Deficiency Records for Mountain Laurel Rehabilitation and Nursing
Updated as of March 01, 2024
A list of the most recent deficiencies for Mountain Laurel Rehabilitation and Nursing. 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? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-14 | 2023-09-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-14 | 2023-09-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-18 | 2022-05-02 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-03-18 | 2022-05-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-18 | 2022-05-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-18 | 2022-05-02 | 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 | 2022-03-18 | 2022-05-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-18 | 2022-05-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-18 | 2022-05-02 | Y |
| Keep all essential equipment working safely. | Health | 2022-03-18 | 2022-05-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-20 | 2022-02-09 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-20 | 2022-02-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-08 | 2021-10-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-08 | 2021-10-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-08 | 2021-08-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-08 | 2021-08-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-08 | 2021-08-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-07-08 | 2021-08-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-08 | 2021-08-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-08 | 2021-08-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-08 | 2021-08-30 | N |
| 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 | 2021-07-01 | 2021-07-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-01 | 2021-07-31 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-01 | 2021-07-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-01 | 2021-07-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-01 | 2021-07-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-01 | 2021-07-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-01 | 2021-07-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-01 | 2021-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-01 | 2021-07-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-01 | 2021-07-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-01 | 2021-07-31 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-03-05 | 2019-04-19 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-03-05 | 2019-04-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-03-05 | 2019-04-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-03-05 | 2019-04-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-03-05 | 2019-04-19 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide appropriate foot care. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-05 | 2019-04-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-05 | 2019-04-19 | 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 | 2019-03-05 | 2019-04-19 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-03-05 | 2019-04-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-05 | 2019-04-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-03-05 | 2019-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-05 | 2019-04-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-05 | 2019-04-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-03-05 | 2019-04-19 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-06 | 2019-04-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-03-06 | 2019-04-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-03-06 | 2019-04-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-11-29 | 2018-01-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-11-29 | 2018-01-17 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-11-02 | 2017-12-16 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-11-02 | 2017-12-16 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-11-02 | 2017-12-16 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-11-02 | 2017-12-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-11-02 | 2017-12-16 | N |
| Provide housekeeping and maintenance services. | Health | 2017-11-02 | 2017-12-16 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-11-02 | 2017-12-16 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-11-02 | 2017-12-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-11-02 | 2017-12-16 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-11-02 | 2017-12-16 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-11-02 | 2017-12-16 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-11-02 | 2017-12-16 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-11-02 | 2017-12-16 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-11-02 | 2017-12-16 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-02 | 2017-12-16 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-11-02 | 2017-12-16 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-11-02 | 2017-12-16 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-11-02 | 2017-12-16 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-11-02 | 2017-12-16 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-02 | 2017-12-16 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-11-02 | 2017-12-16 | N |
| Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2017-11-02 | 2017-12-16 | N |
| Keep complete, dated laboratory records in the resident's file. | Health | 2017-11-02 | 2017-12-16 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-11-02 | 2017-12-16 | N |
