Deficiency Records for Laurel Lakes Rehabilitation and Wellness Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Laurel Lakes Rehabilitation and Wellness Center. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-21 | 2023-11-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-21 | 2023-11-01 | 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 | 2023-09-21 | 2023-11-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-21 | 2023-11-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-21 | 2023-11-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-21 | 2023-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-21 | 2023-11-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-21 | 2023-11-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-21 | 2023-11-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-09-21 | 2023-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-21 | 2023-11-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-21 | 2023-11-01 | 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 | 2023-09-21 | 2023-11-01 | 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 | 2023-09-21 | 2023-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-21 | 2023-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-14 | 2023-07-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-13 | 2023-06-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-20 | 2023-05-16 | 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 | 2023-01-30 | 2023-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-30 | 2023-02-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-13 | 2023-01-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-06 | 2022-11-22 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-10-06 | 2022-11-22 | 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 | 2022-10-06 | 2022-11-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-06 | 2022-11-22 | 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 | 2022-10-06 | 2022-11-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-06 | 2022-11-22 | 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 | 2022-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-06 | 2022-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-06 | 2022-11-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-10-06 | 2022-11-22 | 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 | 2022-10-06 | 2022-11-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-10-06 | 2022-11-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-10-06 | 2022-11-22 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-10-06 | 2022-11-22 | N |
| 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 | 2022-10-06 | 2022-11-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-10-06 | 2022-11-22 | 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 | 2022-11-22 | 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 | 2022-10-06 | 2022-11-22 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-10-06 | 2022-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-06 | 2022-11-22 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-10-06 | 2022-11-22 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-10-06 | 2022-11-22 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-11 | 2022-11-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-10-11 | 2022-11-22 | N |
| Meet other general requirements. | Fire Safety | 2022-10-11 | 2022-11-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-11 | 2022-11-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-10-11 | 2022-11-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-11 | 2022-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-26 | 2022-08-23 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-26 | 2022-08-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-22 | 2022-08-23 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-07-14 | 2022-07-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-10 | 2021-12-21 | Y |
| Dispose of garbage and refuse properly. | Health | 2021-12-10 | 2021-12-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-23 | 2021-11-03 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-09-23 | 2021-11-03 | 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 | 2021-09-23 | 2021-11-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-23 | 2021-11-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-23 | 2021-11-03 | 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 | 2021-09-23 | 2021-11-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-23 | 2021-11-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-09-23 | 2021-11-03 | 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 | 2021-09-23 | 2021-11-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-09-23 | 2021-11-03 | 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 | 2021-09-23 | 2021-11-03 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-09-23 | 2021-11-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-23 | 2021-11-03 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-20 | 2021-08-16 | 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 | 2021-07-20 | 2021-08-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-20 | 2021-08-16 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-03-17 | 2021-04-09 | Y |
| Post nurse staffing information every day. | Health | 2022-01-13 | Not Fixed | Y |
