A list of the most recent deficiencies for Locust Grove Retirement 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 special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-22 | 2023-10-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-22 | 2023-10-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-22 | 2023-10-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-04 | 2023-08-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-04 | 2023-08-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-04 | 2023-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-04 | 2023-08-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-04 | 2023-08-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-04 | 2023-08-29 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-08-04 | 2023-08-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-04 | 2023-08-29 | N |
| Provide or obtain dental services for each resident. | Health | 2023-08-04 | 2023-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-04 | 2023-08-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-04 | 2023-08-29 | N |
| Meet other general requirements. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-29 | 2022-10-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-12 | 2022-09-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-12 | 2022-09-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-12 | 2022-09-21 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-12 | 2022-09-21 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-13 | 2021-10-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-09-13 | 2021-10-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-09-13 | 2021-10-27 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-09-13 | 2021-10-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-13 | 2021-10-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-03 | 2021-10-13 | 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 | 2021-09-03 | 2021-10-13 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-09-03 | 2021-10-13 | 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 | 2021-09-03 | 2021-10-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-03 | 2021-10-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-03 | 2021-10-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-03 | 2021-10-13 | 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 | 2021-09-03 | 2021-10-13 | 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 | 2021-09-03 | 2021-10-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-13 | 2021-06-15 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-13 | 2021-06-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-13 | 2021-06-15 | Y |
