A list of the most recent deficiencies for Laurel Creek Health 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-10 | 2023-04-07 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-03-10 | 2023-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-10 | 2023-04-07 | 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 | 2023-03-10 | 2023-04-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-10 | 2023-04-07 | 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 | 2023-03-10 | 2023-04-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-10 | 2023-04-07 | 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 | 2023-03-10 | 2023-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-10 | 2023-04-07 | N |
| Have a Compliance and Ethics Program. | Health | 2023-03-10 | 2023-04-07 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-03-10 | 2023-04-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-23 | 2023-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-15 | 2022-09-12 | Y |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-07-10 | 2019-07-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-07-10 | 2019-07-30 | 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 | 2019-04-11 | 2019-05-24 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-04-11 | 2019-05-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-11 | 2019-05-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-13 | 2018-06-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-13 | 2018-05-31 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2018-04-13 | 2018-05-31 | 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 | 2018-04-13 | 2018-05-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-13 | 2018-05-31 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-04-13 | 2018-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-13 | 2018-05-31 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-15 | 2018-05-30 | N |
| Use approved construction type or materials. | Fire Safety | 2018-05-15 | 2018-05-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-15 | 2018-05-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-15 | 2018-05-30 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-05-15 | 2018-05-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-15 | 2018-05-30 | N |
