Deficiency Records for Mountain Laurel Healthcare and Rehabilitation Ctr
Updated as of April 01, 2024
A list of the most recent deficiencies for Mountain Laurel Healthcare and Rehabilitation Ctr. 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-05 | 2024-02-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-05 | 2024-02-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-05 | 2024-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-05 | 2024-02-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-05 | 2023-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-05 | 2023-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-05 | 2023-11-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-11-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-05 | 2023-11-22 | 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 | 2023-10-05 | 2023-11-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-05 | 2023-11-22 | 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 | 2023-10-05 | 2023-11-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-05 | 2023-11-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-05 | 2023-11-22 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-10-05 | 2023-11-22 | 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 | 2023-10-05 | 2023-11-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-05 | 2023-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-05 | 2023-11-22 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-05 | 2023-11-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-10-05 | 2023-11-22 | 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 | 2023-10-05 | 2023-11-22 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-10-04 | 2023-11-08 | 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 | 2023-10-04 | 2023-11-08 | 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 | 2023-10-04 | 2023-11-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-04 | 2023-11-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-25 | 2023-08-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-25 | 2023-08-22 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-07-25 | 2023-08-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-25 | 2023-08-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-26 | 2023-08-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-20 | 2023-04-05 | 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 | 2023-03-20 | 2023-04-05 | Y |
| 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 | 2023-03-20 | 2023-04-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-20 | 2023-04-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-20 | 2023-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-20 | 2023-04-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-20 | 2023-04-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-20 | 2023-04-05 | Y |
| 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 | 2023-01-18 | 2023-04-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-04 | 2023-04-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-09 | 2023-03-07 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-01-18 | 2023-02-22 | Y |
| 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 | 2022-11-09 | 2022-11-30 | 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 | 2022-10-06 | 2022-11-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-06 | 2022-11-16 | 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 | 2022-10-06 | 2022-11-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-06 | 2022-11-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-06 | 2022-11-16 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-10-06 | 2022-11-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-06 | 2022-11-16 | 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 | 2022-10-06 | 2022-11-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-06 | 2022-11-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-06 | 2022-11-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-06 | 2022-11-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-06 | 2022-11-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-06 | 2022-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-06 | 2022-11-16 | 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 | 2022-10-19 | 2022-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-23 | 2022-10-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-13 | 2022-05-25 | 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 | 2022-04-13 | 2022-05-25 | Y |
| 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 | 2022-02-01 | 2022-03-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-13 | 2022-02-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-13 | 2022-02-11 | 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 | 2021-10-07 | 2021-11-15 | 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 | 2021-10-07 | 2021-11-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-07 | 2021-11-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-10-07 | 2021-11-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-07 | 2021-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-10-07 | 2021-11-15 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Report COVID19 data to residents and families. | Health | 2021-08-20 | 2021-10-05 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-08-20 | 2021-10-05 | Y |
