A list of the most recent deficiencies for Edgewood Manor of Lucasville Ii. 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? |
|---|---|---|---|---|
| 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 | 2023-08-17 | 2023-11-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-17 | 2023-11-08 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-17 | 2023-11-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-17 | 2023-11-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-17 | 2023-11-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-17 | 2023-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-17 | 2023-11-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-17 | 2023-11-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-17 | 2023-11-08 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-08-14 | 2023-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-14 | 2023-11-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-14 | 2023-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-07 | 2021-10-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-07 | 2021-10-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-07 | 2021-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-07 | 2021-10-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-07 | 2021-10-28 | 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 | 2021-09-07 | 2021-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-07 | 2021-10-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-07 | 2021-10-28 | 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 | 2021-09-07 | 2021-10-28 | 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 | 2021-09-07 | 2021-10-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-07 | 2021-10-28 | N |
| Provide or obtain dental services for each resident. | Health | 2021-09-07 | 2021-10-28 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-09-07 | 2021-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-07 | 2021-10-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-07 | 2021-10-28 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-07 | 2021-10-28 | 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 | 2021-08-30 | 2021-10-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-30 | 2021-10-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-30 | 2021-10-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-18 | 2019-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-18 | 2019-05-17 | 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 | 2019-04-18 | 2019-05-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-18 | 2019-05-17 | 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 | 2019-04-18 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-18 | 2019-05-17 | 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 | 2019-04-18 | 2019-05-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-18 | 2019-05-17 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2019-04-18 | 2019-05-17 | N |
