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Laurel Lakes Rehabilitation And Wellness Center

Inspection Results

Nursing Homes Pennsylvania Chambersburg Laurel Lakes Rehabilitation And Wellness Center

Laurel Lakes Rehabilitation And Wellness Center has been cited for a total of 140 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Laurel Lakes Rehabilitation And Wellness Center.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 690 nursing homes in Pennsylvania with a total of 34,897 deficiencies resulting in an average of 50.58 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

Table describing the severity and scope of deficiencies

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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Assist a resident in gaining access to vision and hearing services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2023-09-21
Corrected:
2023-11-01
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
J
From Complaint:
Y
Standard:
N
Survey Date:
2023-07-14
Corrected:
2023-07-11
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2023-06-13
Corrected:
2023-06-21
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-04-20
Corrected:
2023-05-16
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-30
Corrected:
2023-02-28
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-30
Corrected:
2023-02-28
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-30
Corrected:
2023-02-28
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2023-01-30
Corrected:
2023-02-28
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-12-13
Corrected:
2023-01-10
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-12-13
Corrected:
2023-01-10
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Ensure services provided by the nursing facility meet professional standards of quality.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Nursing and Physician Services Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Observe each nurse aide's job performance and give regular training.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Category:
Infection Control Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category:
Nursing and Physician Services Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2022-10-06
Corrected:
2022-11-22
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-26
Corrected:
2022-08-23
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-26
Corrected:
2022-08-23
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-26
Corrected:
2022-08-23
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-26
Corrected:
2022-08-23
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-22
Corrected:
2022-08-23
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-22
Corrected:
2022-08-23
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category:
Nutrition and Dietary Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-14
Corrected:
2022-07-27
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category:
Nutrition and Dietary Deficiencies
Scope:
G
From Complaint:
Y
Standard:
N
Survey Date:
2022-07-14
Corrected:
2022-07-27
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
B
From Complaint:
Y
Standard:
N
Survey Date:
2022-01-13
Corrected:
Post nurse staffing information every day.
Category:
Nursing and Physician Services Deficiencies
Scope:
B
From Complaint:
Y
Standard:
N
Survey Date:
2022-01-13
Corrected:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-10
Corrected:
2021-12-21
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-10
Corrected:
2021-12-21
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-10
Corrected:
2021-12-21
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-12-10
Corrected:
2021-12-21
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Provide routine and 24-hour emergency dental care for each resident.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Provide routine and 24-hour emergency dental care for each resident.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
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.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Provide and implement an infection prevention and control program.
Category:
Infection Control Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2021-09-23
Corrected:
2021-11-03
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-20
Corrected:
2021-08-16
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-20
Corrected:
2021-08-16
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-20
Corrected:
2021-08-16
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-20
Corrected:
2021-08-16
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.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-20
Corrected:
2021-08-16
Provide safe and appropriate respiratory care for a resident when needed.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-07-20
Corrected:
2021-08-16
Plan the resident's discharge to meet the resident's goals and needs.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-17
Corrected:
2021-04-09
Plan the resident's discharge to meet the resident's goals and needs.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2021-03-17
Corrected:
2021-04-09
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2020-12-03
Corrected:
2020-12-21
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
Y
Standard:
N
Survey Date:
2020-09-18
Corrected:
2020-10-12
Reasonably accommodate the needs and preferences of each resident.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Assure the security of all personal funds of residents deposited with the facility.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category:
Resident Rights Deficiencies
Scope:
B
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
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.
Category:
Resident Rights Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Protect each resident from the wrongful use of the resident's belongings or money.
Category:
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category:
Resident Rights Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Ensure each resident receives an accurate assessment.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category:
Resident Assessment and Care Planning Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category:
Quality of Life and Care Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Provide enough food/fluids to maintain a resident's health.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Category:
Quality of Life and Care Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category:
Pharmacy Service Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
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.
Category:
Pharmacy Service Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Category:
Nutrition and Dietary Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Dispose of garbage and refuse properly.
Category:
Nutrition and Dietary Deficiencies
Scope:
D
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category:
Administration Deficiencies
Scope:
F
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category:
Environmental Deficiencies
Scope:
E
From Complaint:
N
Standard:
Y
Survey Date:
2020-01-17
Corrected:
2020-02-25

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