Mountain Laurel Rehabilitation and Nursing

EHonor the resident's right to organize and participate in resident/family groups in the facility.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0565 · Deficient, Provider has date of correction (May 15, 2025)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Deficient, Provider has date of correction (May 15, 2025)

EHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (May 15, 2025)

EDevelop and implement policies and procedures to prevent abuse, neglect, and theft.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Deficient, Provider has date of correction (May 15, 2025)

EProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0623 · Deficient, Provider has date of correction (Jun 24, 2025)

ENotify 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0625 · Deficient, Provider has date of correction (May 15, 2025)

ECreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0655 · Deficient, Provider has date of correction (May 15, 2025)

EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Jun 24, 2025)

EEnsure services provided by the nursing facility meet professional standards of quality.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0658 · Deficient, Provider has date of correction (May 15, 2025)

EProvide care and assistance to perform activities of daily living for any resident who is unable.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (May 15, 2025)

EProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0725 · Deficient, Provider has date of correction (May 15, 2025)

EProvide timely, quality laboratory services/tests to meet the needs of residents.

Potential for more than minimal harm · Administration Deficiencies · Tag F0770 · Deficient, Provider has date of correction (Jun 24, 2025)

EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Jun 24, 2025)

EDispose of garbage and refuse properly.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0814 · Deficient, Provider has date of correction (May 15, 2025)

ESafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (Jun 24, 2025)

EHave a plan that describes the process for conducting QAPI and QAA activities.

Potential for more than minimal harm · Administration Deficiencies · Tag F0865 · Complaint inspection · Deficient, Provider has date of correction (May 15, 2025)

EConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Potential for more than minimal harm · Administration Deficiencies · Tag F0944 · Deficient, Provider has date of correction (May 15, 2025)

DHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0557 · Deficient, Provider has date of correction (May 15, 2025)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Deficient, Provider has date of correction (Jun 24, 2025)

DKeep residents' personal and medical records private and confidential.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0583 · Deficient, Provider has date of correction (May 15, 2025)

DNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0622 · Complaint inspection · Deficient, Provider has date of correction (May 15, 2025)

DProvide doctor's orders for the resident's immediate care at the time the resident was admitted.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0635 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (May 15, 2025)

DPASARR screening for Mental disorders or Intellectual Disabilities

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0645 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0661 · Complaint inspection · Deficient, Provider has date of correction (May 15, 2025)

DProvide activities to meet all resident's needs.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0679 · Complaint inspection · Deficient, Provider has date of correction (May 15, 2025)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (May 15, 2025)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Deficient, Provider has date of correction (May 15, 2025)

DProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Jun 24, 2025)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (May 15, 2025)

DObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0710 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0711 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure each resident must receive and the facility must provide necessary behavioral health care and services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0740 · Complaint inspection · Deficient, Provider has date of correction (May 15, 2025)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Jun 24, 2025)

DEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Deficient, Provider has date of correction (Jun 24, 2025)

DImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (May 15, 2025)

DProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Potential for more than minimal harm · Administration Deficiencies · Tag F0773 · Deficient, Provider has date of correction (May 15, 2025)

DEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0806 · Deficient, Provider has date of correction (May 15, 2025)

DEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Potential for more than minimal harm · Administration Deficiencies · Tag F0840 · Complaint inspection · Deficient, Provider has date of correction (May 15, 2025)

DDesignate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0841 · Deficient, Provider has date of correction (May 15, 2025)

DArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Complaint inspection · Deficient, Provider has date of correction (May 15, 2025)

DProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Jun 24, 2025)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (May 15, 2025)