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Deficiency Records for Lawson Manor and Rehab
A list of the most recent deficiencies for Lawson Manor and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Lawson Manor and Rehab. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-18 | 2024-04-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-18 | 2024-04-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-03-18 | 2024-04-26 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-03-18 | 2024-04-26 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-03-18 | 2024-04-26 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2024-03-18 | 2024-04-26 | 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 | 2024-03-18 | 2024-04-26 | 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 | 2024-03-18 | 2024-04-26 | 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 | 2024-03-18 | 2024-04-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-03-18 | 2024-04-26 | 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 | 2024-03-18 | 2024-04-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-18 | 2024-04-26 | 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 | 2024-03-18 | 2024-04-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-18 | 2024-04-26 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-03-18 | 2024-04-26 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-03-18 | 2024-04-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-18 | 2024-04-26 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-18 | 2024-04-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-18 | 2024-04-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-03-18 | 2024-04-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-03-18 | 2024-04-26 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-03-18 | 2024-04-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-18 | 2024-04-26 | 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 | 2024-03-18 | 2024-04-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-03-18 | 2024-04-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-18 | 2024-04-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-18 | 2024-04-26 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-18 | 2024-04-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-07 | 2023-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-07 | 2023-12-21 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-11-07 | 2023-12-21 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-11-07 | 2023-12-21 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-12-08 | 2023-02-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-08 | 2023-01-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-08 | 2023-01-19 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-12-08 | 2023-01-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-08 | 2023-01-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-08 | 2023-01-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-08 | 2023-01-19 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-08 | 2023-01-19 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2022-12-08 | 2023-01-19 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-12-08 | 2023-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-08 | 2023-01-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-12-08 | 2023-01-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-12-08 | 2023-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-08 | 2023-01-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-08 | 2023-01-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-05 | 2022-04-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-13 | 2022-02-02 | Y |
| 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 | 2019-09-20 | 2019-11-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-20 | 2019-11-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-20 | 2019-11-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-20 | 2019-11-01 | 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 | 2019-09-20 | 2019-11-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-20 | 2019-11-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-09-20 | 2019-11-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-20 | 2019-11-01 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-09-20 | 2019-11-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-09-20 | 2019-11-01 | N |
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