2024-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-09 | 2024-01-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-09 | 2024-01-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-09 | 2024-01-30 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2024-01-09 | 2024-01-30 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-12-07 | 2023-12-20 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-12-07 | 2023-12-20 | Y |
| Provide appropriate foot care. | Health | 2023-12-07 | 2023-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-05 | 2023-07-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-14 | 2023-07-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-11 | 2023-07-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-11 | 2023-07-17 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-16 | 2022-10-12 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-16 | 2022-10-12 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-16 | 2022-10-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-16 | 2022-03-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-16 | 2022-03-26 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-07 | 2022-02-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-01-07 | 2022-02-24 | 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 | 2022-01-07 | 2022-02-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-01-07 | 2022-02-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-01-07 | 2022-02-24 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-01-07 | 2022-02-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-07 | 2022-02-24 | N |
| Provide activities to meet all resident's needs. | Health | 2022-01-07 | 2022-02-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-01-07 | 2022-02-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-07 | 2022-02-24 | 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 | 2022-01-07 | 2022-02-24 | 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 | 2022-01-07 | 2022-02-24 | 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 | 2022-01-07 | 2022-02-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-07 | 2022-02-24 | 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 | 2022-01-07 | 2022-02-24 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-01-07 | 2022-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-07 | 2022-02-24 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-10 | 2022-02-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-04 | 2022-02-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-04 | 2022-02-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-04 | 2022-02-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-04 | 2022-02-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-18 | 2021-12-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2021-12-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-18 | 2021-12-10 | Y |
| 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 | 2021-08-24 | 2021-09-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-12 | 2021-09-03 | Y |
| 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 | 2021-08-12 | 2021-09-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-12 | 2021-09-03 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-12 | 2021-09-03 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-08-12 | 2021-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-12 | 2021-09-03 | Y |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2021-08-12 | 2021-09-03 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-07-15 | 2021-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-07-15 | 2021-09-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-30 | 2021-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-30 | 2021-04-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-11 | 2021-04-28 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-05-29 | 2019-06-24 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-05-29 | 2019-06-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-05-29 | 2019-06-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-05-29 | 2019-06-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-29 | 2019-06-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-29 | 2019-06-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-29 | 2019-06-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-29 | 2019-06-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-29 | 2019-06-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-05-29 | 2019-06-24 | 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 | 2019-05-29 | 2019-06-24 | 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 | 2019-05-29 | 2019-06-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-05-29 | 2019-06-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-29 | 2019-06-24 | 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 | 2019-05-29 | 2019-06-24 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-05-29 | 2019-06-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-05-29 | 2019-06-24 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2019-05-29 | 2019-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-29 | 2019-06-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-05-29 | 2019-06-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-20 | 2019-06-24 | 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 | 2019-05-20 | 2019-06-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-20 | 2019-06-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-20 | 2019-06-24 | N |
