A list of the most recent deficiencies for Laurelhurst Village. 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-06 | 2023-12-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-06 | 2023-12-20 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-11-06 | 2023-12-20 | 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 | 2023-11-06 | 2023-12-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-06 | 2023-12-20 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-06 | 2023-12-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-06 | 2023-12-20 | Y |
| 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 | 2023-11-06 | 2023-12-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-06 | 2023-12-20 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-11-06 | 2023-12-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-06 | 2023-12-20 | Y |
| 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 | 2023-11-06 | 2023-12-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-06 | 2023-12-20 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-06 | 2023-12-20 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-06 | 2023-12-20 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-11-06 | 2023-12-20 | 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 | 2023-11-06 | 2023-12-20 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-06 | 2023-12-20 | Y |
| Post nurse staffing information every day. | Health | 2023-11-06 | 2023-12-20 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-06 | 2023-12-20 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-06 | 2023-12-20 | Y |
| 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 | 2023-11-06 | 2023-12-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-06 | 2023-12-20 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-11-06 | 2023-12-20 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-11-06 | 2023-12-20 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-09 | 2023-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-21 | 2022-12-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-12-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-21 | 2022-12-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-21 | 2022-12-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-21 | 2022-12-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-12-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-21 | 2022-12-08 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-25 | 2022-12-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-25 | 2022-12-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-22 | 2021-09-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-22 | 2021-09-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-27 | 2019-05-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-27 | 2019-04-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-27 | 2019-04-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-27 | 2019-04-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-02-27 | 2019-04-15 | 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 | 2019-02-27 | 2019-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-27 | 2019-04-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-27 | 2019-04-15 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-02-27 | 2019-04-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-02-27 | 2019-04-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-02-27 | 2019-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-27 | 2019-04-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-02-20 | 2019-04-15 | 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 | 2019-02-20 | 2019-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-02-20 | 2019-04-15 | N |
